The Typical New Uninsured Person

The New York Times ran a story back in March about a woman who could not get health insurance even though she made $60,000. This story speaks of pre-existing conditions and the newest members of the uninsured club. It also explains some of the complexities in our system in real world ways. I’m always weary of single case stories, but the particulars of this story vividly detail the decisions more and more people are making because of a lack of health insurance. And how a lack of insurance can invade so many parts of your life. Take a look.

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5 responses to “The Typical New Uninsured Person

  1. I’d be the last to suggest that our health care system doesn’t need massive reform and this woman’s plight exemplifies several of the issues that would be high on my hit list.

    First, tying health care to employment, while initially providing the benefit of expanding access to health care, has now begun to have the opposite effect.

    Second, pre-existing conditions create a problem when there’s a lapse in coverage for a reason beyond the control of the insured.

    Third, a major contributor to the cost of insurance is legislation that mandates that basic health care service be extended irrespective of the ability to pay. And so long as society’s value system includes this provision (i.e., a fundamental right to basic service), the only solution to bringing health care costs under some level of control is to mandate coverage for everyone, either through UHC or legally mandated insurance (e.g., MA’s plan). Only in doing this can we hope to recoup some payment for services for the indigent that are now being borne by all other patients

    If we’ve solved the third problem, then the first and second necessarily go away, so long as the portability requirements provide accommodation for pre-existing conditions.

    Notwithstanding the fabulous job that our government does in managing a host of complex tasks (Iraq and the IRS come to mind), I just don’t think they’re up to the challenge of making UHC work. And lest you think me unpatriotic, that’s not just an indictment of my dear, sweet US government. Michael Moore’s “Sicko” notwithstanding, the real story of UHC in Canada, Cuba and elsewhere is far from rosy.

    Here’s what I’d like to see: A Federal law that directed the states to implement a plan of their choosing which mandated insurance for all American citizens with penalties for non-compliance and premium support for the indigent. The Feds would collect and publish date on the costs and quality of care, much like the No Child Left Behind report card but normalized for the demographics of each state. States could stipulate a period of time (perhaps five years), prior to which a 2/3 majority of the legislature would be needed to modify any of the provisions of the plan. The plans in each state would represent a crucible for assessing the feasibility of a variety of independent approaches, within which states could develop best practices and point to actual results in other states (good and bad) when considering changes. In combination with this, throw in a provision that would mandate Federal drug recommendations (modeled after Oregon’s) be published and that malpractice pain and suffering be capped as in California.

    OK, I admit this proposal isn’t politically feasible. But neither was Hillary’s back at the beginning of Bubba’s first term. And look…she’s running for Prez now!

  2. Hi,

    I’m not sure if this flows form the conversation, but I am reading some of the conversation over the last week or so. I just saw a client in my social work psychotherapy practice this morning and thought his story was relevant to this discussion. He also had some questions which I will include.

    I first saw this man after he was discharged from the local hospital’s psychiatric ward following his first psychotic break. He was diagnosed with schizophrenia at that time. If you know anything about schizophrenia you would probably know that he was in his early 20’s.
    He was already married and had two small children. He was really devastated by the experience and not being able to go back to work. He grew up in the “projects” and had been working hard since he was 14. He crawled slowly back to life and was diligent in finding work and finally landed a job that provided some benefits. He had another psychotic episode, landed back in the hospital and lost this job. With the stressors on his illness his marriage dissolved and he has now lived with his older sister who also has a progressive chronic illness. She still struggles every day to go to work for fear of losing her health benefits. He now has a part-time job (up to 30 hours a week) that keeps his hours just under the limit so that they do not have to give him the health insurance benefit. Earlier this year he had an injury to his ankle but didn’t go to the doctor for over 6 weeks until he could save enough money. He finally went to a local clinic, paying $90 for an x-ray and $65 for the doctor visit – out of pocket. In the course of the recovery time he lost two weeks of work and two weeks of wages. Fortunately, his foot was not broken, but just needed more time to heal. His job requires him to be on his feet and walking around, so it was slow to heal. He would like to find a job that would be full-time, but he finds that many of the physically demanding jobs are not full-time and without benefits. He can’t afford a car (although he would dearly love to have one), so he must find work (in the suburbs) that is on the bus line or in walking distance.

