Who Are the Uninsured?

Any attempt to make healthcare more affordable to a greater number of citizens should be based on an accurate accounting of the uninsured.

How many of our citizens are uninsured? Who are these people?

According to the Current Population Survey (CPS) by the U.S. Census Bureau, there were about 47 million in 2006, at the time of the survey. However, only about half of those remained uninsured throughout the entire year. Still, as Thomas P. Miller, resident fellow of the American Enterprise Institute, notes that’s too many.

But to know what should be done, we need to know who these people are and why they are uninsured. Back in the spring, Miller provided a breakdown in a useful Q & A format. A few highlights:

Q: Who tends to be uninsured?

A. They tend to be younger, with those most likely to be uninsured between ages 19 and 24. Almost all adults age 65 and above are covered primarily by Medicare, and many of them have supplemental private insurance. Men are a little bit more likely to be uninsured. Married individuals and persons with more than a high school education are much more likely to be insured. Most of the uninsured (88 percent) are in good to excellent health. The likelihood of being insured rises with income and full-time work status, although nearly half (47 percent) of the uninsured are full-time workers. Hispanics are considerably more likely than those in any other ethnic category to be uninsured (over 30 percent). More than a quarter of the uninsured are foreign-born. By Census Bureau estimates, about 10 million uninsured are not citizens and half of them are illegal immigrants.

Q: Do many higher income people choose to be uninsured, even though they could afford to buy coverage?

A. Surveys suggest that one of the more significant sources for recent annual increases in the number of uninsured Americans involves persons in relatively higher income households. According to the CPS, more than 17.6 million uninsured live in households earning more than $50,000 a year, and household income is above $75,000 for more than 9 million uninsured. However, those numbers overstate the actual income available to those uninsured individuals, because household units are defined more broadly than are insurance purchasing units. As the composition of “households” changes, their income isn’t the same as family income available for spending on health insurance. The rising cost of coverage remains the primary barrier to insurance coverage for the uninsured, and in some cases, its value just may not be “worth it” for those in higher income families. But a more narrow and consistent measure of the higher income uninsured is closer to 2 million, involving people with regular incomes over $50,000 who lack insurance for spells of more than a year.

Q: Isn’t affordability of coverage the main problem, particularly for high-risk individuals?

A. The main reason cited by individuals for why they lack insurance is that it costs too much, but it’s not the only factor. Adults with weak or uncertain preferences for health insurance are less likely than others to obtain job offers with insurance, to enroll in offered coverage, and to be insured. On the other hand, individuals with higher health risks are more likely to seek and obtain health insurance coverage, particularly in the large employer group market. Higher premiums for higher risks are not a significant contributor to the large uninsured population.

Q: Don’t the uninsured obtain healthcare anyway?

A. Yes, but not as much, not as quickly, and not as effectively. People lacking health insurance pay out of pocket, receive uncompensated care, rely on other forms of private and public insurance (such as worker’s compensation), and wait until they have access to health insurance. Overall, the full-year uninsured receive about 50 to 55 percent of the dollar amount of medical care per person of those who have coverage for the entire year. People uninsured for only part of the year average more than 80 percent of the healthcare spending by the full-year insured.

Q: How much uncompensated care is received by the uninsured? Don’t the privately-insured pay higher premiums to make up the difference?

Eghty-eight percent of the uninsured are in good to excellent health.

A. Best estimates indicate that about one-third of the cost of health services received by the uninsured is “uncompensated care”—less than 3 percent of all U.S. healthcare spending. Most of those costs are covered by various taxpayer-funded payments (particularly disproportionate share payments to hospitals likely to treat more uninsured and low-income patients). There isn’t much left in the residual costs of uncompensated care to “shift” to private insurance premium payers. To the extent such cost shifting can occur not just in theory but in practice, it’s due much more to public programs like Medicaid and Medicare that have the legal power to pay much lower “below-market” rates of reimbursement to hospitals and doctors. Expanding low-paying Medicaid coverage might actually make any possible cost shifting to private premium payers worse, not better.

I do hope you’ll read Miller’s entire piece. There are some good bits on the use of the emergency room. It strikes me that quite a few people have simply chosen not to have health insurance—and I don’t see why, if they can afford it and are content with the risk, others should be taxed to provide health care insurance for them. We should not pay for their irresponsibility.

The uninsured who actually can’t afford it are another story. But if you look at the last question, you see that their needs are less dire than we are constantly led to believe. We should look for incremental, modest reforms that address their needs.

But we do not need to radically alter the relationship of government to every single citizen in the United States (minus congressmen, who have tip top policies, and that won’t change!) to address a problem that is smaller and different in character from what we are told by those who desire radical restructuring of society in and for itself.

