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Health Care Special Issue: They're Out There

Imagine you are a 55-year-old man with heart problems and no insurance. You are supposed to take blood pressure medication and see your doctor regularly. But you're ignoring both recommendations, since it would cost too much--which is why you suddenly find yourself with pain shooting down your arm, the first sign of a heart attack. Before you know it, paramedics are whisking you to the emergency room--where you catch a break. It was closed to ambulance traffic yesterday, because it was overwhelmed by the influx of uninsured patients using it for routine medical care. Today, the crowds have thinned enough for the facility to reopen. And, because of your life-threatening condition, you jump to the front of the line--more luck!--and ahead of the poor souls waiting hours, even days, just to get seen. Soon, doctors have opened up your clogged artery; you're on the way to recovery and, eventually, discharge. But you'll need even more follow-up care than you did before. And you still have no insurance, which means you have no way to pay the bills. So you're back to ignoring medical advice, rationing your own care, and wondering when another heart attack will land you in the ER--and whether you'll be as fortunate as you were this time.

Is this good health care? President Bush seems to think so, judging by his words in a speech this summer. "People have access to health care in America," he reassured everybody. "After all, you just go to an emergency room." And, while that claim made virtually no sense to anybody who'd actually been through an emergency room lately, it made complete sense to anybody who's been following national politics. Confronted with increasing political pressure to make health care more affordable and available, Bush and a cadre of conservative allies have decided the best solution to the problem is to deny it even exists. Sometimes this means pretending that people without health insurance do just fine. And sometimes it means pretending that people without health insurance aren't as numerous--or as needy--as the well-known figure of 47 million suggests. As N. Gregory Mankiw, a conservative economist who served in the Bush administration and currently advises former Massachusetts governor Mitt Romney, wrote in last Sunday's New York Times, "This number from the Census Bureau is often cited as evidence that the health system is failing for many American families. Yet by masking tremendous heterogeneity in personal circumstances, the figure exaggerates the magnitude of the problem."

Are Mankiw and other critics of universal coverage right? The estimates on the number of uninsured are, like all such estimates, imprecise. But, among the experts--at least those who actually specialize in health care and don't work for right-wing think tanks--there's a pretty solid consensus that somewhere between 40 and 47 million Americans lack health insurance. It's true that not all of these people are uninsured for the entire year. But that is part of the problem: In our patchwork system, people move in and out of coverage constantly. Security is fleeting--particularly since it takes just one illness, or one serious accident, during a period of uninsurance to create a crippling medical debt. In fact, a more important and telling statistic may be the projections by various experts that, over a two-year period, somewhere between 80 and 90 million people will go without health insurance at some point. That's more than one quarter of the U.S. population.

Another supposed flaw in the statistics is that many of the uninsured are already eligible for public programs like Medicaid and the State Children's Health Insurance Program (S-CHIP). This is true--and not particularly relevant. Anybody familiar with these programs, either personally or through an even casual reading of the literature, understands that it's frequently difficult to enroll--and to stay enrolled. People with unsteady incomes--a pretty common situation among the working poor--will inevitably float in and out of eligibility. Those working two or three jobs may not have the time to navigate the formidable bureaucracy; those with poor education or English skills may not have the ability. (And yes, some of the uninsured are undocumented immigrants; see "Foreign Bodies," page 17, for more on this.)

The difficulty of staying on public health insurance programs for the poor isn't exactly accidental. States want to guard against fraud--and if that means excluding some people who might belong on the program, well, that's not necessarily the end of the world, either. You see, the more people who sign up for these programs, the more government has to pay for them. And the money just isn't there right now--at least not for programs that target low-income people. (As the saying goes, programs for the poor are poor programs.) If tomorrow every person eligible for public insurance programs signed up, legislators would blanch at the red ink being spilled and start a panicky debate about how to cut funding. And it would look exactly like the debate we're having right now over the future of S-CHIP--in which, don't forget, President Bush has proposed funding levels that would not keep up with rising medical costs, forcing states to expel current enrollees.

None of which is to say everybody without health insurance is a hapless victim. Many people who don't have coverage really could get it--either by enrolling in an available public program or by purchasing it on their own. Sometimes people are stupid. Sometimes they are selfish. But that's not an argument against universal health insurance. It's an argument for it. Some of the "uninsured by choice" will end up needing extensive, and expensive, medical care. Most of them will get it in the form of charity care from hospitals, which then pass the bill on to everybody else in the form of higher private insurance premiums and higher taxes. Requiring these people to get health insurance would force them to take some responsibility, both for their own eventual expenses and the mutual (if inadequate) protection from catastrophic medical costs they enjoy. This is precisely the reason even some Republicans have endorsed universal health care in the last few years, most notably California Governor Arnold Schwarzenegger and Romney--who, let the record show, was for universal health insurance before he was against it.

Romney's shift, alas, is emblematic of how his party's national leadership is positioning itself on the issue of health care. But, then, we've seen this all before. In 1994, opponents of President Clinton's universal health care plan also insisted the health care crisis was illusory. The fact that we're having the same debate all over again, just over a decade later, goes to show how empty that claim is.

By The Editors