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May 02, 2006

The Uninsured: A Primer

By Kate

Ezra has kindly invited me to be the purveyor of all things health care while he sits by the beach all week in Orange County.  The creeping Kansas humidity has never seemed better...

It's Cover the Uninsured Week, sponsored by the Robertwood Johnson Foundation, the health advocacy behemoth.  They've set up a fairly good website replete with the standard facts, figures, and photos of a guy with an eyebrow piercing (the pierced need health care too!)

I've been thinking deeply about health care for quite awhile.  More than that, I've been talking to people about health care for quite awhile.   Again and again in these conversations, people assert a handful of truths about the uninsured that couldn't possibly be true together: the uninsured are all lazy and poor, the uninsured can afford health care but they don't want to pay for it (which sure works well with that poor meme), the uninsured get health care for free whenever they need it, and because of this, they really aren't a problem serious enough to seriously address. 

Now, because you're all faithful Ezra Klein readers, I know you would never peddle these lies to me should I run into you at a bar or a bar-b-que.  But in honor of Cover the Uninsured week, because you can never stress this stuff enough, I've made a nifty bullet point guide about the uninsured.  So you can funnel your inner health wonk when those less informed go on their usual health care diatribes.

• There are 46 million uninsured people in this country.  The number is increasing; it's jumped six million in the last five years.

• Nearly 20% of the uninsured are children; this problem persists in the face of numerous programs to alleviate it.  That's not because people are too lazy to sign up, but rather the strange cost-sharing mechanisms between the states and federal government encourage both to shirk their responsibilities (peek here at a recent Texas rule change that's bleeding participants).

• The uninsured do not receive free care whenever they want.  The only care hospitals are required to provide by law is life saving measures and/or births.  And providers are blessed by the law to release the debt hounds among those who can't pay for these procedures.

• Only 60% of all employers provide health care; it's also becoming increasingly difficult to secure coverage from one's employer.  That's a 9% drop in just five years.

• Speaking of employment, over 80% of the uninsured work or belong to working families. 

• Two thirds of the uninsured are from low-income families.

Our health care safety nets are failing.  That's because they originated as programs to help widows and their children in the thirties; the current complex network of eligibility requirements exclude millions.  A study released last week found that over 40% of the uninsured delayed needed medical care because of cost last year.  Ignoring this problem won't make it go away.  And as the growth of health costs shows no signs of stopping, more and more people will be forced to check that "uninsured" box. 

May 2, 2006 in Health Care | Permalink


Okay, got it... Now could we get a bullet point guide to the insured? I actually think the thing people don't get is a picture of the complexity of the insurance picture. Who's covered, how well (and how badly), and how the safety net isn't really a safety net. I think it would help.

Just a suggestion.

Posted by: weboy | May 2, 2006 11:17:24 AM

good idea...I'll work on that one

Posted by: Kate | May 2, 2006 11:36:36 AM

If there is no such thing as the existence of people who can afford to purchase health care, but otherwise decide not to, than how to we explain the need for an Individual mandate in the recent Massachusetts health care bill?

Posted by: Dustin | May 2, 2006 11:37:57 AM

Dustin, there are, and that's why I'm in favor of mandates. But they don't account for most of the uninsured by any means.

Posted by: Kate | May 2, 2006 11:46:49 AM

Actually Dustin, it's more complicated than that. The MA Bill was held up in the House until the adoption of the so-called "affordability clause," a line stipulating that the individual mandate only applies to those for whom it is "affordable" to follow. As affordable is yet to be defined, no one knows what it means. But the reason for its inclusion is that families above 300% of the poverty line often find insurance for four too heavy a drain on total income, which is why, though employed, some folks remain uninsured: because they're priced out.

Posted by: Ezra | May 2, 2006 11:57:30 AM

Here's an example of what could happen if you are uninsured:

I recently had a diagnostic procedure (a colonoscopy) performed - recommended for all over 50 to prevent colon cancer, a major killer. The hospital charge for the procedure was over $3,000, not including the physicians charge (which hasn't arrived yet - probably above $1,000 (more than one person on the team). I was in and out of the hospital in about 2.0 hours, half of this time waiting or being prepped to leave.

If someone is uninsured, they probably can't afford this procedure and won't get it. Some of these people will get colon cancer and cost tens of thousands of dollars - either paid by the family (through debt) or possibly Medicaid.

Does it make sense to say that this life-saving procedure isn't financially available to those on low incomes?

Posted by: JimPortlandOR | May 2, 2006 12:26:53 PM

A good diary on dKos today:

"Trying to make tweaks to the current system is really doomed for failure," said Dr. Denis Cortese, Mayo's [Mayo Clinic] chief executive and president. "There really is no system of health care in this country now."

Posted by: JimPortlandOR | May 2, 2006 12:38:03 PM

All true points...
There is no such thing as free healthcare. Though someone may be seen for an emergency in a city hospital, you can rest assured that when they are discharged they will be met with a bill. Jim makes a good point ---screening modalities ie colonscopy not only would be benficial to the patient but to the healthcare system. Though this procedure is pricy its just the tip of the iceberg compared to treating someone with advanced colon cancer.
For people truly in need...there are usually programs around to help, if not federal, then state or local. Now 'truly in need' can be bizzare thing. I had one patient...50 y.o man not currently working and living with his son. Well the local agencies would not provide funding because they felt 'living with the son' meant the son would flip the bills. This is not realistic (especially in the inner city where most of my patients are located) to other family members who are just barely getting by to go into debt to assist each other. So the agencies recommended that the father move to a shelter on his own. This happened and he received local 'insurance'. Now some will say why wasn't this 50 year old working??? Good question. This isn't the norm as reported by Kate above. Most of the uninsured do work. But their work situations are such that they are not provided healthcare. How can we motivate the workplace to reverse its trend of dumping healthcare coverage for its employees?

