GOVERNMENT & MEDICINE

44 million and counting ...

The economy is booming. But a growing number of Americans lack health insurance. Studies show their health suffers and their lives are sometimes shortened.

By Susan J. Landers, AMNews staff. March 27, 2000.

Washington -- Forty-four million uninsured Americans. The statistic is bandied about everywhere: in newspaper articles, on the lips of presidential candidates and members of Congress, and at interest group meetings convened to discuss the seriousness of the problem.

But who are these millions of Americans younger than 65 known collectively as "the uninsured?" The U.S. Census Bureau can provide some shape to the statistic.

They include "young adults in the 18- to 24-year-old age group, people with lower levels of education, people of Hispanic origin, those who work part time and people born in another country," explains Jennifer Campbell, author of the Census Bureau's publication "Health Insurance Coverage: 1998." Children are also well represented among the uninsured.

But Jack Michel, MD, and Randi Abramson, MD, can attach faces to the number. Both direct free health clinics for uninsured people.

For Dr. Michel, one face is that of a cleaning woman who couldn't afford her blood pressure medication. Her visit to a private physician's office drained her already meager resources, so she stopped in at Dr. Michel's Kiwanis Club Colombia USA Medical Clinic in Miami.

Dr. Abramson, who works at the Zacchaeus Free Clinic in Washington, D.C., agrees that her patients don't come to her until they're very sick -- until their hypertension is out of control and they have organ damage.

Others who run clinics describe diabetics verging on comas, patients with enormous undiagnosed tumors and migrant laborers with debilitating foot ailments.

The Zacchaeus Free Clinic, like others, screens patients for insurance eligibility; if they are eligible for Medicaid or the 3-year-old State Children's Health Insurance Program, clinic staff sign them up, says Dr. Abramson.

However, she notes, most of her patients are poor, single adults with no children younger than 18. "They don't qualify for any program."

Many very sick people walk through the doors of the nation's free or low-cost clinics. Dr. Michel's clinic sees 30 to 50 patients per day; Dr. Abramson's tends to 2,500 a year.

But those who run the clinics, as well as the many private physicians who provide free care, are quick to say their efforts can't possibly meet the needs of the uninsured and can't replace a schedule of regular medical care. They urge comprehensive changes to the nation's health insurance system.

No insurance? What's the harm?

The American College of Physicians--American Society of Internal Medicine is operating a campaign to counter the myth that "free clinics abound and emergency rooms are always on hand to provide free care," says the group's president, Whitney Addington, MD.

To reinforce their argument, the internists reviewed 100 studies linking lack of insurance with poor health and compiled them in the report: "No Health Insurance: It's Enough to Make You Sick."

The report revealed that "uninsured Americans tend to live sicker and die earlier than insured Americans," Dr. Addington says. "Uninsured Americans may be up to three times more likely than insured individuals to experience adverse health outcomes."

The internists have called on all presidential and legislative candidates to develop plans to provide insurance to those who have none.

The lack of health insurance has important health and financial consequences for individuals and for the nation, the internists argue. Medical treatment for the uninsured is often more expensive than preventive, acute and chronic care because the uninsured are more likely to receive medical care in the emergency department than in a physician's office.

The AMA has also launched efforts to address the growing number of uninsured. It convened a gathering of representatives from consumer, medical, business, legislative and insurance fields last fall to seek ways to achieve universal coverage.

"The problem of health coverage is one of the most challenging puzzles facing America as we end the 20th century," said Nancy Dickey, MD, AMA past president. "It's time to take action."

The AMA is also raising the profile of the uninsured during the presidential primaries with its National House Call campaign. The AMA's 32-foot recreational vehicle has been a presence at all the state primaries so far, distributing material calling for health insurance for all Americans, a meaningful patients' bill of rights and Medicare reform.

Presidential candidates, members of Congress and a range of health care advocates are all crafting proposals to help the uninsured gain coverage. In a time of economic prosperity and with unemployment down to 3% in some parts of the country, it's now or never, many argue.

In order to develop laws and policies that are effective in providing health insurance to all, a close study of data on the uninsured is necessary.

Census bureau data have been supplemented by a bevy of additional studies on the uninsured. For example, the Center for Studying Health System Change found that one in five uninsured people declines employer-sponsored coverage; most cite cost as the major reason.

Young adults with access to employer-sponsored insurance constitute the largest group to decline coverage, said the center study, a decision that reflects lower incomes and generally robust health.

