How Medical Insurance Impacts Access to Health Care in the United States

Without Insurance Access to Health Care is Limited in the United States
Why the Insurance Model Was Chosen for Increasing Health Care Access
One of the things I learned while a student at the School of Public Health and Community Medicine was that people who lacked health insurance also lacked reliable health care. Let us review some of the national data in this regard. In my fifty-state analysis I reviewed the following components for individual health care measures: evidence of employer based health insurance, the state uninsured population, infant mortality and other clinical outcomes. Listed below are the top performers for the criteria, as well as the laggards.

States with the Highest Levels of Health Insurance, Public or Private
Using the latest Kaiser Family Foundation Insurance Survey , the 2010 results show the number one state for health insurance coverage is Massachusetts, with 95% reporting health insurance plans. Massachusetts has been the model for the national insurance exchanges because its state mandate has achieved near universal coverage and is self supporting. Other states deserving honorable mention for securing health insurance for 90% of their residents include: Hawaii, Vermont, and Wisconsin.

States with the Lowest Levels of Health Insurance, Public or Private
Women ages 19-64
In the same survey, the worst state for provision of medical insurance either public or private was Texas, with only 70% of its women reporting medical insurance coverage. The national average for insured women was 80% at the time of the survey. Florida reported that 74% of its adult women had medical coverage. A host of states reported only 75% of their adult female populations had medical insurance including: Arkansas, Mississippi, Nevada, and New Mexico.
Men ages 19-64
The national average for men with medical insurance was 76% by 2010. For Texas men only 65% had medical insurance. Other low fliers for men with medical insurance were: Georgia (71%), New Mexico (67%), and Florida (69%).
Children <18
Across the nation only 50% of our children had health insurance provided through their parent’s place of work. Though 90% of the nation’s children have medical insurance now, 36% of that figure is provided by public programs like Medicaid. For the children’s health survey, Texas also posted an equally poor level of insured children, the lowest in the nation, with 17% of the state’s children lacking medical insurance. This is despite the federally subsidized Children’s Health Insurance Program, so is Texas failing to enroll its children or are their parents making too much money to qualify?
Other states with high levels of an uninsured children included Florida (16%), Nevada (16%), and Arizona (15%). You would think Nevada could come up with something creative like a gambling tax to subsidize health insurance for its residents. Why do some of these states have so many more children without health insurance?
Cost of Deferred Health Care
Since the United States has chosen to finance its health care through a public and private system, the lack of payment for services for the uninsured gets allocated to hospitals and insurance plans. The federal insurance mandate is an attempt to stave the high costs for hospitals and communities from serving the uninsured population. Those states with higher levels of uninsured individuals mean that more health care is either delayed or delivered in emergency settings. Additionally, uninsured patients are not receiving preventive or basic health care. States that are laissez faire place a disproportionate burden on their hospitals to serve uninsured patients and this impacts the overall health care safety net.
Clinical Outcomes
If evidence of insurance is a factor in securing better health care, let’s see what the clinical data shows for these states. Infant mortality is an indication of prenatal and postnatal care and here are the infant deaths per 1,000 babies for the states with high levels of insurance, versus the low levels. These infant mortality rates are drawn from the 2009 Kaiser Foundation Survey. Infant mortality is just one measure of childhood health, but in adherence to brevity I am not going to list the other metrics I used in my full scorecard evaluation.
Infant Mortality
Best in class for both percentage of the population covered for insurance (95%) and the lowest infant mortality rate in the nation at 4.9 deaths is Massachusetts. Way to go mother Mass! This makes their prenatal and postnatal care equal to most of Europe, which is a high standard. And here is how the other well-insured states ranked for infant mortality per 1,000 babies: Hawaii-6.1 deaths, Vermont-5.6, and Wisconsin-6.3. Now let us compare this metric to the states which reported the lowest levels of children with health insurance and here are the infant deaths per 1,000: Texas-6.3, Florida- 7.2, Nevada-6.2, and Arizona-6.6. When you compare the average infant mortality of the states with higher insurance levels to those without, there is a difference of nearly one life per 1,000 babies, which is significant. Also, in case you don’t know, the United States infant mortality rate on average is 47th in the world, behind all of Europe and most of the developed world. And if you don’t already feel bad enough, some countries, including Singapore boast an infant mortality rate which is one third of the U.S. average at 2.31 deaths per 1,000 babies.

As we listen to the harping about Americans not having a right to basic health care, bear in mind that the United States has the highest percentage of children living in poverty in the industrialized world, at nearly one fourth (24%) of our child population. You have to ask yourself, what do our nation’s children have a right to in this wealthy country?

For more information on 50-state performance metrics come to the Northwest Women’s Show on March 2nd to hear excerpts from my book, Unraveling U.S. Health Care.

This article was written by Robert E. Winter, MHA, MPA and may be reprinted with her permission, but feel free to share it virally.

