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Yes, Those Uninsured Numbers Are Legit

Anthony Wright is executive director of Health Access California, the statewide health care consumer advocacy coalition. He blogs daily at the Health Access Weblog and is a regular contributor to the Treatment.

The new Census numbers are out and they show a grim increase in the number of uninsured in 2008 to 46.5 million--figures that are bound to be worse now 12 months into our current recession.

But this number has been under attack for the past year, as conservative columnists, blogs, and other voices repeat the argument that the Census figures are inflated. This inclination of health reform opponents to fight over this has been so great that President Obama didn't even want to engage the argument last week. In his otherwise excellent speech, he said there were “more than 30 million” who cannot get coverage. I interpreted this as a way to simply acknowledge the significant scale of the problem and focus on the solutions, without having people fall into a debate about numbers. Predictably, the health reform opponents have taken this as a victory.

Those who seek to minimize or dismiss the number of uninsured actually misunderstand the very nature of the problem. It’s better not to think of the uninsured as a discrete population, one that can be marginalized, than to think of uninsurance as a condition that can afflict anyone.

Most estimates of the uninsured are for a specific point in time, or over the course of only one year. When just looking at a two-year period, far more people--nearly 1 in 3--find themselves uninsured, as Families USA has calculated using Census data. And for every day they are uncovered--and most of them are uncovered for more than six months--they are likely to not get care and/or face the risk if not the reality of financial ruin. One trip to the emergency room without coverage can mean thousands of dollars of unexpected bills.

For those who say that two years is too long a period to evaluate, please let our Congress know--as they are busy fretting about the ten-year cost of health reform. If we are going to calculate the ten-year cost, we ought to calculate the ten-year benefit, of how many Americans will be prevented from falling into uninsurance, preventing the gaps that are disruptive to both quality care and a family’s financial stability.

President Obama understands this: This weekend, he cited a new Treasury Department report that indicates about half of non-elderly Americans went uninsured for some portion of 1997-2006. With the continuing erosion of coverage without health reform, the number who would benefit by not having such a gap in coverage over the first ten years of health reform is likely well over half the country. That’s not a problem, or a benefit, to minimize.

But let's go back to that conservative critique of the 46.5 million figure, which comes directly from the U.S. Census. Critics make three arguments here: 1) the number includes immigrants; 2) the number includes people who are eligible but not enrolled for public health programs like Medicaid and SCHIP; and 3) the number includes people who make more than a certain income, and supposedly could “afford” coverage. The implication is there’s really no major problem, that people are simply choosing to be uninsured.

This is wildly misleading, on multiple levels:

* Are they immigrants? Conservatives wildly overinflate the percentage of those without coverage that are undocumented immigrants; they seek to ignore both legal immigrants who are working their way toward citizenship, and even some undocumented workers who are privately covered. In recent studies, the UCLA Center for Health Policy Research found that a small share--about a fifth of the uninsured in California are undocumented immigrants, with the percentage is lower for the nation as a whole.

Put another way, if every undocumented resident were deported tomorrow, we would still have a major health crisis. Peter Orzag, head of the White House Office on Management and Budget, explains in his blog that the President’s uninsured number was in part to acknowledge what was stated explicitly: that health reform won’t provide any federal funds or subsidies to undocumented residents. But just because they won’t get the benefit of federal subsidy doesn’t mean they shouldn’t be counted in describing the reality of the problem.

* Are they already eligible? While Medicaid, SCHIP and other programs exist for some low-income Americans, let’s be clear that there are many, even under the poverty line--like poor adults without kids at home--who are not eligible for any assistance. Under all proposals, our safety-net would be made whole, as these programs would be expanded to cover all under 133 percent of the poverty level--a huge and important step.

And while it’s true that there are low-income family members who are eligible but not enrolled for an existing coverage programs, that’s also a public policy problem in need of fixing.

Pending health reforms includes a range of streamlining and simplification efforts, to make it easier to get on and stay on these programs. Many of these programs have burdensome paperwork to apply and maintain coverage, requiring documentation of income, assets, citizenship, and other matters. To many, some of these programs seem to be complex for the purpose of discouraging enrollment. Indeed, during tough fiscal times, several states have suggested additional paperwork or other administration barriers for the purpose of saving money from more limited enrollment. (Some programs--including here in California--have specified eligibility but have closed enrollments and waiting lists.)

In addition, the very fact that the eligibility is so restricted plays a part in discouraging people from considering applying in the first place--whether for issues relating to stigma, or simply not knowing they qualify. When Santa Clara and other counties in California expanded coverage for all children, they found that their outreach and enrollment they had much greater success bringing in those who were already eligible.

This is a solvable issue, as Medicare shows us with its near-universal take-up. The fact that there are children and others who are eligible for help but not getting it is a public policy problem, and health reform provides many of the solutions, from simply being easier to understand what help is available, to a variety of “automatic enrollment” reforms so people don’t face unneeded administrative barriers.

* Can they access and afford coverage? Finally, the notion that everybody over $50,000 (or $75,000) is simply uninsured by choice ignores real world obstacles, from affordability to basic lack of access. Most striking, there seems to be no consideration of families of all incomes who are denied coverage at any price for “pre-existing conditions.” This population is hard to quantify, but is estimated to be at least 12 million nationwide.

In terms of affordability, the average cost of a basic family coverage plan is over $13,000 a year--even a family of four at $55,000 would have to spend over of their quarter of their income for health coverage.

That cost can be double, triple, or more than that, depending on the age and health status of those seeking coverage. So a couple with kids in their 50s or 60s, if they are lucky enough not to be rejected outright for health status, could see premiums that are a sizable percentage of income even making $80,000 or $90,000. It’s for these situations that subsidies up to four times the poverty level are included in the bills that passed three House committees and one of their counterparts in the Senate. Health reform would also reduce, though not immediately eliminate, the disparity between the costs for the young and old.

The promise of health reform is the guarantee that you won’t have to spend more than a certain percentage of your income (a sliding scale based on income up from 1 percent to around 13 percent) for a premium for a decent benefit package--one that has a out-of-pocket maximum so that you are protected from medical bankruptcy. If opponents of health reform (or those who wish to water down the subsidies that health reform providers) want to argue that it is OK for middle-income people to spend 15 percent or more of their income to have basic protection against bankruptcy, that’s a debate worth having.

And that’s true of this entire issue.

It seems the attack on the 46.5 million doesn’t just seek to undermine the facts; it seeks to both minimize the problem, and place the blame for being without coverage on the uninsured themselves. This is off-message from the establishment Republican opposition line, which is to agree that we need health reform, but to raise questions about the specifics.

But this pervasive argument by health reform opponents, made by Sen. Orrin Hatch on Meet the Press, or Rep. Dan Lungren at a town hall meeting here in Northern California, suggests their true stance… that most of the opponents simply don’t see a big problem in the first place. President Obama should not avoid this rhetorical fight. If opponents want to deny the established Census figures describing the health crisis, to minimize that the problem isn’t that bad, or to blame the victims of our broken health care system, that’s a debate I am confident health reform supporters will win.