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Imagine a country where for at least part of every year one out of three people under age 65 has no insurance to pay for medical treatment. An undeveloped country? No, the United States.



Arthur Kellermann heads the Department of Emergency Medicine at Emory and co-chaired the IOM Committee on the Consequences of Uninsurance with Mary Sue Coleman, president of the University of Michigan. Summaries of the committee's six reports can be found at www.iom/uninsured.


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On Point:
  Insuring America's health
 

by Arthur Kellerman


As an attending emergency physician who works in the Grady Emergency Care Center with Emory medical students and residents, I see firsthand the consequences of uninsurance. My fellow faculty members and I routinely treat patients who suffer from the lack of preventive or primary care. We diagnose conditions that would have been far simpler and less costly to treat if they had been identified and managed sooner. Patients tell us that they were fired or lost their jobs when they developed a medical problem because their employers feared that their health insurance costs would increase. Every one of us has looked into the tear-streaked eyes of family members who are not only worried about their loved one's survival but the high cost of the inevitable medical bills.

Grady is but a snapshot of the fallout from uninsurance for all Americans. Forty-three million people in this country don't have health insurance -- a number greater than the combined population of 26 states.

For the past three years, I co-chaired a committee appointed by the Institute of Medicine (a part of the National Academies of Science) and charged with studying the costs and consequences of uninsurance. Out of this large body of work, four observations stand out:


Contrary to widespread perception, most uninsured Americans have steady jobs or are members of a family in which someone works. The vast majority of the uninsured hold low-wage jobs with employers who either cannot afford or choose not to provide health insurance. Young adults and employees of small firms are more likely to be uninsured, as are immigrants and minorities.

Most of the uninsured have no choice. For example, a family of four earning $36,000 per year (roughly twice the federal poverty level) would have to pay $9,000 per year to purchase family coverage without an employer subsidy. After they pay for food, rent, utilities, gas for the car, and clothes for their kids, few of these families can afford to allocate 25% of their annual income to health insurance.


People without health insurance don't receive the care that they need. They and their families suffer as a result. The uninsured tend to be sicker and die younger than people with health insurance. They skimp on health care services and often forgo preventive care, such as blood pressure and cancer screenings, annual checkups for their children, and routine care of chronic conditions such as diabetes and heart disease. Frequently, they can't afford needed prescription drugs. As a result, when problems are finally detected, they are often more costly and difficult to treat.

Uninsured families live in constant fear of economic catastrophe if a family member sustains a serious injury or develops a life-threatening illness, such as cancer or heart disease. When even one member of a family lacks health insurance, the entire family is at risk for the consequences of unpaid medical bills.

At Grady, my emergency medicine colleagues and I see this drama played out hundreds of times each week. Every year, tens of thousands of uninsured, working-class citizens turn to us for care because they can't get appointments in more traditional ambulatory care settings, because they can't get their medicines filled in a timely manner, or because they waited too long before seeking care, hoping that their symptoms would resolve on their own. When they finally come in, their condition is more advanced and may be incurable.


The fact that millions of Americans lack coverage has adverse effects on the health and security of entire communities. High numbers of uninsured people harm the financial stability of a community's health care providers and institutions, and therefore compromise the services that both the insured and uninsured need. This is particularly true for providers of vital community services such as trauma and emergency care, and those who focus on public health or the treatment of low-income patients.

For example, Grady is struggling to control a $30 million deficit brought on by steadily rising demand for services and falling levels of local, state, and federal support. If Grady closes or significantly scales back its programs, metropolitan Atlanta will not only lose its only public hospital. It will also lose its only level 1 trauma center, level III neonatal intensive care unit, one of our nation's best sickle cell centers, a world-class infectious disease and HIV/AIDS program, one of two burn units in the state, the state's only poison control center, and a top teaching hospital for the Emory and Morehouse schools of medicine.

Likewise, because DeKalb and Fulton county health departments must allocate scarce funds to provide medical care to the uninsured, they have fewer resources to meet the traditional public health missions of restaurant inspections, rat control, tuberculosis control, immunization, epidemiologic investigations, and emergency preparedness.

When a doctor in rural Georgia gives up and moves away because the costs of uncompensated care are too great to sustain his or her practice, everyone in the community loses access to medical care. Likewise, when specialists such as neurosurgeons or orthopedic surgeons stop taking ER call at private hospitals throughout the state because of the high costs of liability coverage and uncompensated care, access to care is compromised for insured and uninsured alike.


The high rate of uninsurance saps the economic vitality of our nation. Taking the same "health capital" approach used by federal agencies to calculate the economic costs versus benefits of other public policy interventions, our committee estimated that poorer health and premature deaths of uninsured people cost this country $65 billion to $130 billion annually.

In light of these consequences and staggering costs, the status quo is simply unacceptable. This is why my committee calls on Congress and the president to immediately develop and implement a comprehensive strategy to achieve universal health insurance coverage by 2010.

Further delay will only lead to more uninsured Americans forgoing care, resulting in more costly illnesses and more premature deaths. Further delay will harm the health of uninsured children, and strain and potentially bankrupt more American families. Further delay will only worsen the financial stress felt by key health care institutions and providers, and quite possibly jeopardize access to care for the 220 million Americans who currently have some sort of health insurance, as well as the 43 million who don't.

Incremental approaches will not solve the problem. A major policy effort at the federal level will be required to ensure that everyone has access to health insurance. The committee proposed five principles to guide this effort.

  • Health care coverage should be universal. Everyone living in the United States should be covered.
     
  • Health care coverage should be continuous. Continuous coverage is more likely to promote better quality care and to result in better health outcomes than coverage that is erratic or inconsistent.
     
  • Health care coverage should be affordable to individuals and families. The high cost of health insurance is the main reason people give for failing to purchase coverage. Because low-wage earners are more likely to be uninsured than people with higher incomes, a significant subsidy will be needed to make health insurance affordable to them.
     
  • The health insurance strategy should be affordable and sustainable for society. The cost of extending coverage to everyone will likely be substantial. It will require mechanisms to control costs and encourage appropriate utilization.
     
  • Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, safe, timely, patient centered, and equitable. The IOM's groundbreaking 2001 report, Crossing the Quality Chasm, supports this recommendation, as do studies that show that insurance which includes preventive and screening services, outpatient prescription drugs, and mental health care is more likely to lead to appropriate treatment and better health than coverage that omits these services.
  • Our committee used these principles to evaluate four generic prototypes for extending coverage, such as tax credits, expansion of existing public programs, adoption of an employer mandate, and the single-payer option. Any of these strategies would be better than the status quo. However, endorsing a specific strategy or blueprint for achieving universal coverage was not within the purview of our committee.

    It will be impossible to achieve universal coverage overnight, no matter how urgent the problem may be. In light of this fact, we strongly recommend that federal and state governments continue to provide sufficient resources for Medicaid and the state Children's Health Insurance Program to cover everyone who is eligible and stop the erosion of outreach efforts, eligibility, enrollment, and coverage. We also recommend adequately funding key "safety net" providers, including public hospitals like Grady and academic medical centers like Emory, until universal health insurance is a reality.

    Imagine what our country would be like if everyone had coverage. This is a reality in much of the industrialized world. It should be a reality here as well. It is time to insure America's health.


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    Web version by Jaime Henriquez.