But Senator Dole….

Elder statesman Bob Dole has taken it upon himself to offer President Obama some tips for health care reform: start afresh with a new bill from the White House rather than Democrats on the Hill:

“Obama’s approval numbers would jump 10 points if Americans knew he was fully in charge. A tactical move of introducing his own plan would also stir more Republicans to become active for reform in critical areas. Right now the president’s biggest problem is with congressional Democrats, who are split and searching for a way out of the medical wilderness.”

There’s a problem to this rosy scenario: an administration bill would most likely include all the things that caused the public to rebel in the first place. But Dole is right that for the time being Obama’s biggest challenge isn’t Republicans.

Yes, Bureaucrats Will Come Between You and Your Doctor

Tired of hearing that America “ranks 37th” in the world in health-care quality? Well, guess what, we’re actually more like No. 1.

Harvard Medical School professors Jerome Groopman and Pamela Hartzband (who are also physicians on the staff of Beth Israel Deaconess Hospital in Boston) have an opinion piece in the Wall Street Journal that explodes the myths about supposedly substandard U.S. health care and, even more significantly, points out that yes, under Obamacare bureaucrats will come between patients and their doctors and Washington will pretty much dictate what sort of care patients receive. The opinion piece is significant because Groopman, at any rate, is a staff writer for the liberal New Yorker who strongly believes in health-care reform.

Here are a couple of the myths that Groopman and Hartzband tackle:

We’re 37th.

That’s what the World Health Organization says about us–suggesting tht we’re down there with the Third World in terms of health care, even though most of us think our doctors and hospitals are first-rate.Here’s what Groopman and Hartzband say:

The World Health Organization ranks the U.S. No. 1 among all countries in “responsiveness.” Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). This is what Americans rightly understand as quality care
and worry will be lost in the upheaval of reform. Our country’s composite score fell to 37 primarily because we lack universal coverage and care is a financial burden for many citizens.

No government bureaucrat will come between you and your doctor.

That’s what President Obama keeps telling us at town halls. Here’s what actually would happen if the House health bill becomes law, according to Groopman and Hartzband:

But his proposal to provide financial incentives to “allow doctors to do the right thing” could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions.

Further, at the AMA convention in June 2009, the president proposed linking protection for physicians from malpractice lawsuits if they strictly adhered to government-sponsored treatment guidelines. We need tort reform, but this is misconceived and again clearly inserts the bureaucrat directly into clinical decision making. If doctors are legally protected when they follow government mandates, the converse is that doctors risk lawsuits if they deviate from federal guidelines—even if they believe the government mandate is not in the patient’s best interest. With this kind of legislation, physicians might well pressure the patient to comply with treatments even if the therapy clashes with the individual’s values and preferences.

Read the whole thing–and pass it on to your liberal friends who think that Dr. Obama offers the best prescription for our health-care ills.

Art for Obamacare

I had no idea that the National Endowment of the Arts was supposed to be the propaganda arm of the White House–until I read this:

I was invited by the National Endowment for the Arts (NEA) to take part in a conference call that invited a group of rising artist and art community luminaries “to help lay a new foundation for growth, focusing on core areas of the recovery agenda – health care, energy and environment, safety and security, education, community renewal.”…

Obama has a strong arts agenda, we were told, and has been very supportive of both using and supporting the arts in creative ways to talk about the issues facing the country. We were “selected for a reason,” they told us. We had played a key role in the election and now Obama was putting out the call of service to help create change. We knew “how to make a stink,” and were encouraged to do so.

That’s filmmaker and arts marketer Patrick Courrielche writing for Big Hollywood. The conference call took place on Aug. 16.

Here’s what Wikepedia says the NEA is supposed to be:

The National Endowment for the Arts (NEA) is an independent agency of the United States federal government that offers support and funding for projects exhibiting artistic excellence.[1] It was created by an act of the U.S. Congress in 1965 as an independent agency of the federal government.

“Independent agency.” That doesn’t mean “tool of the presidency” to me. And I had no idea that that the purpose of art was to “make a stink”–or push socialized health care or whatever. I thought the purpose of art was to use the artist’s skilled craftsmanship to make objects of meaning and beauty. Silly me!

h/t: Ace of Spades HQ

Hentoff: We must guard liberty

Today’s must-read on health care is Charles Krauthamer’s piece. First the good news:

“Obamacare Version 1.0 is dead. The 1,000-page monstrosity that emerged in various editions from Congress was done in by widespread national revulsion not just at its expense and intrusiveness but also at the mendacity with which it is being sold. You don’t need a PhD to see that the promise to expand coverage and reduce costs is a crude deception, or that cutting $500 billion from Medicare without affecting care is a fiction.”

