New solutions sought to help uninsured

Advocates urge federal policy-makers from all sides to come to the table to discuss proposals before the problem gets worse.

By Joel B. Finkelstein — Posted May 24, 2004

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Washington -- The statistics paint a disturbing picture: More than 44 million Americans are without health insurance, and that number rises an average of 2 million each year. Four of five uninsured people are working adults, their spouses or children.

The personal consequences are often even more troubling: Individuals delaying physician visits until their disease has progressed beyond cure; uninsured patients living sicker and dying younger; and families being bankrupted by medical bills.

These statistics were released as part of the recent Cover the Uninsured Week, an effort aimed at drawing national attention to the country's health insurance access problems. For physicians, the numbers represent real patients.

"I could put a face to every one of those groups," said Regina Benjamin, MD, who runs a rural health clinic in Bayou la Batre, Ala.

The problem isn't just social for physicians -- it's also economic. The uninsured will receive an estimated $40.7 billion in uncompensated care in 2004. About 37% of that comes from physicians and clinics that serve low-income communities. Together these two sources provide the bulk of primary care services to the uninsured.

Physicians alone will provide slightly less than $8 billion in uncompensated care this year, according to statistics from the Kaiser Commission on Medicaid and the Uninsured.

"We have never turned anyone away because they did not have insurance or the ability to pay, and we never will," said Dr. Benjamin, who is a former AMA trustee. "But it is getting harder and harder to maintain and keep our doors open."

Overhead costs continue to rise, but revenues have been stable or dropping for years. Dr. Benjamin moonlights to pay her own living costs. This allows her to work at the clinic without receiving a salary. She pays nurses' wages with the help of a private grant. Still, the clinic is barely keeping afloat.

Private-practice physicians don't have such outside funding sources at their disposal.

There is a certain irony in building a public health system that relies on small-office physicians to provide primary care for the uninsured while excluding them from government funding, Dr. Benjamin said.

Experts agree that there are inherent problems with a patchwork system that leaves large swaths of low-income Americans without access to health care.

"If we had to do it all over again, we'd never have this system," said Uwe Reinhardt, PhD, professor of economics and public affairs at Princeton University. "But the employment-based system is like diabetes. Once you have it, you can't get rid of it, and you just have to learn to control it and live with it."

Incremental approaches

Advocates for the uninsured view incremental reform as the only politically feasible approach for now.

"I would not discourage piecemeal approaches," said Louis Sullivan, MD, a former secretary of the Health and Human Services Dept. There is no dearth of strategies on the table, he noted.

Highlighting that point, lawmakers marked Cover the Uninsured Week with a scheduled House vote on three Republican measures and the release of recommendations from the Senate Republican Task Force on Health Care Costs and the Uninsured.

According to supporters, the House bills, two of which were repeats of legislation passed last year, would improve the affordability of health insurance by limiting liability awards, deregulating association health plans and allowing individuals to roll over unspent money from flexible spending accounts. At press time, the House had not yet voted on the measures.

The Senate task force recommended lowering health care costs through liability reforms, technology and reduced paperwork; expanding private coverage through tax credits, purchasing pools and new coverage options; and bolstering the health care safety net with new community centers, more affordable drugs and incentives for doctor participation.

The AMA also weighed in with a detailed explanation of its proposal to broaden coverage through advanceable, refundable tax credits; individually owned health policies; and market reforms to increase the number of group and individual plan options.

The proposal "builds on the strengths of the existing system, and it corrects the deficiencies in the current system," said AMA President Donald J. Palmisano, MD.

Advocates and some lawmakers asked Congress to put bipartisan bickering on hold long enough to talk about some of these strategies.

"All of us -- Democrats, Republicans and independents -- must set aside our preconceived notions and reactionary tendencies and embrace with open minds the full range of possibilities," said Sen. John D. Rockefeller IV (D, W.Va.). "Somewhere, somehow, there is a compromise idea -- perhaps one that is yet to be discovered and discussed."

Incremental not enough

But some stakeholders are not content with piecemeal reform.

"We have an incredible amount of evidence that incremental change doesn't work," said Georganne Chapin, president of Hudson Health Plan, a nonprofit managed care organization based in Tarrytown, N.Y.

"Incremental programs are extraordinarily expensive, and they are by nature temporary and don't really contribute to the health security of people individually or the population at large," she said. Her comments touch on an issue that is of increasing concern to many Americans.

A recent survey by Kaiser and the Harvard School of Public Health found that a third of the respondents were "very worried" about losing their health insurance coverage. Nearly half were worried about having to pay more for their health care or insurance.

Voters are not the only ones worried about rising health costs.

With the support of 50 Fortune 500 companies, the Assn. of Senior Human Resources Executives launched two new national initiatives to create health insurance purchasing pools that would make lower-cost plans available to many of the working uninsured.

"On the policy side, it will indeed take time to reach consensus and to make significant policy changes," said J. Randall MacDonald, senior vice president of human resources at IBM. "However, if employers take the initiative to collaborate, we know that we can achieve immediate action."

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No medical home

Uninsured patients are much more likely to be without a personal physician or other regular health care source.

Uninsured Insured
White 47.7% 14.8%
Black 54.2% 15.6%
Hispanic 69.8% 24.8%

Source: States Health Access Data Assistance Center

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Skipping preventive care

Patients without health insurance are much less likely to receive preventive services.

Uninsured Insured
No flu shot 85.9% 74.3%
No prostate cancer screening 69.6% 47.4%
No dental care 48.6% 22.8%
No mammogram 46.0% 19.9%
No cervical cancer screening 18.4% 7.6%

Source: State Health Access Data Assistance Center

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External links

"Expanding Insurance Coverage Through Tax Credits, Consumer Choice, and Market Enhancements," abstract, JAMA, May 12 (link)

Cover the Uninsured Week (link)

Kaiser Commission on Medicaid and the Uninsured analysis on the cost of the uninsured (link)

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