healthcare for uninsured
TRANSCRIPT
-
8/14/2019 Healthcare for Uninsured
1/16
The Uninsured in the United States:
Public Healths Response and Responsibility
Mary E. Homan, MA
H. Douglas Adams, PhD
Spring 2007
Saint Louis University
School of Public Health
-
8/14/2019 Healthcare for Uninsured
2/16
Homan, ME 2
For the duration of President Bushs tenure in office, the public and private sector
has been consistently reminded of the draining cost of healthcare to insurers, the insured,
and to those who do business with both. We hear tales of small-business owners
suffering the burden of cost to cover employee health insurance. We hear of middle-class
families and working poor struggling to pay healthcare premiums, co-pays, and other
health-related costs. We hear about the uninsured and the growing faction of
underinsured Americans who cannot pay for chronic prescription medication or to take a
child to see a specialist.
However, not all the evidence is as anecdotal of a family member unable to afford
prescriptions or an impoverished mother not being able to establish prenatal visits. The
literature suggests and policymakers concur that lack of access to healthcare is beyond
troubling; it is a crisis. The National Academies (which include the National Academy of
Sciences, the National Academy of Engineering, the Institute of Medicine, and the
National Research Council) reported in September 2006 that the percentage of
Americans without health insurance in 2005 rose to 15.9 percent, 46.6 million people,
according to the U.S. Census Bureau. The number of uninsured children also increased,
for the first time since 1998, to 8.3 million.(1) The Institute of Medicine estimates that
approximately 18,000 Americans die prematurely each year because they lack health
insurance.
Recognizing such a crisis, this issue paper will seek to parse out the underlying
issue of lack of healthcare coverage as well as the challenges to addressing the issue.
Third, this paper will articulate the public health communitys response to the crisis,
taking into particular consideration the tenuous relationship between notions of justice
-
8/14/2019 Healthcare for Uninsured
3/16
Homan, ME 3
versus notions of fairness especially when public health must make recommendations to
policymakers. Finally, this paper will seek to recommend not an outlined procedure or
legislation as that is beyond the scope of the paper but rather what should be the
objectives of such legislation. In analyzing the issue of uninsured and uninsurability, this
paper will operate out of the four-principles approach to bioethics developed by
Beauchamp and Childress(2) in the 1970s, recognizes four key principles that arose from
reflections on common morality and the medical tradition. Accordingly, the four
principles, autonomy, nonmaleficence, beneficence, and justice, provide a simple,
accessible, and culturally neutral approach to thinking about ethical issues in
healthcare.(3)
The Crisis of Lack of Healthcare Coverage
The single most influential factor contributing to the lack of insurance coverage is
poverty. More than 30% of those at or below the poverty level had no insurance
coverage, a rate double that for the total population. However, it should be noted that
many argue that the current and official poverty measure(4)(5) in the United States is
flawed and does not adequately inform policy-makers or the public about who is poor and
who is not poor, according to a national research panel led by Robert Michael, the
Eliakim Hastings Moore Distinguished Service Professor in the Irving B. Harris Graduate
School of Public Policy Studies.(6) One study points out that persons who border the
poverty line (between 100 and 125% of the poverty line) faced an uninsured rate of
28%.(7) It is this pervasive influence of poverty on the uninsured rate that is so
compelling. A review of other factors contributing to a lack of insurance demonstrates
-
8/14/2019 Healthcare for Uninsured
4/16
Homan, ME 4
that for almost every variable influencing the uninsured rate, the addition of poverty
further increases the rate of the uninsured.(8)
The State of Missouri faces similar challenges. The Missouri Foundation for
Health reports that in 2005, between 635,000 and 707,000 Missouri residents were
without health insurance. In 2004 dollars, the total national value of health lost in a single
year because of lack of insurance is estimated at $104 billion, which represents more than
two times the estimated $48 billion cost of covering all of the nations uninsured.(9)
Economically speaking, the more people are ill, the more work is missed, the less pay is
earned and the lower taxes are gathered.
Women and in particular pregnant women find themselves in a very difficult spot
with healthcare coverage. The number of women in the United States who are uninsured
grew 3 times faster than the number of men without health insurance during the late
1990s and early 2000s.(10) In 2003, it was estimated that of the 45 million Americans
(15.6% of the total population) without health insurance for the entire year, 21.2 million
were women (14.4% of all women).(11, 12) This represents an increase from 2002 when
it was estimated that of the 43.6 million Americans (15.2% of the total population)
without health insurance for the entire year, 20.2 million were women (13.9% of all
women).(13) Approximately 13% of all pregnant women are uninsured.(14) The
following diagram from the Institute of Medicine illustrates pregnant women and infants
lack of coverage.