    His questions are: can a potential employer who is interviewing him ask about his health? If that employer offers health care, can the insurance company ask him about pre-existing conditions? If they can, it would be in the best interest of the employer and the best interest of the insurance company to not hire him, leaving him without full-time work and without benefits. Can a group health insurance deny a person based on pre-existing conditions or do they have to take that person because he is employed by that company? Would an employer want to keep the pool of his employees as healthy as possible to that his rates don’t go up?

    This person has worked very hard in his life not to be a “burden to society”. He doesn’t want to be on medicare disability nor or Medicaid, because he can work and because he wants to work. He is doing his part but is “society” doing it’s part? He avoids getting health care as he can’t pay out of pocket for it. “Society” apparently doesn’t want to give him a full-time job with benefits, not does it want to give him health care. Bob, what should he do? Do you think he did anything to deserve this situation? He has never done drugs; he doesn’t drink nor smoke. He is not obese. He either works or stays home living a quiet life.

  3. DGP,

    Let me answer yours and your client’s questions:

    A potential employer should not ask about a health history (but I could see it coming up when reviewing a CV – lapses in work). I’m not sure if it is illegal (but I think it is), but it is definitely unethical. If a person is hired and is offered benefits the insurance company cannot deny him because of pre-existing conditions. The insurance is based on the group. The employer-insurance model and the individual market are two different things. If the company is over 100 people than the group pooling protects the insurance company and allows everybody to be included. However, if that employer has a disproportionate amount of ill people than the premiums for the whole group will go up costing the employer. So it is in the employers benefit to hire young, healthy people. Just a suggestion. The health of your client will be less of an issue with a large employer. A company or business with less than 25 or so people will be affected more by a high cost individual. In that case the insurer could drop the policy or raise premiums because the group is not big enough. Also, the employer is going to have more incentive to worry about a potential worker’s health.

  4. dgp, you posed the question, “Bob, what should he do? Do you think he did anything to deserve this situation?”.

    I would maintain that there are two classes of people being hurt by our current health care system: 1) those who are denied health care through no fault of their own and 2) those who are responsible for their lack of health care (e.g., didn’t buy insurance because they wanted other things, refused to work and/or apply themselves in school, ruined their health with cigarettes, alcohol, etc., making them uninsurable, etc.). I feel the priority should be on improving health care access for the first group (I’ll call them victims and I’d maintain that your guy qualifies) and only when they are fully taken care of do we give so much as a thought to assisting the second group (I’ll uncharitably call them bums).

    But who decides and how is it decided who falls into these two groups? Some would put EVERYONE in the former group, arguing that all the lifestyle illness pre-cursors I’ve mentioned (obesity, alcoholism, sedentary activity, etc.) are, in fact, psychological illnesses. But when monetary incentives alone can “cure” such behaviors, I have trouble accepting such an argument.

    Personal example: My wife has an identical twin sister who is obese (my wife is not). When we came into a bit of money, we offered to pay her $1,000 for each pound she lost during the next six months. She lost 40 pounds like it was nothing and we paid her $40K. I’ve made my contribution as an enabler (she gained it all back within a year, my fault for not putting maintenance provisions into our agreement). I don’t think our health care system should follow my lead.

    There are currently systems (established by insurers and employers) that reward and (by withholding rewards) punish lifestyle practices that jeopardize health. I think such systems need to be part of any health care system, both to provide some level of fairness and to control costs caused by these irresponsible behaviors.

  5. Bob,

    You asked what I thought about your proposal a few comments earlier. The State solution has some interesting and good upsides. The most important you pointed out – that it will act like an experiment to see what works and what doesn’t. It could drive innovation. I believe programs like Massachusetts provide this benefit and as more States (California) adopt health care reforms then we will have more case studies to look at. More the better. However, the problem lies with States that don’t have the resources to come anywhere close to UHC. Alabama and Mississippi do not have enough wealth to pull this off. The second type of State that will have an extremely hard time are those with astronomical uninsured rates – most notably Texas. I believe over 25% of their population does not have insurance (I’ll have to check that number). But lastly, I feel that one of the crucial reasons why our system is broken is because it is so fragmented. It’s a hodge-podge of band-aids with each State doing its own thing, with each insurance company doing its own thing, with each hospital doing its own thing. It might lead to some innovation, but it also leads to large amounts of inefficiency, redundancy and perverse incentives. Having a mandated State by State solution could just increase this mess. As far as caps on liability – I’m all for that (it’s not the most pressing thing unless you are a midwife or an obstetrician). I also like your drug recommendation idea. Quality reporting in general is lacking and consistency in care across regions of our country is disturbingly variant. So I would support this. I will write more on all of this later.

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