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. Illustrations by Kate Forman In this issue From the CEO / LettersHeart and soul Good bone structure Big Idea: The code breakers Moving forward Noteworthy 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:
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.
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.
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.
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. 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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Copyright © Emory University, 2004. All Rights Reserved. Send comments to the Editors. Web version by Jaime Henriquez. |