Posted by: Joel | May 2, 2006 1:46:17 PM

A similar point to JimPortland's above: Having the uninsured get medical care primarily from ERs is very inefficient and expensive. A common scenario is that a medical condition gets neglected (due to lack of insurance, and thus access to primary health care) until it becomes a crisis. The patient then presents to the ER, which has to perform expensive emergency treatment, which may not work. For example, untreated simple tooth infections can lead to endocarditis, a very serious heart infection, that can cause permanent heart damage. These are terrible outcomes for both the patient, and for society (which has to shoulder expenses that might not have been necessary with prompt treatment).

Posted by: Rebecca Allen, PhD, ARNP | May 2, 2006 2:03:03 PM

I have a friend who straddles both sides of these equations. He has been diagnosed with a medical problem that would be cheaper to fix now, but he doesn't have insurance and so he can't afford to get it fixed until it becomes a real problem with much greater costs, both to him personally and to 'the system.'

On the other hand, as long as I have known him he has had trouble keeping a job, both because he has horrible social skills and is quite lazy. I believe he is currently unemployed.

I have no idea if he qualifies for any government assistence (he probably does) but he is either too proud or too lazy (or both) to take advantage of that.

I have no idea how representative he is of the populace, I merely offer him as one example.

What we should do with such a case is sort of tough I think. On the one hand, it would be cheaper and easier for us, and for him, to ensure that he had medical care. On the other hand, do we really want to reward his behavior?

Personally of course I would love to see him get care. I can't deny though that a lot of his problems are of his own making. He has had plenty of chances in life.

Posted by: Dave Justus | May 2, 2006 4:09:11 PM


One important thing to add to your scenario is that the ~$4,000 bill was what the insurance company got billed. Individuals routinely get billed up to 4 times as much as insurance companies.

Instead of imagining how hard it would be to pay $4,000 out of pocket, think about $8,000 or possibly $16,000.

That's why all of this talk about "returning the power" to the consumers is so much bullshit. Individuals have absolutely no bargaining power.

Posted by: Stephen | May 2, 2006 4:27:21 PM

What we should do with such a case is sort of tough I think. On the one hand, it would be cheaper and easier for us, and for him, to ensure that he had medical care. On the other hand, do we really want to reward his behavior?

Data is not the plural of anecdote.

Further, with any kind of social spending or social insurance program, you're always going to "reward" some of the "unworthy". The question to be answered is whether the program has positive net outcomes, not whether it meets some particular definition of "rewarding only the worthy".

Posted by: paperwight | May 2, 2006 6:10:48 PM

Dave, if he's a single man without children under the age of 18, I can almost guarantee you he doesn't qualify for assistance.

Posted by: Kate | May 2, 2006 9:08:49 PM

paperwight : Now if we could get that "question to be answered" engraved in stone at the seats of power. Some net outcomes are much more quickly and easily recognized than others.

Posted by: opit | May 3, 2006 2:29:50 AM


I specifically mentioned that this was just one example and I did not claim to know what proportion of the uninsured he represents.

The question to be answered is whether the program has positive net outcomes, not whether it meets some particular definition of "rewarding only the worthy".

Too much rewarding of the unworthy can itself be a negative net outcome. It is similar in some ways to spending hours getting your kids to properly clean up their room, or just doing it yourself in a few minutes. Doing it yourself would yeild a positive net outcome: the kids room would be clean, you would spend less resources on the problem, and everyone would be happy.

The kids would never learn to clean their own room though.


You may well be right. I don't know all the details of government assisted health care in my state. However, I do believe he qualifies for the Washington State Basic Health program. I don't claim to be an expert.

To some extent it doesn't really matter whether he does or not. I know he has lost 2 jobs that offered descent health care benefits simply because of poor behavior. He has lost other jobs as well, for similar reasons (always with an excuse of course) what health care, if any, they offered I don't know.

Posted by: Dave Justus | May 3, 2006 11:44:25 AM

It is similar in some ways to spending hours getting your kids to properly clean up their room, or just doing it yourself in a few minutes. Doing it yourself would yeild a positive net outcome: the kids room would be clean, you would spend less resources on the problem, and everyone would be happy.

I have to say, this is almost entirely bullshit, because it relies on the notion that the environment in which the "children" are operating is one that actually presents them with meaningful choices and (in this case) support to make the right choices. If you really want to go with family analogies, let's do this one:

The "parent" has 10 children, and requires chores to be done in order for the children to get dinner, but loads the children with so many chores that it's almost impossible to get them all done and still get any sleep. The children still get to eat if they don't clean their room, but that's the only chore they can ignore. One child is just lazy, and doesn't care. The other nine children do care, but mostly, they want to eat and they need sleep occasionally. So, the rooms don't get cleaned. From the outside, it's impossible to tell the difference between the nine who care but simply can't get everything done and the one who doesn't.

The "don't reward the unworthy" folks (in which group I have to include Mr. Justus) would prefer that the room-cleaning be added to the list of chores that have to be done for the children to eat, so that the one lazy child isn't rewarded, and never mind the effect on the nine children who are faced with difficult-to-miserable choices.

Posted by: paperwight | May 3, 2006 12:13:47 PM

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