Problem of the Uninsured: Health Disparities

Health Disparities of Uninsured

Statistics show that approximately 47 million of America's population lacks medical coverage, and another 38 million has inadequate health insurance. What these statistics imply is that one-third of Americans are insecure and unsure about whether they would afford healthcare if they fell sick or needed medical help today. The State of Texas tops the list, with an uninsured population of approximately 8 million, representing 25.1% of the total (Code Red, 2006). Minority groups form a bulk of the uninsured population (Wu & Ringwalt, 2005). The impact of a large uninsured population, however, is massive -- the uninsured affect both themselves and the communities in which they live, compromising the quality of care and placing everyone at risk. They do not often have a primary care physician, which means that they neither seek out medical care when they are supposed to, nor turn up for preventive care like routine check-ups and immunizations. The consequences of delayed treatment spread far and wide; the uninsured end up in emergency rooms, incurring hospitalization costs that would easily have been avoided, and eventually passing on the extra costs to the insured population, and the already-overburdened taxpayer.

Health Disparities of the Uninsured

Uninsured people "are less likely to receive adequate care, and when they do, it comes later with serious consequences such as increased mortality and lower quality of life" (Code Red, 2006, p. 46). The uninsured shun medical bills, which is why they do not seek out medical care when they need to; instead, they postpone care - waiting for their conditions to worsen to the point that they have to receive the most costly care in the emergency room. Anyone who has been in the U.S. long enough knows that it costs way more to treat a condition in the emergency room as opposed to the doctor's office. It makes sense, therefore, that most of these uninsured people receiving ER treatment are often unable to pay for the care they receive; and given their large numbers, the government is often unable to match the expenses, and the taxpayer bears the ultimate cost.

Emergency rooms are intended to handle trauma, urgent health conditions and sudden illnesses. The uninsured, however, who have no access to any other primary sources of care, impact the emergency department's ability and finances to handle the most serious cases, overburdening the local trauma systems, causing longer waiting time in emergency rooms, and consequently lowering the quality of emergency care for everyone else.

Just like they are unlikely to seek treatment when they are supposed to, the uninsured are less likely to turn up for preventive care and routine check-ups. They often are unable to catch things on time, perhaps because they are not aware of their health conditions, but also because they have no medical coverage and are afraid of medical bills. Conditions such as diabetes, cancer and hypertension have significant diverse outcomes; but these outcomes can be monitored and kept in check if the conditions are detected early enough. Prevention is always better than cure; and it indeed costs far much less to treat pre-cancer, pre-hypertension, and pre-diabetes as opposed to the disease once it has taken root.

Literature Review

The existing body of literature largely focuses on demonstrating why America has such a large uninsured population; and how federal policies such as Medicaid and CHIP have affected this population.

Who are the Uninsured?

Prentice et al. (2005) express that a bulk of the insured population comes from low-income working families. Blumberg and Liska (1996) support this view, asserting that despite their low incomes, most uninsured people "do not qualify for public assistance either due to categorical ineligibility or because their modest incomes still exceed eligibility cut-offs" (n.pag). 90% of those who happen to be uninsured come from low and middle-income. It is important to note that in comparison to children, adults are more likely to be uninsured - because the latter seem to benefit more from Medicaid and Children Health Insurance Program (CHIP) (Blumberg and Liska, 1996). The authors posit that a family's work details have little to do with its insurance status as 60% and 16% of uninsured people come from families with at least one full-time worker and one part-time worker respectively. Although uninsured rates vary from state to state, states in the west and in the south have often reported higher rates. Of crucial significance is that people from minority groups are more likely to be underinsured than the majority (Wu & Ringwalt; Abdullah et al., 2009). Blumberg and Liska attribute this to the fact that whites have a high likelihood of coverage (thanks to employer-sponsored insurance) than blacks (67% vs. 48%); and even though blacks are more likely to benefit from Medicaid programs, the leverage is never sufficient to offset employee-sponsored insurance.

Why is the Uninsured Population so large?

The most obvious reason is that health insurance is expensive, and hence, most people are uninsured not because they do not deem coverage necessary, but because the cost is too high (Blankenau, 2009; Gruber, 2008). Employer-sponsored insurance is the most common form of coverage, but then a bulk of the population is either self-employed, or working for small firms that may be in no position to offer health benefits; and even for those that do, the workers may not be able to settle their share of premiums (Gruber, 2008). For instance, last year, the cost of employer-sponsored family coverage stood at $16, 351 - twenty-nine percent of which was covered by a worker's premium share; not forgetting that this premium share had risen by a massive 80% between 2003 and 2013. CHIP and Medicaid provide coverage for children in low-income families, the elderly, pregnant women, and people with disabilities; however, a large portion of the low-income population is still left out, particularly because most states do not provide Medicaid coverage to parents and low-income adults without dependents (Swartz, 2009).

