Sabrina Eagan and Danielle Olds
~Martin Luther King, Jr.
After completing this chapter, the reader should be able to:
1) Identify special sub-populations of uninsured
2) Understand key players and trends within national safety net.
3) Explain health effects/consequences of lack of coverage to uninsured.
4) What factors or circumstances cause uninsurance or underinsurance.
5) Outline myths and misconceptions of public opinion.
6) Describe current policy in effect.
1) Public opinion/knowledge of uninsured situation
2) Reasons/circumstances of uninsured or underinsured status
3) Health consequences of uninsured
III) Safety Net
A) Key players
1) Community Health Centers
2) Public hospitals
3) Emergency Departments
4) Private, non-profit organizations
B) Current trends/problems within the informal safety net system
B) Chronic illness
D) Mental illness
E) Racial minorities
F) Medically indigent
G) Elderly, 55-65 years old
A) Tax credit and current policy
B) Support of safety net
1) address Medicaid managed care
2) curb decreasing federal subsidies
3) federal oversight for integration and efficiency
C) State Health Programs(Oregon Health Plan and Tenncare)
D) Universal health care plan
According to the United States Census Bureau, 41.2 million Americans or 14.6 percent are without health care insurance, compared to 14.2 percent or 40.1 million in 2000. Of this uninsured population, 28.2 percent of them are children and the majority of the population is low income minorities. Furthermore, these numbers would be higher if not for the public programs of Medicaid and State Children Health Insurance Program(SCHIP). Another concern is that of the partially insured or underinsured. In 1995, sixteen to nineteen percent of insured people were underinsured, meaning that they had decreased access to care and an increased risk of out-of-pocket expenses (Stroupe, Kinney, & Kniesner, 2000). In total, 91.1 million or almost one third of the people in the United States are uninsured or underinsured. The number of uninsured and underinsured is predicted to increase in the future. It is estimated that by 2008, there will be 55 million Americans without health insurance (Higgs, Bayne, & Murphy, 2001). In light of the economy and aftershocks from September 11 attack some experts predict that at least 6 million more Americans will lose their health insurance by the end of 2002.(Kellermann, 2001). With the recent economic decline causing a decrease in employer coverage of health care and market pressures raising health care cost and insurance premiums, the number without health care insurance may continue to rise.
Due to consequences of their insurance status, this growing population of Americans is more likely to suffer from a variety of adverse health outcomes. Several studies have outlined the consequences of inadequate health care compared to the insured that includes: not seeking necessary health care as often as insured clients, lack of preventive care, diagnoses of malignancies at more advanced stages, more acute care and hospitalization needed for preventable illnesses and complications, and higher mortality rates (Saha & Bindman, 2001). These health and shifting financial burdens affect not only the individuals, but their families and community.
As awareness has increased with relevant research, there have been several policy initiatives to address these concerns. Federal aid programs such as Medicaid and SCHIP, and legislation including the Public Health Service Act(PHSA), Health Insurance Portability and Accountability Act(HIPPAA), and Health Communities Access Program(HCAP) have served to provide access to healthcare for the uninsured. Several proponents have emerged to play a role in serving the health care needs of those without insurance. This network of community health centers, federally qualified health centers(FQHCs), emergency departments, public hospitals, and private non-profit organizations has served as a “safety net” for the uninsured. With the effects of increasing Medicaid managed care, the rising number of uninsured, and eroding federal subsidies, this safety net has been challenged in its ability and capacity to meet the increasing need. In light of the current trends of health care within our nation, there will be a growing need for evaluation and program development and implementation to address the needs of the uninsured and underinsured.
Although the problem of uninsured and underinsured within the United States is pertinent and far reaching, the American public has a general lack of awareness and an inaccurate understanding of this situation. Contrary to the extent of the problem outlined in the previous paragraphs, public opinion assumes that the number of uninsured Americans is not large. When in fact, 14 percent of America’s population of 277 million is uninsured. Many Americans believe that the uninsured either do not need coverage or have elected not to purchase it, and that lack of coverage is a temporary circumstance that individuals will eventually change, and/or that lack of insurance is not a significant obstacle in obtaining health care (Saha & Bindman, 2001). In fact, the perception that the uninsured had access to necessary care rose from 43% in 1994 to 57% in 1999, and in 1999, almost 25% of Americans believed that the health care provided to the uninsured was equitable to the health care provided to those with insurance (Saha & Bindman, 2001). In contrast the number of uninsured continues to grow and not having basic health coverage has been associated with several different poor health outcomes and indicators. A recent study showed that within a 3 year period, three out of ten people will be uninsured for at least a month.(www.coveringtheuninsured.org) Another belief is that the uninsured are unemployed, when in fact, eight out of ten uninsured are from working families. Finally, people fail to realize that geography has effects on coverage. Some communities, counties, and states have more uninsured than others.(Kellermann, 2001.) In light of the growing uninsured population, what does the American public belief about the adequacy of medical care received by these people? Fifty-seven percent of Americans believe that the uninsured can receive adequate medical care when needed(Families USA, 2001.) Many of these beliefs will be challenged in the following text and be shown as misconceptions. There has been a great deal of research to explore the situation of the uninsured. In light of these prevalent misconceptions, public education campaigns should be conducted regarding health insurance and the implications of non-existent or incomplete coverage.
Causal factors contributing to uninsured status:
There are several factors contributing to the problem of uninsured. Some of these indicating factors include: unemployment, ethnicity, health status, and low income. The research shows that some of these factors and general trends in the economy and health care market have had a causal relationship on the rise of uninsurance.