The bad news is that through a series of maneuvers we could end up with government healthcare “by proxy:”

“And because it’s proxy, and because it will guarantee access to (supposedly) private health insurance — something that enjoys considerable Republican support — it will pass with wide bipartisan backing and give Obama a resounding political victory.

“Isn’t there a catch? Of course there is. This scheme is the ultimate bait-and-switch. The pleasure comes now, the pain later. Government-subsidized universal and virtually unlimited coverage will vastly compound already out-of-control government spending on health care. The financial and budgetary consequences will be catastrophic.

“However, they will not appear immediately. And when they do, the only solution will be rationing. That’s when the liberals will give the FCCCER regulatory power and give you end-of-life counseling.

“But by then, resistance will be feeble. Why? Because at that point the only remaining option will be to give up the benefits we will have become accustomed to. Once granted, guaranteed universal health care is not relinquished. Look at Canada. Look at Britain. They got hooked; now they ration. So will we.”

Anyone who believes that the health care battle is won needs to wake up: This is not something that Obama will drop. He regards it as the cornerstone of radical change.

We have only one hope to fend off socialized medicine (are we allowed to use that term yet?)—ourselves. Nobody understands that better than the columnist Nat Hentoff:

“Startlingly — and wholly involuntarily — President Obama is teaching us that, as Thomas Jefferson often said, ‘the people are the ultimate guardians of their own liberty.’ The growing resistance to the president’s goal of state-controlled health care is moving more of us to act on our constitutional power to protect our quintessential individual liberty — to decide for ourselves how long we are going to stay on this Earth.
”The reverberating town-hall meetings are a legacy of the 1765 meeting in Boston where Samuel Adams and the Sons of Liberty organized against King George III and, not having access to the Internet, later started the Committees of Correspondence that alerted all the colonists to insistent royal threats to their personal liberties. During a secret meeting in Virginia, Jefferson helped organize such a committee in his state.”

Truth to Truth, Part 2: Betsy Markey Lets the Cat Out of the Bag

From the Coloradoan:

Some people, including Medicare recipients, will have to give up some current benefits to truly reform the nation’s health-care system, Rep. Betsy Markey told a gathering of constituents in Fort Collins on Wednesday.

Markey has repeatedly said during the August congressional recess that Medicare spending needs to be reined in to help pay for reforming the broader health-care system.

“There’s going to be some people who are going to have to give up some things, honestly, for all of this to work,” Markey said at a Congress on Your Corner event at CSU. “But we have to do this because we’re Americans.”

And here’s Karl Rove in the Wall Street Journal on one of the “things” that our patriotic senior citizens will have to “give up” in President Obama’s brave new health world:

Two weeks ago, White House Senior Adviser David Axelrod said in a now legendary “viral” email that, “It’s a myth that health insurance reform would be financed by cutting Medicare benefits.” This was sent out the day before Mr. Obama told a Montana town hall that he’d pay for health-care reform by “eliminating . . . about $177 billion over 10 years” for “what’s called Medicare Advantage.” And it was two days before Mr. Obama told a Colorado town hall he’d cover “two-thirds” of the “roughly $900 billion” of his plan’s cost by “eliminating waste,” again citing Medicare Advantage.

Who’s right? As a former senior adviser, I can tell you who: the president. What’s more, according to a White House fact sheet titled “Paying for Health Care Reform,” Mr. Axelrod was misleading his readers. It notes the administration would cut $622 billion from Medicare and Medicaid, with a big chunk coming from Medicare Advantage, to pay for overhauling health care. Mr. Obama heralded these cuts as “common sense” in his June 13 radio address.

Medicare Advantage was enacted in 2003 to allow seniors to use Medicare funds to buy private insurance plans that fit their needs and their budgets. They get better care and better value for their money.

Medicare Advantage also has built-in incentives to encourage insurers to offer lower costs and better benefits. It’s a program that puts patients in charge, not the government, which is why seniors like it and probably why the administration hates it.

h/t: Hot Air, Ace of Spades HQ

Howard Dean Speaks Truth to Truth on Tort Reform

Last week former Alaska Gov. Sarah Palin asked on her Facebook page why the House Democrats’ healthcare bills said not a word about tort reform. A good question, since fear of medical malpractice suits–and the multimillion-dollar ‘non-economic” and punitive-damage jackpots that some of them engender–have jacked up the price of medical care as doctors practice defensive medicine with unncecesary tests and hiked up their fees to cover sky-high malpractice insurance premiums. (An example: the more than 50 $1 million-plus jury verdicts and setttlements scored by former trial lawyer and 2008 presidential candidate John Edwards in lawsuits he filed targeting, among others, an obstetrician who delivered a baby born with cerebral palsy and a psychiatrist whose patient committed suicide.

