TCS Daily

About Those Uninsured Americans...

By Bob Newbell - July 25, 2005 12:00 AM

Over the past several years there has been much discussion in both public policy circles and the media about the plight of those Americans who lack health insurance. "Over 43 million U.S. residents, nearly one in six Americans under the age of 65, lack health coverage," says the website of the nonprofit Institute of Medicine of the National Academies. This or some similar statistic is often used as evidence that there exists a large subset of the country's population that has little or no access to healthcare and that the crisis will only grow worse if some action -- typically government-funded and/or government-mandated healthcare coverage -- is not taken immediately. The facts are somewhat different.

One problem with the 43-45 million uninsured Americans figure is the fact that the statistic is dynamic, not static. "[T]he uninsured population is fluid, with many people gaining and losing coverage," reported the Congressional Budget Office on May 12, 2003, in a brief on Americans who lack health insurance coverage. "Between half and two-thirds of the people who experienced a period of time without insurance in 1998, for example, had coverage for other portions of the year." Thus, the 40-odd million uninsured people in December of a given year are mostly a different group of people from the 40-odd million uninsured from the previous January.

Another problem with the statistic is that it tells us how many uninsured Americans there are, but not who they are. This is an important distinction. A 70 year old with multiple medical problems who lacks health insurance is obviously in a much direr situation than a healthy 20 year old who lacks health insurance. Michael F. Cannon, director of health policy studies at the Cato Institute, looked into the aforementioned report from the Congressional Budget Office to find out just who the uninsured are. He discovered that "the persistently uninsured are mostly young (39 percent are under age 25, and another 22 percent are under age 35) or healthy (86 percent report their health to be 'good,' 'very good,' or 'excellent')."

In discussions about the uninsured, there appears to be a tendency -- in some cases unintentional, in others almost certainly deliberate -- to regard "health insurance" and "access to healthcare" as synonymous. Not having health insurance obviously curtails one's ability to obtain certain medications, office visits, and procedures for fractions of their actual cost since the cost is not defrayed by the premiums contributed by thousands of other policy-holders. But it is inaccurate and misleading to equate health insurance with access to nominal or even emergency medical services.

At my own practice, we frequently see uninsured or "private pay" patients. Some of these patients are working people whose employer does not offer health insurance coverage. A fair number of these patients are small business owners. If asked, most of these people would say that they cannot afford health insurance, but this is simply another way of saying that it makes no financial sense for them to pay an insurance company hundreds of dollars per month in premiums so that the charge for a $55.00 office visit can be reduced to a $25.00 co-pay. While the private pay approach to healthcare carries the obvious risk of great personal financial hardship due to medical expenses in the event of developing a serious medical condition or sustaining a major injury, the unlikelihood of this happening must be weighed against the absolute certainty of having to repeatedly pay out insurance premiums to cover likelier and less costly medical services whose monthly or annual totals will most probably exceed the cost of paying out of pocket for the same services.

A lack of healthcare insurance does not preclude access to emergency medical services; indeed, such access is guaranteed by the Emergency Medical Treatment and Labor Act of 1986 at any hospital taking part in Medicare. While even a brief trip to the emergency room can be tremendously expensive for the private paying patient, relatively few such trips are made. Reuters health and science correspondent Maggie Fox filed a story in October 2004 citing a study that debunks the idea that the poor and uninsured fill America's emergency departments. "Contrary to popular perception, individuals who do not have a usual source of care are actually less likely to have visited an emergency department than those who have such care," said Dr. Ellen Weber, a professor in the division of emergency medicine at the University of California San Francisco, who led the study which was published in the journal Annals of Emergency Medicine. According to the study, 85 percent of patients who visit the country's emergency departments have medical insurance and 79 percent have incomes above the poverty level. Said Dr. Weber, "The mistaken belief that emergency departments are overcrowded by a small, disenfranchised portion of the U.S. population can lead to misguided policy decisions."

None of this should be construed to mean that there is no problem with the delivery of healthcare in America. There are undeniable flaws in our healthcare system that prevent a significant subset of patients from getting the healthcare they require. But such flaws cannot be properly addressed if the problems are defined by statistics that are inflated or considered out of context. Just as an inaccurate set of vital signs or laboratory tests can result in a patient being given an incorrect diagnosis and improper treatment, false assumptions about the extent and character of the problem of uninsured Americans can likewise lead us to spurious remedies.

The author is primary care physician in Alabama. He has contributed to the journal Medical Economics. He recently wrote for TCS about missing the future.


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