Why Care About the Uninsured?

Most of us have health insurance coverage, so why care about those who don't? There are several reasons why Americans who have health insurance should worry about the very real costs and dangers we face as a result of living with 46.3 million Americans who don't have health insurance coverage.

A January 2004 report by the Institute of Medicine of the National Academies entitled, Insuring American's Health: Principles and Recommendations illustrates some of the problems and costs resulting from this societal problem. I have provided comments from this report, which appear in italics, interspersed with my own thinking in ordinary type.

On average, people who are uninsured for a full year pay 35 percent of the overall cost of their medical care.

The roughly $35 billion for uncompensated care provided to uninsured individuals is comprised of $23.6 billion in patients' unpaid hospital bills, $7.1 billion in public expenditures for government grant and direct service programs (e.g. Veterans Affairs, Indian Health Services, Health Resources and Services Administration programs, local health departments) and $5.1 billion in free or reduced cost care provided by office-based physicians and through volunteer service in clinics.

One reason for the growing number of uninsured Americans is the rising cost of health insurance. As premiums continue to grow far faster than the all-items consumer price index, employers are forced to pay more, and usually ask employees to pay more as well. Some employees, faced with paying more, discontinue their coverage. Those most able to replace their coverage with a lower cost alternative are the young and healthy. When they leave their group plans for lower cost alternatives, a consequence is that the demographics of the group become a little older and less healthy. The result is those who continue to be covered by the group plan will face even higher costs. Some employers, faced with rising costs, more aggressive competition, or economic difficulties, simply stop offering health insurance coverage. As more people join the ranks of the uninsured, the amount of unpaid hospital and physician bills mounts, leading these providers to increase their charges to the shrinking pool of patients who have insurance and are able to pay them. This leads to higher health insurance premiums and more employees and employers discontinuing coverage, which leads to more uncompensated care, which leads to higher hospital and physician prices, which leads to more uninsured, in an increasingly vicious circle.

Higher uninsured rates in a community can put financial pressure on certain services and institutions. Trauma Center patients are more likely to be uninsured than all hospital patients. The closure of a regional trauma center or reduction in its scope of services puts the health of everyone in the community--whether insured or uninsured--at risk.

Clinicians in community health centers located in areas with high rates of uninsurance report difficulties in obtaining specialty referrals for all of their patients, not just those who are uninsured.

A community's high rate of uninsurance can adversely affect the overall health status of the community. For example, underimmunization increases the vulnerability of entire communities to outbreaks of measles and influenza. Childhood and adult immunization levels are correlated with having health insurance.

On average, uninsured persons use only one-half to two-thirds the number and value of services compared with their privately insured counterparts and are more likely to use no health services at all.

In the last year, 43 percent of working-age adults without health insurance reported that they did not seek a physician's care when they had a medical problem, compared to 10% of those who had coverage all year.

As more American's become uninsured, we are all at greater risk for sickness, even if we have health insurance, because we shop in stores, go to theaters, attend schools or colleges, work in offices or factories, and pray in churches, synagogues or mosques with neighbors who may not be able to afford health care.

The health of a nation's populace is part of the nation's wealth. The poorer health and shorter lifespan of uninsured people can be thought of as "health capital" lost to the nation. The nation loses some $65 billion to $130 billion in health capital each year.

Uninsured people are more likely to receive too little medical care and receive it too late; as a result, they are sicker and die sooner.

Uninsured adults have a 25 percent greater mortality risk than adults with coverage. About 18,000 excess deaths among people younger than 65 are attributed to lack of coverage every year. This mortality figure is similar to the 17,500 deaths from diabetes and 19,000 deaths from stroke within the same age group in 2001.

Uninsured car crash victims were found to receive less care in the hospital and had a 37 percent higher mortality rate than privately insured patients.

Uninsured individuals with diabetes, cardiovascular disease, end-stage renal disease, HIV infection, and mental illness have consistently less access to preventive care and have worse clinical outcomes than do insured patients.

Uninsured women with breast cancer have a risk of dying that is between 30 percent and 50 percent higher than for insured women.

If common childhood conditions such as asthma, anemia and middle-ear infections are left untreated or improperly controlled -- which can happen if a family lacks insurance -- they can affect mental and language development, school performance, and hearing.

In 1996 and 1997, 15 percent of uninsured pregnant women never went to the doctor before giving birth, compared with four percent of women with private or public coverage.

As Americans compete more often with workers throughout the world, and with countries that have much faster population growth than our own, the added costs of sickness, reduced productivity, and death make our nation and our employers less competitive, less able to keep up in the global marketplace. Increasingly as a society, we bear the costs of the uninsured through higher medical charges. These costs are higher than they would be if we treated the problems at an earlier less costly stage. For example, untreated diabetes leads to expensive hospitalizations and can lead to blindness, circulatory disease and heart disease that could be prevented or minimized with regular medical management of the disease. The uninsured are less likely to get this critical but routine care. These costs, some of which could be avoided, lead to higher health insurance costs for those who are insured, make insurance less affordable to more individuals and businesses, contribute to a greater need for governmental services, and lead to higher absenteeism and lower productivity at work, making our national economy less resilient and our employers less competitive.