Reforming health care for the uninsured

By Michael J.W. Stickings

There are any number of good reasons to reform the health-care system. It should go without saying that one of them -- and, for me, perhaps the most pressing one -- is the appalling number of Americans who on the outside of the current system: the uninsured. (There are many, of course, who have inadequate coverage, and who must rely on their private insurers to sign off on treatment, that is, to determine whether the cost is worth it. This profit basis of the current system is similarly appalling. Millions and millions of Americans don't have choice but are left to the mercy of HMOs, unable to get the care they need.)

The problem is, the uninsured are a largely neglected group. Opponents of reform don't seem to care that millions and millions of Americans don't have coverage and don't have any hope of acquiring it, spinning the lie that the uninsured simply don't want to be insured. And when what matters in Washington is money -- who has it, who uses it to lobby most effectively, and who can buy off decision-makers and fix the system around their own interests (mostly to maximize their own already enormous profits) -- the uninsured just don't have enough clout, even collectively, to make a difference, their voice -- and their concerns -- drowned out by the symbiotic clamour of industry and government. It's like why no one seems to care about the homeless, or about Africa, or about any other group, constituency, or interest that doesn't have what it takes -- money and/or votes -- to buy access and influence in Washington.

Which brings me to an editorial on "The Uninsured" in today's New York Times, which should be applauded for saying what should go without saying but that needs to be said over and over again:

No matter how you slice the numbers, there are tens of millions of people without insurance, often for extended periods, and there is good evidence that lack of insurance is harmful to their health.

Scores of well-designed studies have shown that uninsured people are more likely than insured people to die prematurely, to have their cancers diagnosed too late, or to die from heart failure, a heart attack, a stroke or a severe injury. The Institute of Medicine estimated in 2004 that perhaps 18,000 deaths a year among adults could be attributed to lack of insurance.

The oft-voiced suggestion that the uninsured can always go to an emergency room also badly misunderstands what is happening. By the time they do go, many of these people are much sicker than they would have been had insurance given them access to routine and preventive care. Emergency rooms are costly, and if uninsured patients cannot pay for their care, the hospital or the government ends up footing the bill.

So how many uninsured people are out there, facing those risks? The most frequently cited estimate, 45.7 million in 2007, comes from an annual census survey. That number was down slightly from the year before, but given the financial crisis, it is almost certainly rising again.

Some or even many of those people may have only temporarily lost or given up coverage, but even that exposes them to medical and financial risk. And many millions go without insurance for extended periods.

This isn't just some vague abstraction. 45.7 million is a huge number. What is means is that about one-seventh of the population lacks coverage altogether -- meaning, they lack accessibility to health care (emergency room care is hardly adequate). We're talking about real people -- men, women, and children.

Think about it. It's not just that not having coverage is harmful to their health, it's that they can't do anything about it. What if your child were sick? What if your spouse were sick? What if you were sick and couldn't go to work? What if you had to take care of a sick parent or grandparent? What if the bills were piling up? What would you do if you didn't have coverage? -- not because you opted out, or because you're a healthy young person who chose not to buy coverage, or because you're well off enough to buy care when you need it, but because you're on the outside of the system looking in, without choice and without hope.

It's about time we started thinking about health care far more empathetically than we do now. It's about time we started putting ourselves in others' shoes. If we were uninsured, what sort of system would we want? Surely not the status quo, and surely not the "reformed" system being pushed by industry-influenced insiders in Washington.