Healthcare policy frameworks and implementation

Healthcare Policy:

An Overview of the Uninsured and Underinsured in America

An alarming number of people in the United States today do not have health-care coverage. Many of these people live in urban areas and their income is below the official government poverty line. However, some of them make up to 200% of the government poverty amount, and not all of these uninsured and underinsured individuals are inner-city minority individuals.

According to a recent press release put out by the Kaiser family foundation, 75% of individuals in the United States who don't have health insurance or who recently had a gap or lapse in their health insurance were working families. These people can work full-time or part-time, and some of them are the husband or wife of someone who is working.

These people are not uninsured because their health problems do not allow companies to provide them with insurance, or because they don't want to be. Rather, they are uninsured and underinsured because the money that they make at their job simply does not pay enough for them to be able to purchase health insurance.

Sometimes this is because their company does not offer health insurance, and this is especially true for part-time and seasonal workers. Sometimes employers offer health insurance but the cost of the deductible is so high that the workers cannot afford to have that much removed from their paycheck each week. Many of the workers who cannot afford health care through their employers make too much for Medicaid. Because of this, they are caught in the middle. They don't make enough money to pay for quality health insurance, but they make too much money for the state to pay for health care for them.

Because of this many people in this country are uninsured and this can be very dangerous when a trauma or unexpected illness strikes. Most affected by a lack of insurance are families who make less than $35,000 per year. These low-wage earning, working families tend to have problems with medical bills, and some of them even go without needed prescriptions or doctor visits because they know that they simply cannot afford to spend money on doctors when that money might put food on the table for their children.

In contrast to the working families, the elderly individuals in this country who are covered by Medicare are usually satisfied with their insurance coverage. They have more serious health problems but very few of them have problems getting health care. Only 7% had problems getting health care in the year that the study was conducted. Forty percent of adults under age 65 had difficulty receiving care, and 42% of working-age adults who had no insurance at all had trouble getting care. Those who received Medicare were much happier with their health insurance and more pleased with their doctors than those individuals who rely on Medicaid or have health-care coverage tied in with their jobs.

Special Report prepared for the Commonwealth Fund by some individuals at the center for health policy research at George Washington University indicates that many of the issues in the Kaiser family foundation study are very accurate. The report adds to the information given in the Kaiser family foundation study by stating that over half of the individuals who live in underserved areas are in inner cities. Many of these individuals seek treatment at places that are required to provide service to poor patients such as community health centers, family planning clinics, and AIDS providers.

Often, children's hospitals and providers of school health services, as well as mental health and substance abuse providers, will also help poor and underserved communities, although they are not legally obligated to do so. The report does indicate that those who are in the minority population have more trouble with income and health insurance than their white counterparts. Numbers for the year 1992 show that one-third of African-Americans and nearly one-third of Hispanic-Americans were poor, compared with only 11% of white individuals. This totaled up to 36% of African-American children and almost 39% of Hispanic children being poor, compared with only 16% of white children. To make matters worse, children of ethnic minority are far more concentrated in higher poverty areas.

This means that not only are there very many minority children in cities that are poor, but they are congregated within the same area where there is little hope of access to decent medical care. Studies have shown that minority individuals use fewer health services and are more likely to delay care than Caucasians. This is likely because of their little income and trouble having access to good medical care, or work health insurance to pay for it.

Many of these people end up using hospital emergency rooms and other stat care facilities as clinics for chronic problems, instead of going to the doctor. This is because they wait until their difficulties with their health have reached a level where they need urgent care. If they had health insurance, this would likely not be as much of an issue. While it is true that some people with good health insurance and medical care do not go to doctors simply because they do not trust them or like them, many people who have health insurance will go to the doctor if they feel they really need to.

Those without medical insurance will often avoid doctors even if they know that they really should go, because they are unable to pay for it. Medicaid is facing many challenges because the population that is traditionally on Medicaid is already sicker than the population that has private insurance. Premium payments made to hospitals and other health-care facilities are also less than with traditional insurance. Medicaid is also having trouble finding a sufficient provider base. Many doctors and health-care institutions do not want to take Medicaid because they know that the individuals that are on it often need more care and Medicaid will not pay as well as private insurance does.

Many of the families on Medicaid need more than just medical care. Often they need decent housing, decent food, and mental health counseling or family counseling. Another problem with Medicaid is a short enrollment period. Many people who are on Medicaid are only on it for approximately eight months.

This complicates care somewhat because individuals that have chronic conditions often need care for much longer than that. Sometimes Medicaid is discontinued because the woman has had a baby, a child has reached a birthday, or the breadwinner of the house has gotten a small raise. These things may be just enough to push the person past the income level for Medicaid, but not really enough for them to afford insurance of their own.

A status report about the uninsured in the United States confirms some of the things that the above two documents have discussed. They use less doctor visits and more emergency room visits than those who do not have insurance. They are also more likely to be hospitalized with chronic conditions, and many of these conditions would better be controlled by consistent and reliable access to a good quality physician. Lack of health insurance carries with it an increased risk of mortality because many people ignore a condition until it gets to a critical stage before they go to a doctor.

