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Commentary: Who will lead on health-care reform?

This article first appeared in the St. Louis Beacon, Feb. 17, 2009 - The complexity and effectiveness of medicine has increased exponentially from the time, not too long ago, when many illnesses were untreatable and medicine's role was to support the patient as life slipped away. The stunning advances in our ability to diagnose, treat and cure disease, however, have been costly, and those costs have made access to services more and more difficult for more and more people.

Further, the costs of care, coupled with the system we have in place for securing financial access, have created what can be called (with apologies to Eisenhower), a "medical-industrial complex" - a profusion of businesses, both non-profit and for-profit, that depend on the status quo in the financing and organization of the American health system. The result has been the most costly health-care system in the world. No one but the very rich has the means to pay for complex care out-of-pocket, to function as individual buyers in the health-care marketplace.

The alternative is a collective one - spread the risk of incurring high costs across a large population through insurance, which can be either social insurance or commercial insurance. In our society, this mechanism for spreading risk has become intertwined with employment.

The employment-based health insurance model has major flaws when viewing access as a societal issue. The most obvious is what happens when one becomes unemployed or lacks the skills or opportunities to be employed. This is the fastest rising cause of uninsured status.

Another problem that many are experiencing is the steady increase in premium sharing and co-payments as the cost of a health benefit eats away at profits. Even when offered, uptake rate is falling as workers find the co-pays so high that they cannot meet them and other basic needs, such as food, housing and utilities.

And many service industry firms provide no health coverage or very limited coverage for their employees.

How big is this problem?

The latest figures from the Bureau of the Census tell us that, in 2008, there were 45.7 million Americans who were uninsured. Even more disturbing is the finding that more than 8 million children are included in that figure.

Missouri is notable, however, for the marked increase in the number of uninsured since 2005. From 2006 to 2008, Missouri's uninsured population increased to 729,000 from 668,000 according to the U.S. Census. This 9 percent increase resulted in the percentage of uninsured Missourians increasing to 12.6 percent from 11.7 percent of the state's population. The growth in the uninsured can be tied to both the decrease in Missouri Medicaid coverage in 2005 and a decline in the number of Missourians with employer-sponsored health coverage. As with the national data, the number of Missouri's children who are uninsured is distressing, reaching 150,000 in 2008.

Myth vs. fact

The problem of the uninsured is beset by a great deal of misunderstanding on the part of the public. These myths stand in the way of efforts to deal effectively with the problem.

MYTH: Most people without health insurance are below the poverty line.
FACT: Although two-thirds of the uninsured have incomes below 200 percent of the federal poverty level (about $42,400 for a family of four), about 15 million have larger annual incomes. Since the average annual cost of employer-sponsored family coverage in 2007 was $12,106, even those with moderate incomes can only afford coverage if they receive sizable employer contributions.

MYTH: Most Americans are adequately covered through their employment.
FACT: Less than 60 percent of Americans are covered through employment today. This percentage, which approached 80 percent in the early 1960s, is continually decreasing.

MYTH: It doesn't really matter whether a person has health insurance.
FACT: The Institute of Medicine found about one-quarter of uninsured adults go without needed care due to cost each year. The uninsured are less likely than those with insurance to receive preventive care and services for major health conditions. Lack of access to timely care causes more than 20,000 uninsured adults to die prematurely each year.

MYTH: People without health coverage don't work.
FACT: Approximately eight in 10 of the uninsured live in families with at least one worker. Uninsured workers typically do not have employer-sponsored insurance offered through their jobs and cannot access it through a family member.

MYTH: Virtually everyone who works for a large employer has health coverage.
FACT: More than 26 percent of adult uninsured workers in 2003 worked for a firm with 500 or more employees. The retreat from coverage is broad within the business community, although more marked for small business.

MYTH: The uninsured can access Medicaid and be covered.
FACT: Medicaid eligibility is limited and a large proportion of the uninsured - single adults - are not eligible for Medicaid in Missouri or any state.

Could society afford to cover the uninsured?

For years, the conventional wisdom asserted that there is enough money in the system to cover all Americans. Recently, the Missouri Foundation for Health put that to a test.

A nationally known economist was asked to determine how much is spent in Missouri each year on health care. He examined every source of funds flowing into the system in the state and concluded Missouri spends $30 billion annually on such care.

He was asked to then determine how much more would be required to cover the uninsured (at that time about 550,000 Missourians). After studying the patterns of expenditure in the state, he responded that the cost would be $1.2 billion ... less.

He essentially calculated the cost of covering the entire population of the state if all were enrolled in a Medicare-type program with its lower administrative cost burden.

Now the idea of "Medicare for all" is an unlikely next step in Missouri or the country, but it does demonstrate that there are "empty calories" in the financing system - costs that provide no medical care to anybody.

The perception that there is no problem because it is not my problem lies at the heart of the issue of covering the uninsured.

It contributes to the lack of the political will that is essential if the problem is to be solved.

It allows the national and state policy agendas to be set by political ideologies, provider interests and industry associations with a vested interest in the current system.

It maintains the fiction that there really is a safety net that handles all the health needs of all the medically marginalized.

Unless and until there is wide understanding and acceptance among members of the public of the impact of our flawed system of paying for health care in both financial and human terms, there is little chance that the situation will improve.

Who will take the leadership role in bringing public understanding to the level required to reach the tipping point - to develop the level of understanding and concern that will create the political will to change the system?

It seems to me that the nation's congregations have the opportunity and the obligation to assume the mantle of leadership on this issue. I know that many of your congregations both individually and collectively are engaged with the issue in this community. But I am suggesting something much larger - a national movement, perhaps starting here in St. Louis, to mobilize people of faith to stand up for the medically marginalized - or to paraphrase a line from the old movie Network to say "We're mad as hell and we're not going to take it anymore!"

  • We'll no longer accept 45 million uninsured Americans because changing things doesn't please special interests!
  • We'll no longer accept that pouring dollars into congressional pork has priority over the health of our children!
  • We'll no longer accept that we can't afford health coverage for all Americans while projecting our nation as the last great superpower!

What can the focus for such an effort be? I know there are many opinions. Some actively support single payer health insurance. Others support mixed market-government models. Still others would seek totally market-based solutions.
Regardless of these divisions, proponents of these varying approaches seem to recognize that the system for securing financial access to needed health care is broken.

How can we define a goal for public policy that will allow dialogue across these differing approaches and move us toward a solution to the problem of the uninsured and underinsured? Can we find agreement on a goal that will promote progress? I suggest that we can.

A goal that people of differing views concerning details of a solution might embrace is to seek Guaranteed Affordable Choice for all Americans.

There was a phrase in the General Confession in the 1928 Prayer Book of the Episcopal Church that has come to mind at several points in my decades in public health and health policy:

"We have left undone those things we ought to have done, and we have done those things we ought not to have done and there is no health in us."

It is long past time to do those things we ought to have done - to assure that every citizen of this country, whatever their social or economic status, is guaranteed access to medical care at a cost each can afford and to eliminate the disparities in health status that place many of our fellow Americans on a health status level with the poorest of Third World countries.

We know how to do these things; we know where we need to go. Lead us!

This is adapted from a recent address by Dr. James R. Kimmey, president and chief executive of the Missouri Foundation for Health , at the Webster Groves Presbyterian Church.

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