The Trend in Uninsured Levels

Swartz (2008) and Gruber (2008) contend that there has been a steady increase in the number of uninsured people over the last decade or so, due to the rising cost of healthcare and the massive reductions in employer-sponsored insurance. The 2008 financial crunch led to steep increases in the number of insured people, as most people lost both their jobs and employer-sponsored coverage. Federal interventions in the form of CHIP and Medicaid, however, prevented steeper drops, leveraging eligible Americans' incomes during, and immediately after the recession. The past two years have, however, seen the uninsured rate decline because of the expanded public coverage and the stabilization of employer-sponsored insurance.

Implications of Lack of Coverage

Since they often seek medical care when their conditions have spiraled to levels requiring emergency care, the uninsured often face huge, unaffordable medical bills, which quickly translate into medical debt given their low incomes and dismal savings (Blumberg and Liska, 1996). Uninsured patients often end up paying almost 40% of their healthcare costs out-of-pocket, and consequently putting a strain on their financial and physical well-being (Blumberg and Liska, 1996). This, furthermore, is the case if they indeed seek out medical care -- the uninsured are perfectly aware that they may not afford to pay for their medical care; as such, they develop anxiety and typically delay care, or forgo it altogether (Gruber, 2008; Blumberg and Liska, 1996). Abdullah et al. (2009) analyzed data from 23 million admissions over a period of eighteen years and found that 16,787 deaths and six million hospitalizations would have been avoided had the patients been covered. To this end, the authors reported that lack of insurance coverage produces "a 60% increased risk of mortality" (p.242).

Ethical Principles Guiding the Health Disparities of the Uninsured

Medical care observers have distilled the widely-shared beliefs about caring for the sick into four major principles, commonly referred to as the principles of medical ethics -- justice, autonomy, nonmaleficence, and beneficence (Macklin, 2003). These four "provide a sound and useful way of analyzing moral dilemmas" in the practice of medicine (Macklin, 2003, p. 275). The principles of justice, autonomy, and beneficence are particularly applicable in this case.

Beneficence: it is a healthcare provider's obligation to assist people in need (Macklin, 2003). To this end, a practitioner must strive to improve the health of their patients at all times, regardless of the situation. By either refusing to attend to a patient, or offering a patient dismal care because of their insurance status, a healthcare practitioner compromises this principle, and breaches their duty towards both the profession and the patient.

Autonomy: an informed adult patient has the right to control what happens to their body by choosing, and following their own plan of life and action (Macklin, 2003). It is the obligation of the healthcare practitioner to respect those decisions. Whether to take or not to take medical coverage is a decision of the patient; it is a choice they make in a bid to control their own destiny, and fit in the societal conditions in which they live. A physician compromises this principle by treating a patient negatively because of their choice of not taking coverage; but all the same, the physician has a duty to inform the patient of the probable consequences of their choices (Macklin, 2003).

Justice: a healthcare practitioner ought to treat all their patients in a fair manner (Macklin, 2003). This principle requires a practitioner to treat uninsured patients in the same way they would treat an insured one with a similar condition. The ANA supports the ongoing health reforms because of the current system's inability to accord the same standard of care to all patients. The principle that "all persons are entitled to ready access to affordable, high-quality health services" is a perfect representation of the justice principle (ANA, 2008, p. 5).

What Makes this an Ethical Issue?

The problem of the insured poses an ethical dilemma for the medical fraternity, as much as it does a financial challenge. A healthcare professional has a moral duty to care for all patients equally, with no discrimination; and there is no exception to this moral obligation. However, in the same light, is it really fair to provide 'free' care to a selected group, and then shift the cost to another group that lives in the same jurisdiction, and under the very same economic conditions? Well, an uninsured person could perhaps argue that this is some kind of distributive justice, where the rich help the poor cover some of their costs so that everyone leads a comfortable life, at the least. But then, are we really helping ourselves; is this a sustainable plan? If hospitals keep losing money by providing care to uninsured people who cannot afford it, won't there come a time when the expenses will be too high to match, and hospitals will have no choice but to close down, causing higher rates of unemployment and threatening the health of the entire community?

