Government

Uninsured week spotlights issue; agreement on solutions elusive

Congress is far from consensus on how to get coverage to the 46 million uninsured. Both rich and poor Americans are increasingly unlikely to be covered.

By Elaine Monaghan — Posted May 15, 2006

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Washington -- Physicians, patients and activists joined forces across the country this month to highlight the mounting number of uninsured Americans as politicians locked horns over how to tackle the problem.

The fourth "Cover the Uninsured Week," which began May 1, coincided with the release of data that revealed a spike in moderate-income uninsured people and with protests by immigrants, for whom health insurance is often a distant dream.

"Forty-six million uninsured in the richest nation in the world -- I think that's a national disgrace," said J. Edward Hill, MD, president of the American Medical Association. "It's way past time for something to be done."

The AMA advocates a market-based system in which tax credits linked to income would replace subsidies for employment-based insurance.

Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, said: "Living without health insurance is a gamble that no one in this nation should have to take." The organization is chief sponsor of Cover the Uninsured Week, which is chaired by former Presidents Carter and Ford and co-sponsored by 18 national organizations including the AMA, the U.S. Chamber of Commerce, the AFL-CIO and AARP.

The crowds of people who skipped work and took to the streets May 1 to demand rights for illegal immigrants were dominated by Latin Americans, who are far more likely to be uninsured than other ethnic groups.

"The bulk of them are working in jobs that do not provide insurance or are earning such low wages that they can't afford it," said Jane Delgado, PhD, president and CEO of the National Alliance for Hispanic Health, one of the week's co-sponsors.

But all Americans were less likely to have health insurance last year, according to the latest Commonwealth Fund Biennial Health Insurance Survey. Badly hit are those earning less than $20,000, 37% of whom were uninsured at the time of the survey and 16% of whom were insured but had been uninsured at some point during the previous year.

Families with moderate incomes -- those earning between $20,000 and $40,000 a year -- also have had trouble. Last year, 41% were either uninsured at the time of the survey or at some point in the past year, compared with 28% of those with moderate incomes in 2001.

The Robert Wood Johnson Foundation issued a separate survey showing the impact on health.

Uninsured women ages 40-64 were half as likely to have had a mammogram as their insured counterparts. One in six adults ages 50-64 -- about 7 million people -- were uninsured. That is an increase of more than 2.6 million over a decade.

Little consensus in Congress

Everyone agrees that something has to be done about the problem, but lawmakers seem far from finding common ground.

At press time, Republicans and Democrats were at odds over a proposal by Sen. Michael Enzi (R, Wyo.) to bypass state regulations so that more groups of businesses and associations could buy national coverage. Many medical groups, including the AMA, have expressed concerns about the bill. They prefer an alternative sponsored by Sen. Richard Durbin (D, Ill.) that embraces tax subsidies.

But senators, who had been expected to vote on the Enzi legislation the first week of May, looked likely to postpone action due to a need to pass an emergency spending bill for this year. Other pressing legislation could take precedence as well.

Enzi's bill aims to help small businesses buy cheaper insurance. About half of the uninsured are self-employed or work for a small business.

During Cover the Uninsured Week, President Bush reiterated support for health savings accounts. In a speech before the American Hospital Assn., he noted that between March 2005 and January 2006, the number of people covered by HSAs/high-deductible health plans tripled to 3 million. About 40% of the plans were purchased by people with family incomes of less than $50,000, and more than a third went to the uninsured.

The AMA has said that HSAs are "an important choice in the health insurance mix."

The partisan gap also was evident on this issue. Maryland Rep. Steny H. Hoyer, the House Democratic whip, said that at least Bush was raising the issue, but the emphasis on HSAs showed that the GOP had "no plan to help the uninsured." Bush "seems to stop at HSAs, which will undermine traditional group insurance and discourage American families from seeking important preventive care."

Working for change

While Congress shows little movement, efforts around the country to tackle the issue state by state and community by community are moving forward. Some of these efforts were highlighted during Cover the Uninsured Week.

"To paraphrase Paul Simon," joked Ed Howard, executive vice president of the Alliance for Health Reform, "there must be 50 ways to cover the uninsured." Howard chaired a Capitol Hill briefing that drew attention to innovative efforts in Alabama, California, Florida, Michigan, New York, North Carolina, Rhode Island, South Carolina, Texas and Washington.

Speakers included Vondie Woodbury, executive director of the Muskegon Community Health Project in Michigan, whose "Access Health" initiative has won national attention for its coverage of the working uninsured by splitting costs between employers, workers and the community. She said the HSA proposals would not help people in her community, who "just don't make enough to put money aside."

Leo Greenawalt, president of the Washington State Hospital Assn., said recent legislative proposals threatened to segment the insurance market still further into healthy and unhealthy individuals, making a comprehensive solution harder to reach.

The crisis of the uninsured alarms students entering the medical profession. The AMA Medical Student Section, a traditionally active participant in Cover the Uninsured Week, organized events all over the country to educate professionals and patients.

"The problem of the uninsured makes me much more motivated to be involved with the AMA and to be a part of organized medicine," said Alik Widge, 28, chair of the MSS governing council and a student at the University of Pittsburgh School of Medicine.

Stewart Patrick, 26, a student at Florida State University College of Medicine and MPH candidate at Harvard University, plans to go into general surgery -- the specialty most likely to provide charity care -- despite his worries.

"The biggest concern I have is that the numbers keep on growing, and we've not seen any real efforts at significant reform since 1994," he said.

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ADDITIONAL INFORMATION

A growing problem

The 2005 Biennial Health Insurance Survey by the Commonwealth Fund examined the problem of uninsured adults by income level. It revealed a striking increase in the number of moderate-income people lacking coverage. The survey took place between Aug. 18, 2005, and Jan. 5, 2006.

2001 2005
Low income
Insured now but uninsured
at some point in past year
16% 16%
Uninsured now 33% 37%
49% 53%
Moderate income
Insured now but uninsured
at some point in past year
11% 13%
Uninsured now 17% 28%
28% 41%
Middle income
Insured now but uninsured
at some point in past year
7% 9%
Uninsured now 6% 9%
13% 18%
High income
Insured now but uninsured
at some point in past year
3% 3%
Uninsured now 1% 4%
4% 7%

Note: Low income was defined as earning less than $20,000 a year in 2001 and 2005, moderate income as $20,000 to $34,999 in 2001 and $20,000 to 39,999 in 2005, middle income as $35,000 to $59,999 in 2001 and $40,000 to $59,999 in 2005, and high income as $60,000 or more in 2001 and 2005.

Source: Commonwealth Fund

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Racial disparities

Racial groups are affected disproportionately by the uninsured problem, as shown in the following 2004 U.S. Census Bureau statistics highlighted by organizers of the Cover the Uninsured Week. Percentage of uninsured in the following ethnic groups:

Children Adults
Hispanics 21.1% 32.7%
Blacks 13.0% 19.7%
Asian-Americans 9.4% 16.8%
Non-Hispanic whites 7.6% 11.3%

Source: U.S. Census Bureau

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External links

Cover the Uninsured Week 2006 (link)

"Gaps in Health Insurance: An All-American Problem," Commonwealth Fund report, April (link)

President Bush's speech on health care initiatives, May 1 (link)

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