A Commonwealth Fund study revealed that half of working-age adults think that employers should continue to be a main source of health coverage in the future. Two of every three working-age Americans, or 155 million people, have employer-sponsored health care coverage.

But the survey also found that gaps persist and that working full time is no guarantee of coverage. One of three full-time workers with incomes lower than $35,000 is uninsured, according to the study.

"The employer-based system appears to be working well for millions of American workers, yet far too many remain shut out -- particularly those working hard to raise families on low incomes," says Karen Davis, Commonwealth Fund president.

Employer-sponsored insurance is a boon to both employee and employer. It is not counted as taxable income for the worker, and it is fully deductible for employers.

The self-employed and individuals buying policies on their own don't get the same tax breaks. Their difficulties are reflected in the statistics.

Individuals buying their own policies can deduct insurance costs only if they itemize their tax deductions and their total medical expenses exceed 7.5% of adjusted gross income. Self-employed people are now able to deduct 60% of their health care premium cost and will be allowed to deduct 100% in 2003.

And indeed, the census bureau found that workers offered the most generous plans -- those in large firms -- are most likely to have health insurance. While 66% of employees in firms of 1,000 or more report they have health insurance, only 27% of the self-employed and 27.4% of those working in firms of 10 or fewer employees have coverage.

These insurance trends partially account for the high rate of Hispanics lacking insurance, which at 37% is higher than that of any other ethnic group.

Roberto G. Deposada, executive director of the Hispanic Business Roundtable, notes that many Hispanics work in small businesses or the service industry and neither is likely to offer health insurance. Or they are self-employed and can't afford benefits on their own, he says.

The roundtable conducted a nationwide survey of 1,000 Hispanic adults, and nearly one-third reported they lacked health insurance. Of those without insurance, 45% said its high cost stood in the way.

Some evidence also suggests that cultural differences may contribute to the lack of insurance among the Hispanic population, says Paul Fronstin, PhD, an economist with the Employee Benefit Research Institute.

Dr. Fronstin has been sifting through the recent census data and finds it more difficult than it had been in past years to determine why the number of uninsured people continues to increase.

The census bureau reports 1 million more Americans became uninsured in 1998, the latest year for which figures are available.

Four to six years ago, Fronstin says, employers were responding to high health care costs by dropping benefits or shifting costs to employees, resulting in more workers dropping their insurance.

The nation's booming economy in recent years has actually led to an increase in the number of people with employer-based insurance, Dr. Fronstin says. Employers are eager to find workers and willing to reward them with generous benefits.

The problem persists

Despite this rosy picture, the number of the uninsured has increased. Dr. Fronstin speculates that the growth in the uninsured could be attributed to a drop in Medicaid enrollment as more families left the welfare rolls to accept jobs, including jobs that did not offer health insurance.

Those without insurance also constitute a moving target. One-half of the uninsured spells recorded by the census bureau lasted only five or six months.

While health care costs had held steady between 1994 and 1997, they now are increasing faster than inflation, leading to predictions that employers might, once again, pass that cost along to workers by increasing premiums.

But the nation's continuing tight labor market is likely to preclude that option, Dr. Fronstin predicts. There are other options open to employers, he points out, including trimming wages or raising prices. "I think there are other trade-offs that can be made that are usually ignored."

With the strong economy, low unemployment will continue and the number of Americans holding health insurance will remain stable. However, a recession and the ensuing increase in joblessness could change all that, Dr. Fronstin says.

Coming next week: Congress and the presidential candidates draft bills and proposals to broaden access to health insurance.

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• 80% are associated with a working family member.
• 57% earn below 200% of poverty.
• 20% live in the South and Southwest.
• 37% are Hispanic.
• 60% are workers in small firms or are self-employed.
• 34% are ages 21 to 24.

Sources: Employee Benefit Research Institute and U.S. Census Bureau

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People without insurance by race
White: 15%
Non-Hispanic White: 12%
Black: 22%
Asian and Pacific Islander: 21%
Hispanic origin: 35%

People without insurance by age
Under 18: 15%
18 to 24: 30%
25 to 34: 24%
35 to 44: 17%
45 to 64: 14%
65 and older: 1%

Totals may be more than 100% because some categories reported were not mutually exclusive.

Source: U.S.Census Bureau.
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Additional information

Box: Who are the uninsured?

Box: Details behind the number