A factor that plays less of a role than the general public thinks is unemployment. Research shows that uninsurance is more prevalent than unemployment indicating that a significant portion of the uninsured population is employed and yet without insurance. This status is called medically indigent. While 43.4 million Americans (16.1%) lacked health insurance for a year’s period in 1997, 6.7 million Americans (4.9%) were unemployed in 1997 (Davis, 2000). Moreover, most of the unemployed were unemployed for a temporary period; a smaller fraction, 1.1 million Americans, were unemployed for 6 months or more (Davis, 2000). The unemployment rate is usually an underestimate due to the narrow definitions of unemployment. However, after broader definitions were applied, the number of unemployed Americans was 8 million, still significantly less than those without health insurance coverage. Even when unemployment was adjusted for its indirect effects on family members of the unemployed adult, the resulting population was approximately 24 million Americans, just over half of the number directly affected by a lack of health insurance. This comparison highlights the magnitude of the problem of lack of health insurance in the U.S. and it illustrates that lack of insurance is not due to lack of employment alone (Davis, 2000). In fact, eighty percent of the uninsured work or live with a family member who works. The full picture of the working uninsured consists of 22.8 out of 41.2 million people with 18 million working full-time and 4.7 million working part-time.(Census, 2001 report) Due to their working status, many of the medically indigent do not qualify for Medicare and do not make enough money to afford health insurance.
Consequently, lack of health coverage is strongly related to low income. In a study comparing low income, race, and health status to insurance coverage it was found that uninsurance and partial insurance were both associated more with low income than with race or health status. Race was also associated with lack of or partial insurance, but not as strongly as income. These findings lead the researcher to suggest that Medicaid has provided more insurance coverage for minorities and those with poor health, although the problem of coverage for low-income individuals has not been sufficiently addressed. Other vulnerability factors studied by the researcher yielded information regarding disparities. Those who were less likely to be insured included more young people than elderly, more males than females, those with no college degree versus those with college degrees, and those living in the Northwest and Midwest versus those living in the South (Shi, 2001).
There are several factors and trends contributing to the situation of the medically indigent and can be summarized as economic and health care costs. With a slowing economy and rising costs in the health care industry, there has been decline in employer-based coverage and an increase in health insurance premiums. The decline in employer-based coverage went from 63.6 to 62.6 percent. The unstable economy and declining corporate revenues has led to employers scaling back the health benefits they offer and decreasing the dollar amount that they contribute to employee coverage.(AP article) Hence, employees who want coverage have to pay increased premiums. In fact, a recent census showed that the largest jump in uninsured was among the $75,000-and-up bracket. Also, twenty percent of the uninsured declined employer-based coverage because of affordability issues.(Cunningham, 1999.) Hence, having a job does not guarantee health insurance. Furthermore, some types of employment are more likely not to offer coverage including: self-employed or contractors, part-time workers, small firms(less than 200 employees), and service-oriented industries(lower incomes.)
The cost of health care is an obstacle for the uninsured. It is projected that health spending will rise from 13.6 percent of gross domestic product in 1999 to 16.2% in 2008. The relative cost for families differs significantly according to their socioeconomic status: families with incomes over $100,000 spend 3% of their annual income on health care, families with incomes of $45,000 spend 6% of their annual income on health care, and families whose incomes are below $10,000 spend 17% of their income on health care. Essentially, low-income people are spending six times as much as wealthy people on health care. Furthermore, insurance plans offered by employers with a typical wage of 15 dollars average around 84 dollars per month; whereas, hourly, lower wage companies offer premiums around 130 dollars per month for their employees. The average employer health plan costs $2,426 for an individual and $7,035 for a family policy. In 2000, health insurance premiums rose by 8.1% and they were expected to rise by an additional 11% in 2001 (Hellander, 2001). In 2001, employee costs for health premiums were expected to rise by 18%, while employer costs were expected to rise by 9.8% (Hellander, 2001). Thus, low income workers are paying for the majority of the rise in health cost while receiving less coverage. The majority of uninsured workers cite cost as the most important reason for lack of coverage (Cunningham, 1999).
Health consequences associated with no health insurance:
A great deal of research has been done to assess the effects of not having insurance on general health status. Research has found that having health insurance is associated with better health outcomes. This association with well-being most likely is a result of access to preventive services, regular and effective care for chronic conditions, and better quality of acute care. In general, the quality and length of life differ between uninsured and insured. Those without coverage experience greater declines in health and die sooner (Kellerman, 2002.)
One factor that plays a role in the health consequences for the uninsured is access to primary care. Regular primary care access is essential to receiving adequate and effective care tailored to the individual, and obtaining regular preventive screening and services. Without the continuity of access necessary for comprehensive care, it is difficult to maintain good health and well-being. A study comparing low-income insured to low-income uninsured, two relatively comparable groups; thus, isolating the distinguishing effects of being uninsured, shows that 60 percent of uninsured have a usual source of care compared to 85 percent in the insured population.(Holahan, 2002.) Cost plays a significant role in limiting the access of care to the uninsured. Seventy percent of those who have been uninsured for more than a year and were in poor health reported that cost was the main barrier that kept them from seeking necessary care from a physician (Hellander, 2001). Since more than 50% of the uninsured live below 200% of the federal poverty level, cost of care is a critical concern. Even among the insured, it was found that office visits are reduced by 10 percent when a five dollar co-pay was enforced (Saha & Bindman, 2001). In light of the cost barriers to access, a recent study showed that 45 percent of low income uninsured compared to 70 percent of low income insured were likely to schedule a visit with a doctor for illness.(Holahan, 2002.) Due to the decrease in access to regular care, uninsured patients are more likely to delay treatment and seeking intervention for illness; thus, they report with more advanced and costly stages of disease. Likewise, without regular screening, diagnosis is delayed and cancer findings are more advanced and lead to a higher mortality. “For example, uninsured women with breast cancer have a 30 to 50 percent higher risk of dying than women with private health insurance.”(Kellerman, 2002.) Ultimately, the barriers and lack of access to care in primary care settings, forces the uninsured population to seek care in emergency room, which is inefficient at providing routine care and is extremely cost ineffective. The cost of higher morbidity and mortality effects not only the individual, but society as a whole.