-
8/14/2019 Healthcare for Uninsured
5/16
Homan, ME 5
The challenges to addressing healthcare coverage
It should be noted that because someone is uninsured or underinsured does not
mean that they are Medicare/Medicaid eligible. Medicare was established as a federal
health insurance program in 1965 under the Social Security Act. This act provided a
hospital insurance program for the with a supplementary medical benefits program. This
expanded program of medical assistance was to increase benefits under the Old-Age,
Survivors, and Disability Insurance System and to improve the Federal-State public
assistance programs. Whereas, Medicaid is a state administered program and each state
sets its own guidelines regarding eligibility and services. Medicaid is a program of health
coverage for certain people with low incomes or very high medical bills where eligibility
-
8/14/2019 Healthcare for Uninsured
6/16
Homan, ME 6
for depends on age, disability or family status and on an individuals (or familys) income
and resources. Although the Federal government establishes general guidelines for the
program, the Medicaid program requirements are actually established by each State.
Whether or not a person is eligible for Medicaid will depend on the State where he or she
lives.(15)
The Missouri Foundation for Health reported in 2005 that Missouri Medicaid
currently covers over 540,000 low-income children and more than 200,000 low-income
adults in families with children. The majority of covered adults in families with children
are women. Children represent the largest demographic group served by Missouri
Medicaid, with nearly 56 percent of all Missouri Medicaid consumers being age 18 or
younger. (16) Missouri Medicaid also covers approximately 74,000 Missourians age 65
and over as well as 140,000 residents who are blind or disabled.
Between 2000 and 2004 Missouri experienced a sharp economic decline.
Missouris seasonally adjusted employment topped out at 2.886 million in December of
2000 and then hit a low of 2.827 million in August of 2003 for a job loss of 59,000.
Employment has since climbed to 2.903 million for a job gain of 76,000 jobs off of the
low. Despite this increase in jobs, it should be noted that in the most recent recession,
Missouri had a 2% decline in employment compared to a national decline of only 1.5%.
Furthermore, despite the fact that Missouri employment is up 2.7% off of the low in
August of 2003, the nation as a whole has experienced an increase of 6.5% in its total
employment since coming off of its employment trough in January of 2002.(17)
During this period of time, the number of people below 200 percent of the federal
poverty level (FPL) increased by 330,000 (194,000 adults and 136,000 children). The
-
8/14/2019 Healthcare for Uninsured
7/16
Homan, ME 7
rate of employer-sponsored insurance (ESI) fell from 71.9% to 64.2% while Medicaid,
SCHIP, and state-sponsored insurance only increasing 3.8%.(18) The Missouri
Foundation for Health reports that a loss of Medicaid coverage because of the 2005
cutbacks in eligibility will likely translate into increases in the number of uninsured
Missourians. The decline in Employer-Sponsored Insurance (ESI) is likely to continue.
Increases in health care costs and thus insurance premiums are likely to continue to grow
faster than workers earnings. The decline in ESI will be further exacerbated if
employment losses in large firms and the shift in employment from high-ESI industries to
low-ESI industries continue. The increased numbers of uninsured will place heavy
pressures on safety net providers throughout Missouri.(18)
Many cannot afford the health premiums of large insurance companies typically
offered by employers. The Kaiser Family Foundation reports that the average annual
premium for an individual was $4,242, while family coverage cost an average of
$11,480. The 2006 poverty threshold for a family of four in the United States was
$20,000.(19) That means over half of the family income would be going towards health
insurance. The US Census Bureau reported in 2004, over 13% of Missourians lived in
poverty. Therefore, at minimum 13% of Missouri residents would have no way of paying
for employer health insurance.
President Bushs healthcare reform plan from the 2007 State of the Union
Address encourages a tax-credit for businesses for employee health insurance. Under
this new plan, the President's proposal levels the playing field for Americans who
purchase health insurance on their own rather than through their employers, providing a
substantial tax benefit for all those who now have health insurance purchased on the
-
8/14/2019 Healthcare for Uninsured
8/16
Homan, ME 8
individual market.(20) The Presidents plan lowers taxes for all currently uninsured
Americans who decide to purchase health insurance.(20) The plan begs the following
questions: Shouldnt all people have health insurance? Why should a low-income family,
who statistically is at greater risk for workplace injury, chronic workplace disease, and
other diseases and illness derivative of lower socio-economic status, be forced to hand
over almost one-fourth of their family household income (under the new plan, workers
would receive a tax deduction $7,500 for singles, $15,000 for couples and families)
because their income would be taxed at $35,000 instead of $20,000.(21) These
unreasonably high costs dont only affect persons of lower-income status. Middle-class
families and working adults will also face an increase in costs especially when searching
for companies willing to cover high-risk occupations (factory line jobs, construction, etc.)
that previously were not as high when employers purchased an employee package.