SCHIP veto, Rossi Response

Last month our illustrious president, George Bush voted not to provide health care for 900,00 low income children by vetoing the expansion of the Supplemental Childrens Health Insurance Plan, known as SCHIP. According to the nonpartisan nonprofit Kaiser Family Foundation, in 2005 there were 46.1 million people under the age of 65, without insurance in the United States. Of that group, only 25% are eligible for state Medicaid programs, including the SCHIP. Fifty six percent of the uninsured are not eligible for public health care programs but need financial assistance to purchase health insurance or health care. This means that if you are a family of four and earn more than $20,650, you are over the Federal Poverty Level. The SCHIP guidelines allows families earning no more than 200% of the FPL rate or $41,299, to apply for Medicaid coverage for their children. The proposed federal expansion for SCHIP would have allowed families with incomes up to 300% of the federal poverty level (about $61,950) to apply for Medicaid coverage for their children. The presidential veto of this legislation caused a schism among Republican legislators and considerable ire with Democratic representatives as well. The fallout of this decision was felt throughout the country, including Washington State where Dino Rossi, the loser in the last gubernatorial election and who is running for governor again commented on the President’s decision.

According to CounterIntelligence journalist, John Feit, gubernatorial candidate Rossi had this to say, "The majority of the children that are going to be coming on (to SCHIP expansion) are either illegal or currently have health insurance from the private sector." This article addresses the inaccuracies of Mr. Rossi’s statement, though one has to wonder about Rossi’s Catholicism and whether or not he is adhering to Catholic principles when he views children of immigrants who are living in this country as less valued than children who were born in America.

Here are the facts Mr. Rossi:

Your assertion that uninsured children have access to insurance coverage through private employers is wrong. The Kaiser Commission on Medicaid and the Uninsured reviewed this very question in 2007 and here is what they found:

Fact-The majority of the uninsured (56% according to the 2007 findings) are not eligible for public programs for health care and have incomes below 300% of the Federal Poverty Level. Of the six million children who live in poverty (200% of FPL), seventy percent live with families with parents who work, largely for small employers. Small employers do not offer health insurance to their employees at the same frequency as larger employers and fewer employers are offering coverage to their employees. The Kaiser Survey of Employer Sponsored Health Benefits for 2007 shows a precipitous decline in the proportion of small employers offering health insurance to their employees. For firms with fewer than ten employees, only 45% offer health insurance now, down from 56% in 1999. For all firms with less than two hundred employees, only 59% report offering health insurance today, versus 65% in 1999.

Your assertion that the expansion of SCHIP for families with incomes up to 300% of the FPL would disproportionately cover "illegals".

Fact- According to the Kaiser Commission, 85% of the pool of children who would be eligible for the SCHIP expansion are native United States citizens. Additionally, most new immigrants are excluded from Medicaid coverage during their first five years of residency, except for emergency treatment. Finally, the Deficit Reduction Act of 2005 requires residents to show proof of citizenship when applying for Medicaid, which also applies to SCHIP.

Rossi’s assumption that private employers are indeed making health insurance available and affordable for families living at 300% or less of the federal poverty level.

Fact-Most of the families who earn 300% or less of the federal poverty level are employed by small employers, many of whom do not offer insurance. According to the 2007 Survey of Employer Sponsored Health Benefits, the average cost for an individual enrolled in an employer sponsored health plan in the United States is $4,479 and $12,106 for a family of four. Since employees are usually expected to pay a significant portion of their health care premiums under private employer benefit plans, how can a family of four earning less than $ 41,300 per year afford medical insurance? The budget in this chart assumes the employee is expected to pay all of the cost for his dependents enrolled on insurance.



Family of Four Budget

Income Ceiling for SCHIP Expansion

$ 61,949

FICA & Medicare

4,740

Taxes at minimum rate after credits

7,981

Net available for living expenses

$ 49,228

Expenses

Housing

12,000

Utilities

3,000

Phone, cable television

591

Food

10,950

Transportation-inc. repairs, insurance, parking, maintenance, payment or lease

10,000

Savings/retirement-3% minimum

1,858

School expenses

500

Clothing

500

Personal care-hair cuts, etc,

1,000

Miscellaneous-repairs, etc,.

1,200

Subtotal for living expenses

$ 41,599

Net available for Health care

$ 7,629

Health Care Costs

Healthcare copayments

250

Health insurance premiums (employee, spouse & 2 children)

12,106

Subtotal health care expenses

$ 12,356

Net After Purchasing Health care

$ (4,727)



Since you are wrong on so many levels about your health care assumptions, is this what we can expect from your gubernatorial ambition? Next time get your facts right.



This article was written by Roberta E. Winter, MHA, MPA, who is a graduate of the University of Washington School of Public Health and the Evans School of Public Affairs.