The lack of access to regular care has a significant impact on those uninsured who have chronic health conditions. Without regular check ups it is difficult for patients with chronic conditions such as: diabetes, cardiovascular disease, end-stage renal disease, HIV and mental illness to manage their condition. Similar this population has difficulty purchasing prescribed medicine that is essential in the treatment and maintenance of their health. Hence, without prevention and proper management, conditions progress towards further complication and morbidity. This unchecked progression of chronic conditions can lead acute or emergency situations that require costly intervention and hospitalization. In fact, the uninsured have been found to be four times more likely to require avoidable hospitalizations and emergency care than the insured for conditions such as diabetes, ulcers, pneumonia, and hypertension (ACP/ASIM, 2000.)
A lack of health coverage also has ill effects on quality of care; especially, with regards to racial and economic disparities within the heath care system. The general quality of care has been shown to be less for the uninsured as they are less likely to receive necessary diagnostic tests and labs when hospitalized, and they have a higher mortality rate when hospitalized than insured patients (Kellerman, 2002.) In the health care facilities where the uninsured are actually able to receive care, there are limited hours, longer waiting periods, and a lack of adequate equipment for comprehensive care of complicated problems. To enable and empower many minority groups, several enabling services have been developed that provide necessary support to racial minorities who are likely to be uninsured. Consequently, there has been a decline of these enabling services such as: translation, transportation, outreach, and case management because of a lack of insurance revenue from the people who need these services.
Finally, a lack of health coverage has an effect on quality of life for the individual, the family, and the community. There is a large amount of emotional and psychological cost associated with being uninsured. Many individuals and families have to make decisions between going to the physician and/or buying prescription medicine, and their basic needs such as food, rent, or utilities. Parents are unable to provide their children with regular pediatric visits, immunization, and care of routine health problems. Individuals and families may live in fear and anxiety of incurring some injury or health problem with no means of affording and obtaining care. The pressures and fears inherent in lacking coverage may force parents to restrict their children’s daily activities away from sports and school. The cost also shifts to the community and society. Ultimately, the cost of providing for the uninsured is directly paid for taxpayers through public programs and hospitals and indirectly by increased premiums to the insured population. The cost shifts to the community at an inflated cost of both monetary capital and the spirit and hope of the people within the community as a whole.
In 1999, there were an estimated 1,300 public hospitals affiliated with the National Association of Public Hospitals(NAPH) within the United States(Legnini et al., 1999) with most of these hospitals being located in urban centers. Public hospitals are the main source of care for the uninsured, they represent 38 percent of discharges from public hospitals and 47 percent of outpatient visits. The hospital revenue sources reflect this as well: 38% of funding is from Medicaid, 16% from Medicare, 12 % from commercial insurers, and 33% from other public sources (Rask & Rask, 2000). Public hospitals provide for a disproportionate amount of the nation’s uncompensated hospital care(measured as bad debt and charity care) at 23 percent and nearly 85 percent of all patients had family incomes below 150 percent of the federal poverty level (National Association of Public Hospitals and Health Systems, 1999). In stark contrast, these costs represent 29 percent of the annual budget of public hospitals compared to 6 percent of private facilities. The funds to reimburse these costs primarily come from state and local government subsidies. In order to remain financially viable, public hospitals have to provide care for a large number of patients. A study of hospitals in smaller cities revealed that safety net hospitals recorded 30 percent more inpatient admissions and 39 percent more patient days than their private counterparts (National Association of Public Hospitals and Health Systems, 1999).
In the changing climate, with many not-for-profit hospitals changing to for-profit standing, there is an accompanying decline in uncompensated care. One study of hospitals from 1991 to 1998 reported that that decline was from 5.3% of hospitals’ total expenses to 4.7%, while public hospitals underwent a more drastic decline, from 5.2% to 2.5% (Hellander, 2001). Further research is necessary in order to evaluate the cost-effectiveness of public care vs. private insurance (Rask & Rask, 2000). When public hospitals provide such a large percentage of uncompensated care, it will be difficult for the national safety net to maintain its current level and extent of care.
Community Health Centers
Community health centers (CHCs) represent an important safety net for many uninsured individuals. These centers are geared towards providing access to primary care and preventive services to communities with a high percentage of low-income patients who lack insurance. Many of these centers receive federal funding under the Section 330 grant of the Public Health Service Act and are designated as federally qualified health centers(FQHC) and receive the rest of their funding from Medicaid and a patchwork of state and local grants. In order to be classified as a FQHC the center has to meet certain mission criteria such as: being located in a medically underserved area(MUA), maintain a nonprofit status, have a Board of Directors with member from the community, strive to provide culturally-competent and comprehensive care, and offering a sliding fee scale. Currently, there are over 698 FQHCs that have over 3,000 individual service delivery sites and serve over 8.7 million patients. This is a large increase from 1990 when there were 545 FQHCs serving 5.1 million patients (Bureau of Primary Health Care, 1991, 1998). Of this large number of patients, a significant proportion are uninsured(41 percent) or on Medicaid (33 percent). It is estimated that in 1998, FQHCs served approximately 9 percent of the 32 million Medicaid beneficiaries, 8 percent of all the 44 million uninsured Americans, and 20 to 25 percent of the 43 million poor and near poor uninsured people in America (Bureau of Primary Health Care, 1998). Adults using the CHC differ in several ways from the rest of the uninsured population in the U.S.; CHC users were found to have higher rates of poverty, they are more frequently minority (Hispanic, African-American) versus white, female vs. male, less educated vs. more educated, and more likely report that their health is fair or poor CHC users reported higher rates of access to care than their other noninsured counterparts in other locations and higher rates of satisfaction with the care provided.
