The ACP Advocate Blog

by Bob Doherty

Monday, October 18, 2010

Record Number of Uninsured, While Millions More Look to the Government for Help

Last month, the U.S. Census Bureau released its annual survey on health insurance coverage. The results were startling, yet few politicians seemed to take notice.

- The number of people with health insurance declined for the first time ever in almost two decades. In fact, as reported by CNN this is the first time since the Census Bureau started collecting data on health insurance coverage in 1987 that fewer people reported that they had health insurance: "There were 253.6 million people with health insurance in 2009, the latest data available, down from 255.1 million a year earlier." The percentage of the population without coverage increased from 15.4 percent to 16.7 percent.

- Almost 51 million U.S. residents had no health insurance coverage at all, a record high, and an increase of almost five million uninsured from 2008.

- Fewer Americans received health insurance coverage through their jobs, continuing a decade-long trend. The number covered by employment-based health insurance declined from 176.3 million to 169.7 million, reports the Census Bureau. Based on the Census numbers, the Economic Policy Institute observes that "the share of non-elderly Americans with employer-sponsored health insurance declined for the ninth year in a row, down from 61.9% in 2008 to 58.9% in 2009, a total decline of 9.4 percentage points since 2000."

- More people than ever relied on government programs for coverage and fewer on the private sector. The number with Medicaid coverage increased from 42.6 million to 47.8 million. According to the Census Bureau: "Comparable health insurance data were first collected in 1987. The percentage of people covered by private insurance (63.9 percent) is the lowest since that year, as is the percentage of people covered by employment-based insurance (55.8 percent). In contrast, the percentage of people covered by government health insurance programs (30.6 percent) is the highest since 1987, as is the percentage covered by Medicaid (15.7 percent)."

These are the facts on the ground, folks, no matter how much the politicians choose to ignore them. Without Medicaid and Medicare, many tens of millions more Americans would be without health insurance. Financially-strapped states already are picking up much of the tab of enrolling millions more in Medicaid. And the Great Recession has shown us that most of us are just a lay-off away from losing our health insurance.

The Affordable Care recognizes the unreliability of our current health insurance system and fills the gaps. If it is allowed to be implemented, the ACA would give people who don't have job-based coverage access to subsidized and affordable private health insurance. The federal government would pay the states more for enrolling low-income people in Medicaid (100% of the cost initially, dropping to 90% by 2020); this would be money the states would be able to count on, instead of being buffeted by higher Medicaid costs whenever there is an economic downturn.

The Great Recession should also have taught us that lack of health insurance isn’t someone else's problem, but everyone's concern. The fact that "nearly every demographic and geographic group posted a rise in the uninsured rate" last year shows how vulnerable we all are to losing our health insurance coverage. The Affordable Care Act isn't perfect, but at least it would provide coverage to 95% of all U.S. residents, a far cry from the record number of uninsured in 2009.

Today's question: What is your reaction to the Census Bureau findings and what does this mean for health reform?

10 Comments :

Blogger rcentor said...

Well stated! Many argue that we cannot afford to insure everyone, but one could just as easily make the case that we cannot afford to have increasing numbers of uninsured patients.

The ACA is not perfect, but it does a credible job of trying to address this issue. Of course, without the individual mandate, the bill falls apart.

October 18, 2010 at 2:31 PM  
Blogger ryanjo said...

One of the most ridiculous contentions of the ACA apologists, such as our ACP Advocate, is that it makes sense to extend a government sponsored program such as Medicaid to those presently uninsured. As anyone knows who actually cares for patients in the Medicaid program, it is very broken and dysfunctional. The payment rates are abysmal. In my state, Florida, doctors currently lose money treating Medicaid patients. For an intermediate level visit, Medicaid pays about $24. It is virtually impossible to get a breast mass biopsy approved promptly, and there are no services approved in the first trimester of pregnancy. Most drugs are minimally covered, and there is no guarantee that a patient on chronic medication will be able to obtain a regular supply. Even worse, the state is beginning to enroll some Medicaid patients in private for-profit HMOs, a marriage of the horror of government fiscal waste with the penny-pinching philosophy of commercial managed care. And when benefits are determined by shrinking state budgets, the patient is left short.