So it seemed pretty natural for Roland Tulino, a resident of Reston, Va., attending an Aug. 25 town hall sponsored by Democratic Rep. Jim Moran of Virginia, to ask Moran why the none of the 1,000-page-plus House healthcare draft bills contained any provision for doing something to cap the outrageous damage jackpots that have made the practice of medicine unnecessarily expensive for doctors and patients.

Moran, after hassling Tulino over whether he was really a Reston resident (Tulino proferred identification, and Moran later apologized), turned the podium over to Howard Dean, a physician, former Vermont governor, and former Democratic Party chairman. Here’s what Dean said (and you can watch the vid):

“This is the answer from a doctor and a politician,” said Dean. “Here is why tort reform is not in the bill. When you go to pass a really enormous bill like that the more stuff you put in, the more enemies you make, right? And the reason why tort reform is not in the bill is because the people who wrote it did not want to take on the trial lawyers in addition to everybody else they were taking on, and that is the plain and simple truth. Now, that’s the truth.”

Uh huh. Over the past decade trial lawyers have contributed some $762 million to Democratic candidates for public office. Not surprisingly, they expect tit for tat. House Republicans narrowly succeeded in blocking from the House health bill a proposal that would have allowed freelance trial lawyers to go on bounty-hunting expeditions–supposedly on behalf of the government, but without asking the government’s permission–to collect hypothetical Medicare liens against defendants in malpractice and other accident lawsuits and then keep a portion of the proceeds for themselves.

Kleenex-time?

During the presidential campaign, I had the privilege of witnessing one of Michelle Obama’s “roundtables” for working women. It was in Richmond, and the future first lady came prepared with an ostentatious box Kleenexes that would come in handy for, well, sob stories. Here is some of what I saw:

“‘Mary, you think you are ready to get us going? So, Mary, just take your time and tell your story,’ Obama says. Henley reports that her husband died suddenly, while the couple were in their car, and now Henley, who still works part time, lives on a reduced income and has “a lot of debts.”

“‘Well, again, unfortunately, there are thousands of senior citizens like Mary, people who have worked hard, not sitting in an office, but worked, worked until the bitter end. This is the fate of many seniors,’ Obama says. If you have any doubt that there are Oprah elements in today’s program, Michelle reaches over and hands Henley a Kleenex.

“Mrs. Henley’s story is sad and disturbing. I almost want a Kleenex because it is not only touching but the sort of story that inspires a shudder in the hearts of all of us who have ever had retiree bag lady fears. Even for one well-disposed towards widows and orphans, however, there is some missing information. How were the Henleys’ debts incurred? It may be that they were unavoidable, but we don’t know, and adding to the mystery, Henley vaguely notes, ’I made some mistakes’ in handling her money. Most of us have, but the question is whether Mrs. Henley’s plight stems from her mistakes or factors in the economy that require government intervention. Throughout the two-hour roundtable, the same question might be asked of each participant–but isn’t.

“The next panelist, Leigh Hite, a “full-time college student,” who is also a “full-time” mother, who works “full-time”–whew–has been in the same job for 19 years and now wants to make a change. College tuition is eating her family alive, and they can no longer live “paycheck to paycheck” as they did before the Bush administration came to office.

“Instead of raising the question as to why college costs astronomically more than it once did (some have suggested government aid might, ironically, be a root cause), Obama invokes the specter of former senator and McCain adviser Phil Gramm, without quite naming him. She says some people believe that the ‘challenges people face are not real’ and ‘then we start to blame ourselves.’ The Obama campaign doesn’t want you to ever blame yourself.”

I dredge up this memory because I think we’re in for another wave of politically-useful tears. As is their right those who support Obamacare—opps! Make that Kennedycare—are now planning to take back the town halls (SEIU, the Obama-friendly union, says that a “radical fringe”—that would be the American people—have taken over the town halls and that this radical fringe must be thwarted).

My prediction: We will be hearing lots of sob stories. The media won’t challenge them—they certainly didn’t after Mrs. Obama’s Richmond roundtable. But we must be skeptical. This is one time when a jaundiced eye may better serve than a tearful eye.

Hippocrates? Who He?

I’m loving following the war of words between Betsy McCaughey, the woman whose 1994 articles for the New Republic  nearly singlehandedly sunk Hillarycare, and the Washington Post’s  Obamacare-promoting editorial writers over Ezekiel Emanuel, the White House health-care advisor who thinks that babies, small children, and people over age 65 shouldn’t be “guaranteed” medical services once the government takes over health care.