The other major challenge to uninsured persons aside from lacking healthcare
coverage is going without needed medical services. Uninsured families report the most
financial difficulties accessing care: nearly 25 percent of low-income uninsured families
reported forgone care, and almost 20 percent of uninsured families across all income
groups did so.(22) The Commonwealth Fund found that 54 percent of underinsured
people went without at least one of four needed medical services because of costtwice
the rate of those with adequate insurance.(23) A 2005 Kaiser study found that the care-
seeking behavior of those with private coverage and medical debt was more like the
uninsured than the insured without medical debt: about 28 percent of both the insured
with medical debt and the uninsured postponed care because of costs, compared to six
percent of the privately insured without medical debt.(24) Kathleen Stoll, health policy
-
8/14/2019 Healthcare for Uninsured
9/16
Homan, ME 9
director at the Families USA consumer advocacy group, said 10.7 million insured
Americans spend more than a quarter of their annual paychecks on health care.(25)
In 1999, the Missouri pools average yearly premium for individual coverage was
$4,920 (the highest of all pool states), which is about 12.2 percent of the states median
household income. Also, Missouris quoted rate relative to pool rate is upwards of 300%.
Therefore the premium cap as a percentage of the average comparable plan is 150-200%.
For mental health benefits, Missouri has $25,000 lifetime maximum on benefits allowing
for 30 inpatient days per year, and $3,000 per year for outpatient services.(26)
The following table illustrates reasons why families forgo medical care.
-
8/14/2019 Healthcare for Uninsured
10/16
Homan, ME 10
Responses from the Public Health Community
Diane Rowland, executive vice president of the Kaiser Family Foundation
believes that "States that are using Medicaid to broaden health care coverage are using it
as a foundation to build upon for low-income people, which frees up other ways to make
insurance more affordable. However, as recent as 12 April 2007, the MissouriSenatepassed legislation(27) that would move the state's Medicaid patients into three health
plans, two of which would be administered by managed-care companies. The new benefit
packages would replace the state's existing Medicaid program by 2013. Some critics
argue that Missouri ended Medicaid coverage prior to this bill. Timothy McBride, PhD,
Director, Division of Health Policy and Professor, Department of Health Management
and Policy at Saint Louis University School of Public Health recounts that, they
[Missouri General Assembly] voted in 2005 to end Medicaid as we know it in Missouri.
This [MO HealthNet] would be its replacement.(28)
In replacing Medicaid with MO HealthNet, Missouri is taking advantage of new
federal rules, which took effect last year, that allow states to modify their Medicaid
programs on their own rather than through the burdensome process of petitioning the
federal government for approval.(29) SB577 repeals the June 30, 2008 expiration date
for Missouris Medicaid program. The bill establishes a pay-for-performance system for
doctors and other medical providers. It also introduces healthy lifestyle choice incentives
that work on a debit card system where one is credited for signing health improvement
plans and making healthy lifestyle choices. These credits could be spent on co-payments,
over-the-counter medications, vitamins, and other health-related services. Women age 18
-
8/14/2019 Healthcare for Uninsured
11/16
Homan, ME 11
and older who earn up to 185% FPL ($18,889/yr single woman) can access various
womens health and family planning services but they cannot have access to employer-
sponsored health insurance.(30)
Amy Blouin, executive director for the Missouri Budget Project blasts the
changes in a letter to the editor. She writes that MO HealthNet does not move Missouri
towards universal coverage by not restoring health coverage to the more than 300,000
low-income Missourians whose Medicaid health insurance was cut or decreased over the
past several years. Nor does HealthNet help the more than 700,000 uninsured
Missourians.(31) Other democrat senators agree that a restoration of previous Medicaid
cuts is necessary because to not bring the tens of thousands of people back into
Medicaid is burdensome to hospitals that treat the uninsured in emergency rooms.
