March 2003

Comments, Suggestions?

The impact of the uninsured

By Ruth SoRelle, MPH

In 2002, 41 million Americans lacked health insurance coverage – their ticket to the hospital and the doctor when they are ill. However, that figure minimizes the problem because when the U.S. Census determines it, it looks at people who were without insurance for an entire year.

Recently, Families USA, a patient advocacy group, took a different look at the problem of the uninsured and looked at individuals who lacked insurance for part of the year. According to the group’s analysis, 74.7 million Americans were without health insurance for all or part of the years 2001 and 2002. Most of them were without insurance for more than six months.

That means that nearly one in three Americans under the age of 65 went without health insurance for a period of time in those years. In some states, the percentage without insurance was even higher. Texas led the pack with 39.9% without insurance during that period, followed by New Mexico at 38.6%, Louisiana at 36%, California at 35.5%, Mississippi at 34.9%, Arizona at 34.7%, Arkansas at 34%, Florida at 33.8% and Oklahoma at 33.7%.

The problem is not going to get better in the coming months. Across the nation, state governments are battling with growing budget deficits and most are taking aim at what is considered their biggest cost – health insurance for the poor and disabled. The Children’s Health Insurance Program (CHIP), designed to provide health insurance to the children of the uninsured, working poor, is also another target of the budget cutters.

In an annual meeting with the nation’s governors at the White House Feb. 24, President Bush said states were already getting enough federal funds and that no more help would be coming from Washington. The administration is seeking to give states more control over Medicaid, whom is covers, and how much is spent on what. Advocates for the poor have expressed concern that that will mean larger numbers of uninsured people in many states as budgets get cut more and more.

A new study from the Institute of Medicine, “A shared destiny: The effect of uninsurance on individuals, families and communities,” demonstrates that everyone suffers when large portions of a city or state are without health insurance. Emergency rooms become overcrowded as people who can find care nowhere else are forced into that doctors’ office of last resort. They are the only place mandated by law to evaluate and treat those who are ill and in an emergent condition.

Hospitals, hit by increasing bills that are not paid, begin to close services that they once provided because the community needs them – not because they make money. Doctors who find themselves increasingly called out to provide care to people without funds begin to take themselves off call lists, making their specialties less available.

“It is misguided and even dangerous to assume that lack of health insurance harms only those who are uninsured,” said Arthur Kellerman, MD, MPH, co-chair of the IOM committee that wrote the report and professor and chair of emergency medicine at Emory University School of Medicine in Atlanta. “The rest of the community pays for uncompensated medical care either directly or indirectly, and high rates of uninsurance can strain community health systems to the point that important services have to be cut or eliminated.”

The report notes that when people lack access to care, their health problems have a direct impact on the community. For example, its authors noted, approximately 20 percent of people with HIV lack insurance. For that reason, many of them do not even know they carry the virus and are more likely to transmit it to others for that reason.

The availability of services to those without insurance is shrinking. Los Angeles County in California closed 11 of its 18 public health clinics and one of six public hospitals last year along with 5,000 health care jobs. In Milwaukee, Boston and Hillsborough County, Fla., public officials gave three large urban hospitals over to private ownership, according to the report. This also cuts the availability of care to those who are poor.

As hospitals nationwide have struggled with rising health care costs and greater numbers of uninsured people, they have cut the number of hospital beds for which they hire staff. However, fewer beds mean longer waits for patients who come to the emergency rooms extremely sick or dreadfully injured – whether they have insurance or not.

Is this a crisis? Ask the physicians laboring in the nation’s emergency departments to care for patients with and without insurance. Their answer is clear. Ask the parent who must decide whether to take a child to the doctor or hope that the youngster will get over what is spiking a fever or causing a pain. Taking the child to the doctor may mean spending the grocery money for the week.

Ask the hospital administrator who is considering whether to close a wing. Ask the public health administrator who has to shift funds into immunization and away from disease surveillance – an increasingly important area in times of possible bioterrorism.

If you do not have health insurance, you know the answer. If you do not, the fallout from the current situation could hit the next time you go to the emergency room or need to get into a hospital with several floors closed by a budget crisis.

Being uninsured is a crisis – for the person without insurance and for us all.

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