Central to the mission criteria of CHCs is understanding and responding to the health care needs and status of the community they serve. With this goal in mind, CHCs have been very effective at providing quality care and comprehensive service. The care providers at CHCs were assessed for their ability to follow such guidelines to provide culturally relevant health promotion, and it was found that these care providers met or exceeded the goals (Carlson, Eden, O’Connor, & Regan, 2001). This indicates that CHCs serve a focused purpose for uninsured Americans, who come from a broad and complex range of social and demographic populations. Many CHCs have expanded their services to the uninsured by staying open during off-hours such as evenings, weekends, and holidays, by providing language interpretation if necessary, as well as transportation, outreach activities, and payment plans (Weiss, Haslanger, & Cantor, 2001). FQHCs employ a number of case managers, education specialists, and pharmacy personnel (Dievler and Giovannini, 1998). CHCs have filled an essential and vital part of the national safety net.
For many uninsured and underinsured individuals, the emergency room (ED) becomes the first point of service for health care. This results in increased ED patient loads, ED patients at more advanced stages of illness, and ultimately, increased mortality rates from preventable and treatable illnesses. In the 1990s, ED visits rose by 15.7%, although 830 hospitals and 232,000 hospitals were closed during the same time period. Due to the increased patient load and a number of other factors such as the nursing shortage and ED physician shortage, EDs are often forced to temporarily close their doors to patients (Hellander, 2001). There is controversy as to whether or not health care reform would actually result in decreased use of the ED. Some researchers say that ED use would not decrease, and possibly would increase (Barish & Doherty, 1995). In fact, one study found that ED use rose by 40% when it was provided free of charge. Moreover, Canada, which is similar to the U.S. in terms of medical personnel, but different in that health insurance is run by the government, reports 83.8% higher ED use than the U.S. Most patients use the ED for one of three reasons: assessment and treatment of an emergency; in lieu of other care providers; and because they are convenient. While the first is an appropriate use of an emergency facility, the other two reasons would not necessarily be addressed with universal coverage: access and convenience would be important considerations for patients (Barish & Doherty, 1995).
As for hospital admissions from the ER, researchers examined the rates of admissions versus patient health outcomes. It was found that the uninsured were significantly less likely to be admitted than those with insurance, even after adjusting for factors such as SES, income, employment, lack of a regular care provider, and baseline health status. However, the authors could not demonstrate that uninsured individuals had increased adverse health outcomes compared to those with insurance, suggesting that either the uninsured did not need to be hospitalized, or that the insured were being overhospitalized (Sox, Burstin, Edwards, O’Neill, & Brennan, 1998).
The role of local health departments(LHD) has been one of three functions: assessment, assurance, and policymaking(Institute of Medicine, 1998). These functions have been mandated in a list of criteria established by the US Department of Health and Human Services. Some but not all LHDs provide direct health care services. Those that do provide direct services included immunizations, well child clinic services, Special Supplemental Nutrition Program for Women, Infants, and Children(WIC), Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program, STD testing and counseling, family planning services, and school-based health clinics. Overall, LHDs tend to provide free health care to populations with special needs (Institute of Medicine, 2000). Although a smaller part of the safety net, LHDs continue to provide a means for the overall public health of the uninsured and addressing the needs of special populations.
Recently, many economic and structural pressures have been brought to bear on the current national safety net. There is question of whether the current infrastructure is adequate and financially viable to continue to meet its mission and level of care. A growth of the uninsured population has increased the number of population seeking service. The erosion of federal financial subsidies in regards to the recent Balanced Budget Act of 1997, declining Medicaid enrollment, and declining coverage of immigrant populations. Welfare reform effects on Medicaid coverage and immigrant coverage have increasingly altered revenue streams to core safety net providers. Finally, the growth of the Medicaid managed care market has shifted and squeezed the Medicaid revenue away from safety net providers. This trend is specifically concerning considering the essential nature of Medicaid revenue to the budgets of safety net providers, and that the penetration of health management organizations(HMO) continues to increase.
These evolving pressures have challenged core safety net providers. FQHCs have had to increase their network of financial resources in both the public and private arena. Core safety net providers have began to embrace and collaborate with the managed care market. In general, these challenges have forced providers to become more efficient, more customer oriented, and more performance based (Institute of Medicine, 2000). Overall, the national safety net has been able to adapt and survive, but as the health care and economic market continue to evolve it will be imperative that some of these growing stresses are addressed from a structural and political manner if the safety net is to remain intact.
With an estimated 11 million children uninsured in 1997, the Clinton Administration signed Title XXI of the Social Security Act into law. This created the State Children’s Health Insurance Program (SCHIP), which aimed to provide block grant funds to enable states to expand health care assistance to low-income children not covered by Medicaid or private insurance (Shi, Oliver & Huang, 2000). States can execute SCHIP coverage by creating a separate program, expanding the current Medicaid program, or creating a combination of the two. States electing to create a separate program are able to have flexible eligibility requirements, whereas states that choose to expand their Medicaid coverage must adhere to the preexisting Medicaid eligibility requirements. Allocation of funds is based upon each state’s share of the nation’s uninsured children with family incomes 150 percent of the state’s Medicaid eligibility or 200 percent of the federal poverty level. Although states must contribute their own funds to the program, the federal government provides at 65 percent of SCHIP costs. From 1997 to 2007, an estimated $40 billion will be allocated for the SCHIP program (Shi, Oliver & Huang, 2000).
Although the purpose of SCHIP is to reduce the number of uninsured children, it is estimated that the program will only cover 5 million children (Shi, Oliver & Huang, 2000). Due to complicated application procedures, almost half of the children in New York State will lose SCHIP coverage at re-enrollment time (Hellander, 2001). Furthermore, only about 2.9 million children meet the eligibility requirements for the SCHIP program. Because of a decrease in the number of children covered by private insurance, no net gain in coverage occurred in 1998 – 1999 despite an increase in public insurance coverage due to SCHIP (Shi, Oliver & Huang, 2000). For SCHIP to be successful in increasing the availability of health care to children, programs must be established to simplify the application process and actively find eligible children.