They do this obviously because they cannot pay for it. The underinsurance is a little more difficult to discuss. According to this study, there are significant differences in what many people consider being 'underinsured.' For example, someone who has a low income and an insurance policy with a very large deductible will likely be considered to be underinsured. They cannot pay the deductible if they would need to. However, a person with a high income and the same policy would not be considered underinsured because they have the means to pay the deductible for their insurance without having financial difficulty. This is why it is difficult to study whether people are actually underinsured. Risk factors, income, and the specific benefits of the individual's health policy must all be considered.

The underinsured are usually adults who are under age 65, and their children. Many of the underinsured are working families and quite a few of them are single parent households. Many of these individuals will purchase insurance for their children if they can afford it, and have no insurance on themselves. This is somewhat easier to do because Medicaid tends to favor children. In other words, it is easier to get a Medicaid policy for a child that it is for an adult. Only very poor families with real need and an income at or below the poverty level can get a Medicaid policy for an adult.

Usually, Medicaid covers adults with a 'medically needy-share of cost' policy and many times the deductible for this policy is so high that the adult could not pay it anyway. Once again, they are underinsured, and this stops them from going to the doctor. However, if their child is on Medicaid they will usually take their child to the doctor for proper screenings and checkups. Medicaid has been expanding, and the plan was for all children who were under 18 years of age and living in families that had incomes below the official U.S. government poverty line to be eligible for Medicaid. It is also worthy of note that underinsurance and uninsurance rates tend to be higher among younger adults.

There is some debate as to whether this is caused by lack of money to pay for insurance, or whether it is caused by unwillingness to purchase insurance when these people feel they are at a very healthy age. Over 22% of individuals in this country who are between the ages of 18 and 34 do not have health insurance. That number seems to drop as age goes up. It is also true that Caucasian individuals are more likely to be covered by employer-sponsored insurance then those of minority status. Unfortunately, many of the businesses around today that employ younger workers do not offer health insurance for these people, either because the workers are part-time, or because the firm is too small to be able to afford health insurance for their employees.

If they did offer health insurance, it would cost so much to each employee that it would not benefit them to purchase insurance. With some of the insurance rates available, it is often cheaper for individuals who must go to the doctor to simply pay for the doctor visits and prescriptions than it is to continue paying health insurance premiums. Especially in the younger generation, this attitude seems to be more prevalent. This is likely due to the fact that many younger individuals will work for quite some time and pay into insurance premiums that they will never use because they do not have chronic conditions or other problems that they may develop as they get older.

The health-care market is changing, and managed care organizations are becoming very prevalent in the insurance market. Many of them are replacing private insurance companies, and although the benefits are often not quite as good as private insurance benefits were, it is true that the premiums and deductibles are often much cheaper. There are some drawbacks to some of these organizations, however.

The main drawback is that there is a specific list of doctors that a person must choose from. They cannot simply go to any doctor or hospital that they wish. There is also the fact of needing a specific referral to go to a specialist. Private insurance does not always require this but HMOs, PPOs, and EPOs, which are all different types of health maintenance organizations often feel that they will not pay for a visit to a specialist unless it is authorized by the go family doctor and accepted by the health organization before the patient visits the specialist.

Medicaid is expanding as well. They are trying to make sure that everyone who needs health-care coverage in the United States gets it. The problem with this is that Medicaid often does not cover very much. It will cover the basics for children, and it will cover doctor visits and most prescriptions. It will not cover glasses or dental work, which many children need. Often, these children go without vision or dental work because the insurance that they have will not pay for it. Medicaid only covers the very basics, and while that is certainly better than nothing, it is not as good as having a good private insurance policy.

Originally, comprehensive health reform had been planned. That has been put on the back burner, but support for the smaller, incremental reforms at both the state and national level still remains. The desire is to significantly decreased or wipe out completely the number of uninsured and underinsured people in the United States. It is difficult to say whether or not these reform ideas will actually make much difference to many of the people that cannot afford insurance now.

Some of the reform ideas look good on the surface, but when digging a little bit deeper they don't look as good as they do at first. For example, one thing being look at was a guaranteed issue provision that would help with things like pre-existing conditions and other issues that stop some people from getting insurance. It would also help those who have small groups of workers and those who are moving away from group coverage and cannot afford individual coverage.

These provisions would allow these people to obtain insurance, where many of them now cannot. However, there would be no specific cap on what kind of premiums could be charged, and because they could charge whatever they want it is possible that the same people that this provision allegedly is attempting to protect would actually not gain anything because the insurance that they were now able to buy would not be affordable to them.

The biggest problem pointed out by this study is that having a job does not mean that health insurance is available. Of the uninsured individuals in the United States, around 80% are working. Three-quarters of these people are working full time. This means that those who go around talking about lazy people on welfare wanting the state to pay for their medical coverage need to stop and look again.

Many of the people who are getting state coverage or getting no coverage at all are working and trying to support their families in the best way that they can. Insurance premiums are so high that many of these people who make slightly too much to qualify for Medicaid cannot afford to purchase insurance of their own. Their choices come down to feeding their children or insuring their children. They choose to feed them in the hopes that will be enough for now, but it doesn't stop them from worrying.