The uninsured

A New York Times editorial

One of the major goals of health care reform is to cover the vast numbers of uninsured. But how vast, really, is that pool of people? Who are they? And how important is it to cover all or most of them?

Critics play down the seriousness of the problem by pointing out that the ranks of the uninsured include many people who have chosen to forgo coverage or are only temporarily uninsured: workers who could afford to pay but decline their employers’ coverage; the self-employed who choose not to pay for more expensive individual coverage; healthy young people who prefer not to buy insurance they may never need; people who are changing jobs; poor people who are eligible for Medicaid but have failed to enroll. And then there are the illegal immigrants, a favorite target of critics.

All that is true, to some degree. But the implication — that lack of insurance is no big deal and surely not worth spending a trillion dollars to fix — is not.

No matter how you slice the numbers, there are tens of millions of people without insurance, often for extended periods, and there is good evidence that lack of insurance is harmful to their health.

Scores of well-designed studies have shown that uninsured people are more likely than insured people to die prematurely, to have their cancers diagnosed too late, or to die from heart failure, a heart attack, a stroke or a severe injury. The Institute of Medicine estimated in 2004 that perhaps 18,000 deaths a year among adults could be attributed to lack of insurance.

The oft-voiced suggestion that the uninsured can always go to an emergency room also badly misunderstands what is happening. By the time they do go, many of these people are much sicker than they would have been had insurance given them access to routine and preventive care. Emergency rooms are costly, and if uninsured patients cannot pay for their care, the hospital or the government ends up footing the bill.

So how many uninsured people are out there, facing those risks? The most frequently cited estimate, 45.7 million in 2007, comes from an annual census survey. That number was down slightly from the year before, but given the financial crisis, it is almost certainly rising again.

Some or even many of those people may have only temporarily lost or given up coverage, but even that exposes them to medical and financial risk. And many millions go without insurance for extended periods.

The Agency for Healthcare Research and Quality in the Department of Health and Human Services estimates that 28 million people were uninsured for all of 2005 and 2006 and that 18.5 million of them were uninsured for at least four straight years. That does not sound like a “temporary” problem, and the picture today is almost certainly bleaker.

Various analyses have tried to decipher just who the uninsured are. These are the main conclusions, with the caveat that there is overlap in these numbers:

THE WORKING POOR The Kaiser Family Foundation estimates that about two-thirds of the uninsured — 30 million people — earn less than twice the poverty level, or about $44,000 for a family of four. It also estimates that more than 80 percent of the uninsured come from families with full-time or part-time workers. They often cannot get coverage at work or find it too expensive to buy. They surely deserve a helping hand.

THE BETTER OFF About nine million uninsured people, according to census data, come from households with incomes of $75,000 or more. Critics say that is plenty of money for them to buy their own insurance. But many of these people live in “households” that are groups of low-wage roommates or extended families living together. Their combined incomes may reach $75,000, but they cannot pool their resources to buy an insurance policy to cover the whole group.

Still, about 4.7 million uninsured people live in families that earn four times the poverty level — or $88,000 for a family of four — the dividing line that many experts use to define who can afford to buy their own insurance.

Those people who could afford coverage but choose not to buy it ought to be compelled to join the system to lessen the possibility that a serious accident or illness might turn them into charity cases and to help subsidize the coverage of poorer and sicker Americans.

YOUNG ADULTS Some 13 million young adults between the ages of 19 and 29 lack coverage. These are not, for the most part, healthy young professionals making a sensible decision to pay their own minimal medical bills rather than buy insurance that they are unlikely to need. The Kaiser foundation estimates that only 10 percent are college graduates, and only 5 percent have incomes above $60,000 a year, while half have family incomes below $16,000 a year. Many of these younger people would be helped by reform bills that would provide subsidized coverage for the poor and an exchange where individuals can buy cheaper insurance than is now available.

ALREADY ELIGIBLE Some 11 million of the poorest people, mostly low-income children and their parents, are thought to be eligible for public insurance programs but have failed to enroll, either because they do not know they are eligible or are intimidated by the application process. When such people arrive at an emergency room, they are usually enrolled in Medicaid, but meanwhile they have lost out on routine care that could have kept them out of the emergency room. They will presumably be scooped up by the mandate under reform bills that everyone obtain health insurance.

THE UNDERINSURED The Commonwealth Fund estimates that 25 million Americans who had health insurance in 2007 had woefully inadequate policies with high deductibles and restrictions that stuck them with large amounts of uncovered expenses. Many postponed needed treatments or went into debt to pay medical bills.

NON-CITIZENS Some 9.7 million of the uninsured are not citizens; of those, more than six million may be illegal immigrants, according to informed estimates. None of the pending bills would cover them.

If nothing is done to slow current trends, the number of people in this country without insurance or with inadequate coverage will continue to spiral upward. That would be a personal tragedy for many and a moral disgrace for the nation. It is also by no means cost-free. Any nation as rich as ours ought to guarantee health coverage for all of its residents.

http://www.nytimes.com/2009/08/23/opinion/23sun1.html?pagewanted=2&_r=1