Elderly (Prescription Medications)
Most people age 65 and older have health insurance through Medicare, but individuals between the ages of 55 and 65 are at high risk for losing health benefits. During this transitional phase of life many people retire from their primary occupations taking up other jobs without health insurance. If these retirees do not have retiree coverage they may be unable to afford health insurance until Medicare eligibility begins. Individuals may be self-employed or widowed. Furthermore, individual health risk increases for stroke, cancer, heart disease, and multiple prescription medicines. Consequently, with increased health problems comes increased premiums and limited benefits. Private market premiums increase sharply with age and a significant amount of the policies place restrictions on pre-existing health problems. Premiums for this age bracket are nearly twice as high as rates for people ages 35 to 54 (Simantov, 2001). There is an estimated 3.2 million older adults between the age 55 and 65 lacking health coverage (Johnson, 2001). This number may increase as number of employers offering retiree health plans follows a decreasing trend (Simantove, 2001).
As individuals become older and develop increased health problems, there is an increased need for long-term prescription medication. This trend has implications on the health expenditures of elderly individuals because prescription medication is the fastest growing health care expenditure in the United States (Hellander, 2001). Spending has risen almost 24% annually, from $12 billion in 1980 to $51.9 billion in 1994. This has been due mainly to an increase in the number of medications prescribed, and an increase in the cost of the medications prescribed. Although there has been a drop in the amount of prescription drug expenditures paid out-of-pocket and in full from 66% in 1980 to 42% in 1994, prescription drugs continue to account for the largest component of out-of-pocket medical costs (Mott & Kreling, 1998). Although most large and medium sized companies offer some coverage for prescription medication coverage, many of those employed in small firms and Medicare do not provide prescription medication coverage. Even for those with prescription medication coverage, co-payments can range from 20 – 50%. This cost barrier provides a significant barrier for the majority of elderly individuals and can lead to compliance issues and problems managing chronic illness.
Due to the nature of chronic illnesses, individuals suffering from these conditions are likely to need protection against high medical expenses incurred over many years. The authors of a study comparing chronically ill individuals with healthy individuals in Indiana found that the presence of a chronic illness decreased the probability of insurance coverage by 2 to 8 percent and increased the probability of being underinsured by 3 to 7 percent (Stroupe, Kinney & Kniesner, 2000). Those with chronic illnesses are especially vulnerable to being under- or uninsured due to medical underwriting practices. Insurance companies, using a practice called experience rating, may set premiums or terms of coverage based on age, gender, occupation, and health status. Waiting periods, upper limits on the amount of money the policy will pay, and exclusion of coverage for certain tests and procedures may be applied to the policies of those with chronic illnesses. A practice called renewal underwriting occurs when medical conditions that employees develop are added to the list excluded conditions when a policy is renewed. Within-group underwriting occurs when less healthy individuals are selected out of the policy group for higher premiums and/ or reduced coverage. Because of higher premiums, individuals with chronic illnesses may forgo coverage (Stroupe, Kinney & Kniesner, 2000).
At worst, some underwriting practices may permanently exclude those with preexisting medical conditions. In fact, the authors of the Indiana study found that a major contributing factor to inadequate insurance among individuals with chronic illnesses was exclusion of coverage based on a preexisting medical condition. Chronic illness decreased the probability of adequate health coverage for unmarried individuals by 25 percent when exclusions were used for preexisting medical conditions. When such conditions were not used for exclusion, unmarried individuals with chronic illness were approximately 15 percent less likely to have adequate insurance coverage (Stroupe, Kinney & Kneisner, 2000).
Because of the detrimental effects of underwriting on obtaining and maintaining adequate insurance coverage, in June 1997 the Health Insurance Portability and Accountability Act (HIPPA) went into effect. The purpose of HIPPA is to limit the ability of an insurance company to permanently exclude those with preexisting medical conditions for those who already have insurance and move into a new coverage group. HIPPA also prohibits insurance companies from increasing premiums of individuals with chronic illnesses if that individual is within a policy group. This makes it difficult for insurance companies to engage in within-group underwriting (Stroupe, Kinney & Kneisner, 2000).
Although HIPPA is a significant health care reform policy, it does have gaps. There is no protection against the reduction of coverage for a specific chronic illness or a limit to the premiums insurers may charge. In addition, HIPPA provides no protection for those previously without health insurance. Furthermore, HIPPA is not always fully enforced. States are charged with enforcing HIPPA, however if they do not do so, the responsibility is left to the U.S. Department of Health and Human Services (DHHS). Unfortunately, DHHS resources are strained making enforcement of HIPPA difficult (Stroupe, Kinney & Kneisner, 2000).
It is important to note that as an individual’s number of chronic illnesses increase, out-of-pocket spending on health care services rises, even after controlling for insurance status and demographic variables. When compared to families of healthy young adults, those with a chronically ill young adult are almost three times as likely to spend over $1,000 out-of-pocket annually for medical care. Not surprisingly, chronically ill individuals without health insurance had the highest out-of-pocket expenditures and were five times less likely to seek medical care (Hwang, Weller, Ireys & Anderson, 2001). Chronically ill individuals represent a population vulnerable to inadequate insurance coverage and financial hardship due to out-of-pocket expenses. It is vital that current legislation is enforced and that policy makers are mindful of the needs of this population.