But then, maybe I'm just thinking about how government health care works in the real world, not the world of the glorious ACA and its visionaries. Maybe a little math lesson: 95% of Americans covered by nothing = nothing.

October 18, 2010 at 9:08 PM  
Blogger Arvind said...

Health insurance is not the answer. Not having insurance does not mean lack of health care - you are welcome to our practice to see first hand. There are more people on Medicaid that have lack of access to care than the uninsured willing to work out a payment plan with their doctors. Coercion to purchase a commercial product is not the American way, not to mention loss of freedom.

October 18, 2010 at 10:58 PM  
Blogger PCP said...

One can try their best to put lipstick on a pic but in the end a pig it is.
What liberals do not comprehend is that these promises/benefits have associated costs. The are not paid for by some imaginary money tree or by the printing presses of Mr Ben Bernake. These reckless policies have consequences, which when the ay of reckoning arrives will put us all collectively in the poor house.
What we ought to have done is kept the numbers on Gov't insurance constant and make cuts to benefits. Not all the benefits currently delivered under the guise of healthcare is realistically health care. It is vaguely peripherally related and highly profitable for those who deliver it. There is ample room to reduce expenses. That then would have lowered the costs in the private sector, hence making insurance MORE affordable for those in the privage sector and reduce the "rationalization" for more Gov't reach into the system.
While at the same time address our country's dangerous march to insolvency.
The "need" will always be there. It has existed from biblical times and will exist 1000 yrs from now. It is insatiable. That is not a rationale for financial suicide.

October 18, 2010 at 11:24 PM  
Blogger Steve Lucas said...

I can understand the attraction of universal coverage, and we as a country have made insurance a prerequisite for treatment, but the real issue is treatments and outcomes.

Recently the government has started a program for high risk patients who are unable to get insurance. The government has been disappointed at the response as they saw a need, but yet people have managed to receive care. We all know people who are being treated by doctors at reduced, or no fees at all, for chronic conditions.

The Oct. 10, 2010 WSJ blog post by Katherine Hobson highlights the issue of outcomes and cost in the US:

“You’ve probably heard that while the U.S. spends a whole lot of money on medical care, our citizens aren’t healthier than in other countries that spend far less.
In fact, a new study published online in Health Affairs finds that fifteen-year survival rates for U.S. 45- and 65-year-olds declined from 1975-2005, relative to a dozen other developed countries. The survival rate for 45-year-old women is now the lowest among those countries.”

After reviewing a number of the common concepts for health care spending and the resulting issues such as obesity, car accidents and others we find this:

“In addition, the authors note that when health care eats up an ever-greater portion of the federal budget, funding for other programs that might improve survival — public-health efforts, education and community-development programs — gets squeezed out.
Moreover, the fee-for-service structure of the system, combined with an emphasis on specialty care, may not only boost spending but also lead to unnecessary procedures and perhaps “secondary complications.”

My own experience has been that I have had, on a number of occasion’s doctors and nurses block the door and state:

With your insurance we need to medicate you so we can get you in here more often.

My job is to maximize your insurance.

With your insurance I should have the right to force you into a hospital until I have completed all the test I determine are needed.

The list does go on.

Input does not equal outcome. Insurance for all will not solve our lagging medical standing in the world community. We need to see a return to a doctor/ patient relationship. Currently the system is biased towards gaming the insurance companies, as noted on one recent blog, where a doctor outlined how to bill without seeing a patient.

As the old song goes:

Hey children what’s that sound
Everybody look what’s gong down.

Steve Lucas

October 19, 2010 at 7:59 AM  
Blogger Jay Larson MD said...

The results of the Census Bureau are not unexpected. The trend for more Americans to be uninsured will proceed on its current path so long that insurance companies continue to cherry pick and the health care industries continue to have gluttonous appetites.

October 19, 2010 at 2:40 PM  
Blogger David said...

We'll have to wait and see how the rapid shift to national Medicaid works out. In the meantime, here in Michigan we are seeing Medicaid patients at our local Free Clinic (for free) because they can't find a provider to treat them, including the local county health department. I don't think Obamacare will be driving our Free Clinic out of business anytime soon.

October 22, 2010 at 9:02 AM  
Blogger The Unseen Patient said...

Living Without Health Insurance

The line formed long before the doors opened. The National Association of Free Clinics had organized a one-day medical clinic in Little Rock, Arkansas to provide free care for anyone without health insurance. I traveled from Boston to volunteer.