Democrats also say the move ensures that Missouri will lose hundreds of millions of
dollars in matching federal funds to other states.(32)
Another bill receiving significant attention addresses insurance portability in
compliance with HIPAA.(33) Rep. Sam Page of the 82nd District feels this bill shows a
movement to protecting high-risk individuals who move from one group health insurance
to another.(28) One insurance broker, Rick Gary, CEO, Equos Financial Group, LLP
points out that the bill is an attempt to make Missouri more compliant with an already
existing statute particularly in cases of pre-existing conditions. Rick Gary suggests that
those who are opposing the bill because it does not impact those who are uninsured.(28)
It only addresses people who have health insurance currently. It does, however, address
high-risk (risk will be assessed by members) individuals and that care is retained for that
30% risk. This means people who typically paid 300% of premiums would pay 150%
-
8/14/2019 Healthcare for Uninsured
12/16
Homan, ME 12
instead. Another opposition comes from insurance companies because the bill does not
address group termination (how can they selectively eliminate group they dont want to
cover; this bill prohibits group health providers to terminate group at will). This bill
protects people who move from one company to another especially a smaller company
because once a person is dropped from group health coverage, obtaining individual
insurance is problematic.
Fellows from the Brookings Institution believe that individual health plans could
work if the individual health plan market were not such a disaster.(21) Much of the mess,
they write, is due to inadequate pooling of risks. Pooling risks means grouping people
with high and low expected health outlays. Pooling makes health insurance affordable
for the average person. The workplace serves that function not ideally but adequately.
Individual health plans cannot serve this function. They also write that the bigger
problem with the Bush plan is that it would not ensure that people would be able to find
insurance at a reasonable price.
President Bushs insistence on privatizing a public good puts millions of healthy
and ill Americans at risk. It places the burden of finding an affordable insurance plan
with adequate coverage on the shoulders of families who are barely making it through the
month. The new plan will force insurers to question every procedure, every office visit,
more so than before. Families will be forced to endure higher co-pays and longer wait
times because so many families will not be able to afford private insurance. With this
plan, less money will go to services such as Medicare and Medicaid which will endanger
seniors, the disable, and the poor.
-
8/14/2019 Healthcare for Uninsured
13/16
Homan, ME 13
Recommendations for Policy Objectives
As discussed in the introduction, this paper will seek to recommend not an
outlined procedure or legislation as that is beyond the scope of the paper but rather what
should be the objectives of such legislation. In naming objectives and goals, it is
pertinent that legislatures and public health practitioners operate out of a sense of justice.
Beauchamp and Childress concede that justice is often equated with fairness or
equality.(2) Another way to look at justice is from the perspective of the common good
and acting in good stewardship. David Hollenbach explains that the common good is the
good of being a community where people work and make choices together about the
direction in which our lives are going to go together.(34) The common good is
understood as the social conditions that allow people to reach their full human potential
and to realize their human dignity. The promotion of the common good involves the
principles already considered: respecting human dignity, protecting the poor and
vulnerable, calling for full and active community participation and practicing good
stewardship. Ideally, the common good enables each and every human person to achieve
his or her human development more fully. The principle of common good is the total of
social living, not just the sum of individual goods.
In order to establish a universal healthcare system that benefits all, administrators,
policymakers, and the general public (to name a few) must operate out of a sense of
social justice and from the operating principle of the common good. We might attempt a
cost-benefit analysis pertaining to prenatal women that might prove when women receive
prenatal visits they are at a lesser risk of delivery problems as well as a greater chance of
appropriate birth weights, etc. Limiting services based on cost alone needs to be
-
8/14/2019 Healthcare for Uninsured
14/16
-
8/14/2019 Healthcare for Uninsured
15/16
Homan, ME 15
References:
1. Pickoff-White L. Number of Uninsured Americans Up. In: Sciences NAo, ed.:Office of News and Public Information; 6 September 2006.2. Beauchamp TL, Childress JF. Principles of Bioethics. 4th ed. New York: OxfordUP; 1994.
