In June of 2003, Maine enacted a law creating Dirigo Health, which is Maine’s attempt to provide free or heavily subsidized health insurance coverage for the estimated 136,000 citizens who do not have health insurance. As of the end of 2005, there were reportedly less than 2,000 previously uninsured individuals who had signed up for Dirigo Health. How can it be that less than 2% of the uninsured population of Maine has taken advantage of this bonanza? In the case of the uninsured, reality falls far short of perception.
How Myth Became Fact
Throughout our national discourse on universal health-care initiatives, one statement has been repeated so often that both sides arguing this issue have accepted it as fact. The comment that there are 40 million Americans with no access to health care has been accepted a priori. Seldom does one ever see any analysis of this fact. This is more than just an academic point since, as in the case of Maine, health-care policies and significant amounts of taxpayer monies have been directed at this issue.
Just where did this 40 million number come from anyway? Who are these Americans with no health insurance? Most people think of the elderly, the disabled, and the indigent. However, physicians realize that these groups of people are insured through Medicare and Medicaid. As it turns out, the 40 million people quoted as being the uninsured in America are a very heterogeneous, fluid, and constantly changing group. The 40 million number is also misleading.
The 40 million people quoted as being the uninsured in America are a very heterogeneous, fluid, and constantly changing group. The 40 million number is also misleading.
In May 2003, the Congressional Budget Office (CBO) published a paper on the uninsured, which revealed that between 39 and 42.6 million people lack health insurance at a specific point in time during the year. However, the CBO paper also reports that one-half to two-thirds of these people had health-care insurance during other parts of the year. Forty-five percent were lacking insurance coverage for less than four months.
Confessions of an Uninsured Doctor
Confession time. I have been among the 40 million uninsured Americans-several times. In the years 1986, 1992, 1994, 1995, and 2000 I would have been included among the 40 million uninsured Americans for at least part of the year. It sounds outright scandalous that a physician would be among the uninsured for 5 of the last 20 years. That’s one out of every four years without health insurance!
So a little explanation here-I was between jobs. As in the case of most Americans, I had my health insurance coverage through my employer. Each time you leave a job, you are among the uninsured until starting your new job.
This is not as bad as it sounds. Whenever you leave a job, you can elect to continue your medical insurance coverage under COBRA regulations. The individual, not the employer, pays the price for health insurance under the COBRA laws. However, the laws state that you have a two month period from the time you leave your former employer to decide whether you want to elect to have insurance coverage through COBRA. If you elect to insure under COBRA at the end of the two months, you are covered retroactively and you pay for the premium due since you left your job. The first premium under COBRA laws is due 45 days after election of coverage. So, after leaving a job you can obtain insurance coverage and not owe any premium until three and a half months later. In other words, in the four times above when I was between jobs, I could have insured under COBRA. The reason I didn’t obtain coverage: I didn’t need to. There were no pressing health concerns during those time periods. If there was a need for health insurance during those times, I could have obtained retroactive coverage-all the way up to three and a half months after leaving a job.
Dr. Gianoli, an ENToday Editorial Board member, is Clinical Associate Professor of Pediatrics and Otolaryngology-Head and Neck Surgery at Tulane University School of Medicine in New Orleans, and Vice President of The Ear and Balance Institute in BatonHow the 40 Million Breaks Down
Most of the 45% of the 40 million Americans who are without health insurance for less than four months during the year are between jobs and are temporarily without insurance until their new job begins. Like my personal situations described above, these people are covered or could be covered by health insurance retroactively through COBRA for up to three and a half months after leaving their job before a premium is due. So nearly half of the uninsured for all practical purposes are insured. There is no burning imperative for most of these Americans to obtain health insurance.
Well, what about the other 20 million or so Americans who go without health insurance for more than four months? The vast majority of this group can be separated into four categories: Medicaid undercount, Medicaid eligible, illegal aliens, and non-believers.
The CBO reported that the surveys of the uninsured undercount Medicaid enrollment by 4 to 5 million Americans. These individuals are erroneously classified as uninsured. This 4 to 5 million does not include those who are Medicaid eligible who have never had the need for any significant health service and consequently have never enrolled in Medicaid. For these people, Medicaid provides a form of conditional coverage. Such people can apply for Medicaid at the time they obtain care and receive retroactive coverage for their expenses. Nearly 3 million children fell into this category, which represents approximately one-third of the uninsured children.
The number of illegal aliens in this country has been estimated to be at least 10 million and they are overwhelmingly among those without health insurance. A recent study by the Center for Immigration Studies of immigrants from Mexico (no distinction was made whether they were legal or illegal immigrants) who have been in the US for less than 10 years demonstrated that 62.9% were uninsured. Illegal immigrants have been estimated to represent anywhere from 25% to 43% of the uninsured population.
The growth in the uninsured can be traced to the growth in the illegal alien population. The Center for Immigration Studies’ analysis of Census Bureau data demonstrates that almost three-fourths of the increase in the uninsured population over the last 15 years is due to immigrants and their children.
Finally, 4 to 5 million of the uninsured Americans in the CBO study stated that they did not have health insurance because they did not need health insurance or they did not believe in health insurance. This is not an unreasonable position if you are either very wealthy, or very healthy and poor. After all, do you think it makes economic sense for Bill Gates or Warren Buffet to purchase health insurance? Or did it make sense for me to buy health insurance when I was a medical student, had no income, and had a negative net worth?
Insurance versus Access
The most erroneous part of this myth of 40 million Americans without access to health care is the access part. No health insurance does not equate to no health care. A more appropriate, but still inaccurate, statement would be 40 million Americans have no health insurance. People without insurance are treated for free in every hospital across America. All physicians have treated patients who do not have health insurance.
In fact, this has been the case in America for decades. Free medical care is offered throughout our nation at Public Health Clinics, county hospitals, and free clinics. This is not counting the VA system of hospitals and clinics as well as some private individual medical offices that offer free care or discounted care to those who can’t afford to pay. A Google search for free medical care reveals 275 million Web sites-13,500 Web site hits for the state of Maine alone. The US Department of Health and Human Services Web site (http://ask.hrsa.gov/pc ) does a particularly good job at listing many of the free clinics via a search engine-there are 81 free clinics listed for the state of Maine.
However, since the introduction of EMTALA in 1986, it is currently a law that no one can be turned away from an emergency room without being treated regardless of their ability to pay. The threat of government sanction of both the hospital and the physician for noncompliance exists. In other words, someone without health insurance and with no funds can arrive at an emergency room at 2 o’clock in the morning in any hospital in our nation and demand that an otolaryngologist be consulted in the treatment of their nasal obstruction. The hospital and the otolaryngologist must provide these consulting services free to the patient. If they do not treat this patient in a timely manner, the physician may be liable for a $50,000 fine (per infraction) that is not covered by any insurance policy.
As you can see, all of the uninsured population has access to health care. The vast majority of the uninsured population has access to health insurance coverage but does not take advantage of this benefit for one reason or another. Often their reasons are quite good. Consequently, it is not surprising to see less than 2,000 previously uninsured individuals sign up for Maine’s Dirigo Health among the estimated 136,000 uninsured population. While insuring the uninsured may be a noble goal, not understanding the true nature of the problem can cause more than wasted resources. It can prevent us from looking for answers to the real problems. As Mark Twain said: It isn’t what we don’t know that kills us, it’s everything we know that ain’t so.
©2006 The Triological Society