The American Nurses Association (ANA) has thrown its weight behind the uninsured, expressing that adverse selection is a principle not applicable to the heath sector. Speaking during a White House event in 2009, Rebecca Patton, President of ANA, expressed support for President Obama's Capitol Hill project of healthcare reform and reiterated the association's commitment to "the principle that healthcare is a human right and that all persons are entitled to ready access to affordable, high-quality health services" (ANA, 2008, P. 5). The Association does not blind itself to the fact that the uninsured impose an extra financial burden on the insured population; however, it refurbishes the popular belief that they overcrowd ER facilities, holding that most of them would not seek emergency department services unless they really are in a crisis situation.

However, ANA appears not to be the only association calling for healthcare reform. The American College of Emergency Physicians (ACEP) has also raised concern on the current system's ability to advance the same standard of care to every patient. In its 2013 factsheet, ACEP expresses that it is unfair for anyone to view the uninsured as a burden on the nation's emergency system because "emergency care is the safety net of the entire national health system, caring for anyone regardless of ability to pay or insurance status" (n.pag). This view has been reiterated by the Alliance for Health Reform (AHR), which posits that what the uninsured need is assistance and not seclusion, because after all, a community is only as healthy as its weakest member (Kumar, 2007). The organization thereto advocates for the development of a comprehensive insurance plan option that ensures access to services, fosters marketplace competition, increases affordability, and provides a broader choice for patients.

Coverage Features Do Matter

The research literature and the various organizations within the medical fraternity associate quality healthcare with comprehensive and continuous coverage. According to the AHR, intermittent coverage increases unmet medical needs, lowers the use of service, and makes it difficult for people to access care. This is in addition to the fact that it contributes "to health disparities for people with low educational attainment and for the poor" (Bernstein, Chollet & Peterson, 2010, p. 2). Furthermore, premature death is more common among the uninsured, and those whose coverage is non-continuous (Kumar, 2007). The AHR advocates for the development of an employer mandate requiring all employers with a certain minimum employee threshold to not only offer health coverage, but also pay a certain pre-determined proportion of the premiums; or to alternatively pay tax in support of a state-run insurance program, to which their employers can subscribe. The government could additionally offer individuals a tax credit for a part of their expenses, and employers a tax break for providing coverage (AHR, 2007).

The ANA, the AHR, and ACEP concur that there is need to reform the current system so that it provides universal health coverage in a target-based incremental manner. Some of the options being advocated for include allowing uninsured 50+ year olds to buy into Medicare; offering Medicaid to low-income adults without dependents; and allowing parents with eligible children to buy into the CHIP program. ANA has taken a leadership role in advocating for a comprehensive insurance plan that covers preventive services, prescription drugs and mental health services, and provides for affordable cost-sharing.

The Impact of a Large Uninsured Population

i) On Access to Care

Access to care basically means that individuals "have the financial and other means of obtaining healthcare services" (Code Red, 2006, p. 48). A large uninsured population impacts access to care in a number of ways.

Higher Costs of Health Insurance: the cost of health care services provided to uninsured patients every year is approximately $65 billion, 35% of which is usually settled out-of-pocket by the patients (Code Red, 2006). In this case, the remainder is mainly covered using two sources -- government programs (one-third), and insured people in the form of higher premiums (two-thirds) (Code Red, 2006). The states of Idaho, Arkansas, Alaska, Montana, West Virginia, Oklahoma, and Texas have the "highest amounts of added premiums due to unreimbursed costs of healthcare for the uninsured" (Code Red, 2006, p. 49). Today, a family with employer-sponsored coverage in Texas pays approximately $2.786 higher annually in insurance premiums due to the unreimbursed costs of the uninsured population (Code Red, 2006).

More Costly Health Services: healthcare providers nationally bear approximately 33% of the cost of healthcare services advanced those who are uninsured (per annum) (Code Red, 2006). In 2002 for instance, the cost incurred by hospitals nationally as a result of uncompensated care was a massive $22 billion (Code Red, 2006). This cost imposes an extra burden on a "system already struggling to meet increases in the demand for services resulting from demographic and reimbursement changes" (Code Red, 2006, p. 49). The number of admissions to Texas Hospital, for instance, rose from 1.9 million to 2.6 million between 1992 and 2003; and that of outpatient visits rose from 16 million to 35 million (Code Red, 2006). The demand is even higher now, thanks to the aging of the Baby Boomer generation. All these factors put a strain on the resource base, with the impact being felt in the unprecedented increase/rise of charity care and bad/doubtful debts, as well as the increased ER use (Code Red, 2006).