Between 1981 and 1989, it is estimated that the homeless population tripled. The generally accepted causes are a decline in affordable housing, increased use of crack cocaine, loss of long-term care for the mentally ill, and a decline in federal spending for welfare programs. For the growing number of homeless individuals, poor living conditions often worsen existing health problems (Krieder & Nicholson, 1997). Traditionally, health care for the homeless has consisted of emergency care or non-care (Elliott, 2000). When homeless individuals are compared to the general population, their health status is generally poorer. This may be due to individuals in relatively poor health at the time of becoming homeless, individuals in relatively good health initially but whose health status diminishes due to poor living conditions, or individuals who are relatively healthy and are able to leave homelessness quickly and find an improved living situation (Krieder & Nicholson, 1997).
In a study of homeless individuals in Alameda County, California, the authors found that 29% had health insurance during the entire 18-month study period. Of these, 19% received insurance through the government in the form of Medicare, Medicaid, or the Veteran’s Administration. However, it was estimated that 65% of the homeless study participants were eligible for some type of health insurance coverage (Kreider & Nicholson, 1997). In 1997, coverage programs included: Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Aid to Families with Dependent Children (AFDC). SSI does not require a previous work history and recipients are immediately eligible for Medicaid. SSDI does require a substantial work history and beneficiaries are eligible for Medicare after two-years. Sixty-one percent of those in the study were eligible for SSI or SSDI based on physical disabilities, mental illness, and drug or alcohol abuse. ADFC is available for female-headed households with sufficiently low incomes. In the Alameda County homeless sample, an estimated 66% of women were eligible for this aid (Kreider & Nicholson, 1997). Clearly, active case finding and enrollment assistance for the various federal insurance programs would greatly impact the number of uninsured homeless.
The disparity between the numbers of those enrolled in an insurance program and those who are eligible is thought to be due, in part, to the fact that the mentally ill have difficulty completing the enrollment procedures for the various programs. In addition to mental illness, male gender was also negatively associated with insurance coverage. Older individuals, those with a disability, those with employment, veterans, and those who had custody of a child were more likely to have insurance coverage (Kreider & Nicholson, 1997). Not surprisingly, insurance coverage affects health care utilization for homeless individuals, with insured individuals utilizing significantly more medical services than uninsured individuals. The authors of the Alameda, California study found that universal health coverage would increase hospital admissions by 38 percent. Furthermore, alcohol and drug abuse, and mental illness would produce the strongest effects on hospital admissions (Krieder & Nicholson, 1997).
Although increasing insurance coverage would increase hospital utilization among the homeless, alternative programs have been implemented. In Savannah, Georgia, a partnership has developed between the Union Mission homeless shelter and Memorial Health University Medical Center. A health center has been established within the homeless shelter to provide primary and respite care. Chronic and routine illnesses are managed at the center, in addition to 32 beds that provide a safe and comfortable environment for the recovery of those recently discharged from the hospital. Those utilizing the respite care services are able to be discharged from the hospital sooner and are less likely to be readmitted with complications. Within the first quarter of operation, the health center saved the hospital almost $800,000 in unnecessary emergency room visits. It is estimated that the health center will save the hospital almost $17 million annually (Elliott, 2000). This case study provides evidence that partnerships between shelters and hospitals are cost-effective and could be implemented at other sits across the country.
Mental health services have traditionally been underprovided in this country. A study conducted in the early 1980s showed that only 29% of those needing mental health or substance abuse treatment that year received any care. The problem is due, in part, to limited levels of insurance coverage for these services (Katz, Kessler, Frank, Leaf & Lin, 1997). It is estimated that 25% of Americans have no mental health insurance. For low-income individuals, the number without mental health coverage increases to approximately 40%. Only about 10% of highest income individuals reported lacking mental health insurance coverage. Medicaid recipients and those without mental health insurance coverage are less likely to use mental health services compared to those with full private insurance coverage. Third-party payors are often unwilling to provide mental health coverage because of fears that spending will increase on services of uncertain value and duration (Katz, et al., 1997).
The authors of one study sought to compare the utilization of mental health services in the United States to that of Ontario, Canada, where there are no explicit limits on inpatient or outpatient psychiatric care (Katz, et al., 1997). Overall, about 9% of Americans reported at least one mental health visit, compared to about 7% of Ontario residents. More specifically, it was found that individuals in the United States with lower mental health morbidity were more likely to receive care compared to Ontario. Conversely, those in Ontario with higher mental health morbidity were more likely to receive care compared to those in the United States. After controlling for mental heath morbidity, the lowest income residents of Ontario were more likely to utilize mental health services. It is hypothesized that this is due to greater vulnerability to psychosocial problems and a less social support in the lowest income individuals (Katz, et al., 1997). This finding indicates that lowest income individuals in the United States are not receiving adequate mental health care due to an increase in the need for mental health services and a decreased likelihood of mental health care coverage.
Parity legislation is one proposed solution for increasing the availability of mental health coverage for the 10.2% of Americans who have general medical health insurance, but not mental health care coverage (Katz, et al., 2000). The Mental Health Parity Act of 1996 is a federal act that requires insurers to provide the same mental health care coverage, including annual or lifetime limitations, as they would for physical illnesses. As of 1998, 20 states had adopted parity legislation (Levin, Hanson, Coe & Taylor, 1998). Although this legislation increases mental health care coverage for the insured, it may lead insurers to more aggressively manage care in an effort to control costs. Cost increases may cause employers to reduce benefit packages or drop health care coverage altogether (Zuvkas, 2000). However, Maryland and Rhode Island both reported a less than one percent increase in total plan costs under parity legislation. In fact, Texas found a 48% decrease in mental health and substance abuse costs after parity legislation was enacted (Levin, et al., 1998). Because of the minimal increase in cost, it is unlikely that individuals would lose health insurance coverage due to parity legislation. Therefore, legislators should be encouraged to adopt such policies.