Having practiced primary care medicine for 40 years, I was assigned to triage the waiting line. By 9AM, 150 people stood patiently. The clinic opened at 10AM. I walked among the crowd introducing myself and asking how we could help. When the clinic ended at 10PM, we had treated 1046 people.

Most of those waiting had not seen a doctor in two years. For some it was more than five years. A few had seen a doctor but could not afford to fill the prescription. More than three quarters of the patients were either self-employed and could not afford insurance or their job did not provide health benefits.

In the first hour, I could not find anyone with a diastolic pressure less than 100.

A previously self employed plumber with below knee amputation came hoping we could help obtain a prosthesis. His medical insurance denied his request, sinking hopes to walk again, return to his job and support his family.

A woman treated for cancer two years ago but unable to continue without insurance, grimaced with the pain. But it was an abscessed tooth not the cancer causing the pain.

On the edge of the line, an emaciated frame hidden in a trench coat was a woman who had three seizures in two weeks. A week ago, an emergency room discharged her after stating that her medication was “OK”. The seizures had fractured all her teeth and could not eat.

Another woman was panting after walking a half a block to get in line. She had not had asthma medication for six months.

Behind her was a 30 y/o year old man with labored breathing. He was diaphoretic; hiis voice weak. He had just been discharged from intensive care after being treated for “fluid in my legs”. He did not understand, and could not afford his discharge medications. He did not know why his legs had swollen or why it had recurred. For a month he had chest pains walking a block and slept propped on pillows to prevent shortness of breath from awakening him.

An hour after I had brought him to the front of the line, the EMTs were taking him back to the emergency room with a possible heart attack. Why had he not been evaluated for unstable coronary disease before discharge? Could it be that he had no health insurance?

A depressed appearing young man avoided eye contact. His slouched posture signaled he did not want to talk but had something heavy on his mind. Later, I learned that the clinic had averted the suicidal plans of three young people. Clearly, he was one. What would have happened if there was no free clinic?

Through the day patients repeatedly remarked “I don’t have insurance. I don’t have a doctor, I don’t have health care”. I had seen patients with this burden of illnesses but that was before Medicare in my first year of medical school.

Now forty years later I saw patients excluded from the medical advances of the past 4 decades because they were living in the pre-Medicare era because they had no insurance. I was overwhelmed. Believing that health care is a right for all citizens, that day I promised to volunteer at all future free clinics.

Since Little Rock, I have volunteered at free clinics in Kansas City, Hartford, Atlanta, Washington, DC and New Orleans. More 10,000 patients have been treated and provided follow-up. The refrain “I don’t have insurance, I don’t have a doctor, and I don’t have heath care” has been echoed in all clinics.

Tell me that we do not need health reform!

It is not a question of cost because we already pay for the uninsured when they are deathly ill. It is a question of equality. It is a question how we see the 50,000,000 fellow citizens who go to bed and awaken praying they do not become. How we see ourselves.

Ralph B Freidin, MD http://theunseenpatient.blogspot.com

October 24, 2010 at 8:56 PM  
Blogger ryanjo said...

We all want health care available to everyone, as Dr. Freidin expresses. But as I said in my comment above, I won't be satisfied with a program that pretends to be reform and ends up the same as other government-created messes. The only difference between the patients that Dr. David & Dr. Freidin see and ours are that ours say "I don't have health insurance, I have Medicaid".

October 25, 2010 at 9:07 PM  
Blogger PCP said...

I rather take care of most of the unfortunate and circumstantial uninsured and work within their meager budgets than many of the entitled folks within medicaid.
There is a huge difference in their attitudes.
All of us have a human side and most of us provide some charity care, we just don't appreciate the Gov't jawboning us into doing it for a pittance to an entitled recipient.
This is something many doctors will tell you in private. This is also something those outside of Medicine like Bob cannot understand/comprehend.
Those of us who have witnessed how attitudes/expectations of the public have changed over the years are well aware of this issue.

I repeat myself to "the unseen patient" ............the need out there is not a rationale for our collective financial suicide as a nation. Those who clearly think this issue through will realise the solutions albeit imperfect, lie elsewhere.

October 27, 2010 at 5:45 PM  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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