3. Gillon R. Medical Ethics: Four Principles Plus Attention to Scope. BMJ;309:184-90.4. In the 1960s, Molly Orshansky, an employee of the Social SecurityAdministration, developed the original poverty thresholds by using the U.S. Departmentof Agriculture's Economy Food Plan, which she used to estimate a family's minimumfood needs. In 1955, Orshansky had determined that most families spent approximatelyone-third of their after-tax income on food. Therefore, the Economy Food Plan forvarious family sizes was multiplied by three to determine the poverty threshold figures.5. Poverty at Issue. University of Missouri Extension. (Accessed 6 November 2006,at http://outreach.missouri.edu/cfe/quiz/1a.htm.)6. Harms W. Poverty definition flawed, more accurate measure needed. University
of Chicago Chronicle;14(17).7. Census UBot. Health Insurance Coverage in the United States: 2002. In;September 2003.8. Trotochaud K. Ethical Issues and Access to Healthcare. Journal of InfusionNursing 2006;29(3):165-71.9. Consequences of the Lack of Health Insurance on Health and Earnings: MissouriFoundation for Health; January 2006. Report No.: 1.10. Labrew J. Diagnosing disparities in health insurance for women: a prescription forchange. New York: The Commonwealth Fund; 2001.11. DeNavas-Walt C, Proctor B, Mills R. Income, poverty, and health insurancecoverage in the United States:2003. In: Bureau USC, ed.; 2004.12. 2004 annual social and economic supplement. Current Population Survey. In:Bureau USC, ed.; 2004.13. Mills R, Bhandari S. Health insurance coverage in the United States: 2002.Consumer income. Current Population Reports. In: Bureau USC, ed.; 2004.14. Thorpe K, Flome J, Joski P. The distribution of health insurance coverage amongpregnant women, 1999.: March of Dimes, Emory University April 2001.15. Medicaid at a glance 2005: a Medicaid information service. In: Department ofHealth and Human Services CfMMS, Center for Medicaid and State Opportunities, ed.;2005.16. Missouri Medicaid Basics 2005: Missouri Foundation for Health Winter 2005.17. Economic Forecast 2006 3rd Quarter: Bureau of Economic Research, College ofHumanities and Public Affairs, Missouri State University; 2005.18. The Missouri Economy and Changes in Health Insurance Coverage, 2000-2004:Missouri Foundation for Health; March 2006. Report No.: 3.19. Pugh T. Bush moves to expand health insurance by revising tax code. McClatchy-Tribune 22 January 2007.20. The 2007 State Of The Union Address. In: Communications WHOo, ed.; 2007.21. Aaron HJ. The healthcare three-step. Los Angeles Times 10 February 2007.
http://outreach.missouri.edu/cfe/quiz/1a.htm.http://outreach.missouri.edu/cfe/quiz/1a.htm. -
8/14/2019 Healthcare for Uninsured
16/16
Homan, ME 16
22. Blumberg LJ, Clemans-Cope L, Blavin F. Lowering Financial Burdens andIncreasing Health Insurance Coverage for Those with High Medical Costs: UrbanInstitute; 2005 19 December 2005.23. Schoen C, Doty MM, Collins SR, Holmgren AL. Insured but not protected: howmany adults are underinsured? Health Affairs 14 June 2005;Supl Web
Exclusives:w5.289.24. Hoffman Cea. Medical Debt and Access to Health Care: Kaiser Commission onMedicaid and the Uninsured 23 September 2005. Report No.: 7403.25. Karash JA. Report finds insurance coverage inadequate: Even those who areinsured struggle making medical payments. The Kansas City Star (MO) 23 March 2007.26. Achman L, Chollet D. Insuring the Uninsurable: An Overview of State High-RiskPools. New York: The Commonwealth Fund August 2001.27. Enacts the "Missouri Health Improvement Act of 2007". In: 2227S06P. 94thGeneral Assembly ed; 2007.28. Homan ME. personal communication. In: Timothy McBride P, Director, Divisionof Health Policy and Professor, Department of Health Management and Policy at Saint
Louis University School of Public Health, ed.; 2006-2007.29. Lopes G. States tailor Medicaid to meet individual needs. The Washington Times12 April 2007.30. A look at Medicaid overhaul legislation. The Associated Press 11 April 2007.31. Editor Ltt. Blunts HealthNet plan does nothing to aid the uninsured. TheColumbia Tribune 16 April 2007.32. Rosenbaum J. HealthNet garners vote by senators: Revamped Medicaid advancesin House. The Columbia Tribune 12 April 2007.33. Establishes the Missouri Health Insurance Portability and Accountability Act andchanges the laws regarding the Missouri Health Insurance Pool, prescription drugformularies, and claims information. In: 1261L05P. 94th General Assembly ed; 2007.34. Higgins RJ. Interview with David Hollenbach. Boston College Magazine;Summer2002.35. Insuring America's Health: Principles and Recommendations. Washington, D.C.:Committee on the Consequences of Uninsurance. Institute of Medicine; 2004.