The phenomenon of employed, but uninsured individuals continues to constitute a major challenge in the United States. In 1997, 71% of uninsured families had at least one family member employed full-time (Blumberg & Nichols, 2001). Of the uninsured workers, almost 50% were either self-employed or employed by companies with fewer than 25 workers. Of those with incomes below $10,000, approximately 31% were uninsured, compared to 5% of those with annual incomes above $40,000 (Long & Marquis, 2001). Americans, in general, feel that the provision of health insurance is very important. In one study, 64 percent of employees with employer-based health insurance indicated that they chose health insurance over other benefits such as a pension, paid leave, and life insurance (Blendon, Young & DesRoches, 1999). Being employed, but uninsured has been attributed to making individuals feel afraid, powerless, and vulnerable both physically and financially (Orne, Fishmon, Manka & Pagnozzi, 2000).
One study examined the characteristics of low-wage workplaces in the provision of health insurance. Low-wage workplaces were defined as those in which at least two-thirds of employees are low-wage workers, that is earning less than $7 an hour or less than $14,000 annually in 1997. It was found that less than one-third of workers in low-wage workplaces were enrolled in an employer-provided health plan, compared to two-thirds of workers in other businesses (Long & Marquis, 2001). Compared to 87% of employees in other workplaces, only 60% of employees in low-wage establishments had employers who provide insurance. It is also important to note that only 67% of workers in low-wage workplaces are eligible to enroll in their employer’s insurance plan, compared to 86% of other workers. Often employers require employees to work at least 30 hours per week to be eligible for insurance benefits. Thus, those working multiple part-time jobs are excluded from coverage. Furthermore, workers in low-wage workplaces are more likely to face waiting periods after being hired before being eligible for insurance coverage. In addition to waiting periods, the greater turnover of employees in low-wage workplaces further exacerbates the number of uninsured workers (Long & Marquis, 2001).
However, even when low-wage workplaces offer insurance coverage, eligible employees often do not enroll. Low-wage workplaces tend to offer less coverage, contribute a smaller amount towards the premium, and contribute a smaller share towards covering the employee’s family (Long & Marquis, 2001). A closer examination of those who decline health insurance found that compared to those who were not offered insurance, those who declined were more likely to have had insurance within the past year. Counterintuitively, those who declined insurance were more likely to be in poor health and to have had difficulty accessing the health care system, compared to those who were not offered coverage. It is hypothesized that people in the study who declined health insurance did so because they perceived a low value to insurance if they foresaw paying high out-of-pocket fees (Blumberg & Nichols, 2001). Family income has also been hypothesized as a factor in that many low-wage employees would rather accept a slightly higher wage than insurance coverage (Long & Marquis, 2001).
When asked about possible solutions for providing coverage to the employed, but uninsured, 21% of Americans surveyed supported a national health care system. Two of the most recent policies put forth to alleviate the burden of the uninsured among the employed are: 1) mandating employers to provide insurance or 2) the provision of a system of individual tax credits to enable employees to purchase insurance. One-third of participants in the survey favored one of these two plans (Blendon, Young & DesRoches, 1999). However, a study examining the decision to purchase insurance by uninsured workers found that a 60% premium subsidy would only induce one-quarter of eligible families to purchase insurance (Marquis & Long, 1995). When discussing funding of such plans, it is important to consider that barely half of Americans in 1999 expressed a willingness to pay increased taxes or premiums to provide coverage for the uninsured (Blendon, Young & DesRoches, 1999).
Income is a variable most associated with insurance coverage. However, among low-income individuals, whites are more likely to be uninsured compared to minorities. This is due, in part, to the fact that greater proportions of low-income minorities are enrolled in government insurance programs or are partially insured through private payors. Whites, however, are more likely to be privately insured compared to minorities (Shi, 2001). In 1999, 11% of non-Hispanic whites were uninsured, compared to 21% of blacks, 33% of Hispanics, and 21% of Asians (Hellander, 2001).
Unfortunately, very little is known about the insurance status of specific minority groups. Hispanics are one of the fastest growing ethnic groups in the United States, growing at 58% per year compared to 16% of for the African-American population and 3% for the white population. Compared to 5.9% of the white population, 14.7% of the Hispanic population currently has an annual income less than $10,000 per year. Lower socioeconomic status puts individuals at risk for inadequate insurance coverage and a decreased ability to pay out-of-pocket expenses (Ruiz, 2002). Of the 11 million uninsured Hispanic families, nine million have at least one employed family member (Hellander, 2001). The growth rate of this population, combined with a lower socioeconomic status and a large number of uninsured, but employed, individuals indicates a need for policy development to increase the number of insured Hispanics. In addition, more research is needed in terms of assessing the numbers of uninsured and underinsured Hispanics as a group and also as subgroups, including Mexican Americans, Puerto Ricans, Cuban Americans, Dominicans, Salvadorans, etc. (Ruiz, 2002).
Asian Americans and Pacific Islanders are comprised of over 50 different ethnic groups. Rates of poverty vary widely among the groups. For example, in 1990 over 60% of Hmong were living below poverty compared to 7% of Japanese Americans. Asian Americans and Pacific Islanders are more likely than whites to lack health insurance, however specific information about this group is not known because Asian Americans and Pacific Islanders have historically been labeled as “other” in epidemiological and health studies (Ro, 2002). It is important that future research and policy development clearly delineate this group from other ethnic and racial minorities. Aside from socioeconomic factors, both Hispanics and Asian Americans/ Pacific Islanders are at increased risk for being uninsured due to language and cultural barriers that increase the difficulty associated with understanding eligibility, completing forms, etc.