That’s because McCaughey’s winning the debate!

Item No. #1: McCaughey (who also happens to be a former lieutenant governor of New York) in an Aug. 17 op-ed for the New York Post that quotes chapter and verse from Emanuel’s own articles for the Journal of American Medicine and the Lancet:

Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else.

Many doctors are horrified by this notion; they’ll tell you that a doctor’s job is to achieve social justice one patient at a time.

Emanuel, however, believes that “communitarianism” should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those “who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia” (JAMA, Feb. 27, 2008).

Translation: Don’t give much care to a grandmother with Parkinson’s or a child with cerebral palsy.

He explicitly defends discrimination against older patients: “Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years” (Lancet, Jan. 31).

Item No. #2: An unsigned Aug. 22 editorial in the Washington Post, pointing out that Emanuel is “a respected bioethicist who opposes euthanasia and physician-assisted suicide (the editorial also accuses McCaughey–and former Alaska Gov. Sarah Palin–of “cherry-picking” Emanuel’s writings to make him look unfeeling):

Dr. Emanuel struggled with the question of how to determine, in a system where everyone is guaranteed health coverage, what services patients are entitled to…In any event, Dr. Emanuel said he has since become convinced that there is enough waste in the health-care system that universal coveragecan be achieved without rationing….

Dr. Emanuel’s writings reveal him to be a thoughtful person grappling with difficult ethical issues. The same cannot be said of his critics, who seem less intent on discussing what is in the health reform proposal than in deploying scare tactics to defeat it.

Item No. #3: A second op-ed from McCaughey, this time for the Wall Street Journal on Aug. 26, that again uses Ezekiel’s own writings to refute the Washington Post’s breezy assertion that Ezekiel thinks that removing “waste” from the health care system will obviate the need for rationing:

As he wrote in the Feb. 27, 2008, issue of the Journal of the American Medical Association (JAMA): “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely ‘lipstick’ cost control, more for show and public relations than for true change.”

True reform, he urges, must include redefining doctors’ ethical obligations. In the June 18, 2008, issue of JAMA, Dr. Emanuel blames the Hippocratic Oath for the “overuse” of medical care: “Medical school education and post graduate education emphasize thoroughness,” he writes. “This culture is further reinforced by a unique understanding of professional obligations, specifically the Hippocratic Oath’s admonition to ‘use my power to help the sick to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of cost or effect on others.”

In numerous writings, Dr. Emanuel chastises physicians for thinking only about their own patient’s needs. He describes it as an intractable problem: “Patients were to receive whatever services they needed, regardless of its cost. Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life. . . . Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold down costs.” (JAMA, May 16, 2007).

Of course, patients hope their doctors will have that single-minded devotion. But Dr. Emanuel believes doctors should serve two masters, the patient and society, and that medical students should be trained “to provide socially sustainable, cost-effective care.”…(JAMA, June 18, 2008).

Me, I’m rerelieved to learn from the Washington Post that Emanuel is against euthanasia–whew! I’m also happy to be assured that he’s a “thoughtful person” who really doesn’t hate kids and old folks all that much. But the idea of being treated by a doctor who thinks the Hippocratic Oath is archaic hooey and that his real patient isn’t me but, rather, “society” gives me the willies.

It’s also disturbing to know that Ezekiel sits on the Federal Panel on Comparative Effectiveness Research, a brand-new agency (its creation was sneaked into February’s stimulus bill) specifically designed to devise one-size-fits-all courses of medical treatment aimed at saving the government money once it takes over health care.

Remember that the backers of Obamacare expect to pay for it by cutting Medicare by $500 billion. As someone who’s not getting any younger, I’ll take Hippocrates over Dr. Ezekiel any day.

Nancy Pelosi Rides Queequeg’s Coffin

Remember how Rahm Emanuel said, “You never want a serious crisis to go to waste”?

Here’s House Speaker Nancy Pelosi just hours after Sen. Edward Kennedy expired of brain cancer:

US House Speaker Nancy Pelosi vowed Wednesday to push through embattled health reform legislation this year following the death of Senator Ted Kennedy, who called the effort “the cause of my life”.

“Ted Kennedy?s dream of quality health care for all Americans will be made real this year because of his leadership and his inspiration,” Pelosi said in a statement.

I hate to indulge in a watery literary reference with respect to the late senator, especially a Massachusetts watery literary reference (De mortuis nil nisi bonum and all that), but Nantucket isn’t that far from Hyannis Port–nor from Chappaquiddick.