Welfare and economic reform has played a role in establishing the current health care situation of many of the uninsured. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), also known as the welfare reform law, replaced Aid to Families with Dependent Children (AFDC) with the block grant program Temporary Assistance for Needy Families (TANF). This law separated the link between Medicaid and cash assistant welfare. Under the new legislation states are required to provide Medicaid coverage to all families meeting income and structure guidelines that had applied to the state’s AFDC program. In general, these policy changes have decreased the number of Medicaid enrollees. In addition, since 1988 states have been required to provide Transitional Medicaid Assistance to all families that had left AFDC due to increased income. Despite these extensions of health care coverage, many women and children become uninsured. It was found that after one year of leaving welfare 49 percent of women and 29 percent of children were uninsured. It is hypothesized that few women take up Medicaid because of the stigma attached to the coverage, complexity of Medicaid eligibility rules, and complicated application procedures (Garrett& Holahan, 2000). For those who obtain employment after leaving welfare, only a third receive private health insurance through their employer. This is especially problematic considering that in 32 states, a parent working full-time for minimum wage will exceed the income requirements of Medicaid (Hellander, 2001). These factors contribute to the large population of medically indigent, those working people who do not qualify for Medicaid and do not have insurance. Economic reform introduced by the Balance Budget Act of 1997 contributed to changes in Medicaid eligibility, the use of Medicaid managed care, and cost-based provider reimbursements. Both the use of Medicaid managed care and the elimination of cost-based provider reimbursements has had significant financial impact on safety net providers. These changes in the governmental
The recent implementation of the Health Insurance Portability and Accountability Act of 1996(HIPAA) has the potential provision the help some insured maintain their coverage. The Act limits insurance company’s ability to use preexisting conditions as a means of denying coverage; thus, guaranteeing the renewability of insurance. The provision of medical savings accounts(MSA) within the act allowed for the start up of MSAs for up to 750,000 people as a trial demonstration of the system.
There has been a focus from the current presidential administration to strengthen the nation’s current health care safety net. Many of the problems affecting the current safety net stem from change in revenue streams from welfare reform and the BBA of 1997. Addressing these changes and expanding support in answer to these changes is essential to the survival of the national safety net. The administration has put forth the Healthy Communities Access Program to further address the issue of the uninsured. The President hopes to increase support to the National Health Service Corps(NHSC) that has served to bolster the number of providers serving in MUAs. Some of President Bush’s campaign promises to improve Medicare and to provide tax credits as an incentive for the uninsured to buy insurance have been deemed too expensive following September 11 and the economic downturn (Scott, 2001).
Several organizations have supported the implementation of employer tax subsidies in order to initiate and expand coverage for low-wage workers. This proposal has encountered criticism for the limited amount of uninsured who would be covered (less than 50%) and for the benefits it would provide to private insurance companies (Hellander, 2001).
In 1994, Oregon implemented an innovative new health plan with the goal of providing universal care within the state. The basis of the Oregon Health Plan(OHP) was the realization that the current system of providing comprehensive care to a limited number of people could be converted to providing limited coverage for prioritized health care services to all of the population. Three populations were targeted: high-risk individuals above the poverty line (within 100 percent of the federal poverty line), medically indigent through mandated expansion of employer benefits, and Medicaid-eligible individuals not already enrolled. Health care services were prioritized by the Health Services Commission and formed into a comprehensive Prioritized List of Services. This list was determined by quantification of mortality and public health risk and budgeting these concerns to the funds available. The entire process was a participatory, public decision-making process that involved input from health care professionals, social workers, community leaders, and the community. The OHP has been successfully implemented, but it has continued to struggle to maintain the initial projected goals in light of market pressures.
The Oregon Health Plan has been successful in several of their initial goals, but not in all. OHP has been able to lower the number of uninsured from 18 percent in 1990 to 10 percent in 1999. The number of uninsured children is now 21 percent and the emergency room use has declined almost 10 percent(Office of the Oregon Health Plan Policy and Research, 1999). Despite these successes, the plan has met some difficulty. The continued climb of pharmaceuticals has increased the OHP spending by 112 percent over the last six years. In light of these rises, the state has called for federal subsidies. The initial hope of mandating employee insurance benefits was never implemented. The plan has met severe criticism from some parties about the rationing nature of the Prioritized List of Services as the plan has had to drop some health benefits and preventive services as the cost increases. Consequently, the plan has continued to evolve. It has also been continuously revisited and streamlined, with the establishment of lower cutoff points (i.e. less coverage) and the enforcement of stricter eligibility requirements (i.e. no full-time college students or individuals with more than $5000 in assets). Ultimately, the OHP has been innovated and explored some of the possible solutions to uninsured in America.
In 1994, Tennessee implemented TennCare, a new managed care system with the goal of increasing coverage. They targeted three populations: uninsurable individuals(high-risk conditions), Medicaid eligibles, and the medically indigent. Through TennCare, the state contracts with ten managed care organizations (MCOs) to provide care to clients. The MCOs use the gatekeeper system to provide care that enhances continuity of care. Copayments are not required for preventive services, encouraging health promotion and disease prevention. TennCare has also developed a quality assurance program that focuses on prevention and access and measures have been taken to assure that TennCare’s growth is congruent with that of state revenues.
Overall, there has been a decrease in the number of uninsured in Tennessee, but there also is much concern throughout the state of whether the program will be able to continue to deal with the increase cost of health care. As of 1997, the number of enrollees was 1.2 million and the number of individuals receiving care who had previously been uninsured or uninsurable was over 400,000 (Long & Kirsch, 1997). Consequently, the cost per capita has increased 50 percent over a 5 year period(U.S. Census Bureau, 2001). Due to pressures from the federal government in terms of subsidies, there has been a great deal of political debate on whether to change back to the old system of Medicaid or to maintain the current system. As one can see, even these new, innovative health care systems are finding it very difficult to address the issue of the uninsured. Yet, even in their problematic aspects, they offer the possibility of change and the opportunity to serve as learning points for future solutions.
There have been many proponents of instituting a national health care system that will provide insurance for all Americans. This system would be similar to the health care programs in many other developed countries. I will refer you to the chapter within this on-line text for further details of this possible solution.
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