As Noah Wyle stepped up to the podium last week, camera flashes went off and a buzz went through the room.
It may have been May sweeps for the television networks, but Dr. John Carter from "ER" was not in Washington to promote his show. Instead, he shared a stage with Catherine Edwards, who is uninsured and suffers from myasthenia gravis pseudoparalytica, a neuromuscular disorder, and Sarita Scarbrough, a small-business owner who cannot afford to buy insurance for her employees or herself.
For the issue of the uninsured to be taken seriously, it apparently was determined that the best spokesman for Americans with no health coverage would be a Hollywood actor who plays a doctor on TV and who by his own admission has not gone without health insurance since he was 3 years old.
As Cover the Uninsured Week gets under way this week, the usual hype surrounding it has already shifted into high gear. Last week the Robert Wood Johnson Foundation kicked off the campaign with its news conference attended by Wyle, the effort's national spokesman; Senate Majority Leader and physician Bill Frist (R-Tenn.); Sen. Jay Rockefeller (D-W.Va.); along with other officials and several Americans who lack insurance. A report indicating that at least 20 million working Americans don't have health coverage was also released at last week's news conference. According to the report, in six states at least 20% of working adults are uninsured, while in 38 other states at least 10% of the workforce are not covered.
But amid all the hoopla was a grudging admission that to date, very little has been done for the uninsured, despite yearly attempts to bring attention to the issue
"It's a depressing matter to talk about," said Ed Howard, executive vice president of the Alliance for Health Reform, a think tank that has looked for ways to bring affordable healthcare to the public.
After declining from 1998 to 2000, the number of uninsured Americans has gone up thanks to a sour economy and rising healthcare costs. At last count, the figure stood at 43.6 million in 2002, or 15.2% of the population, according to the U.S. Census Bureau. That's up from 42.1 million, or 14.6% of the population, in 2001. Once the figures for 2003 are tallied, they are expected to show another increase.
But even as the numbers rise, the country is no closer to a solution today than it was a decade ago, when similar spikes in the number of uninsured and healthcare costs pushed the issue onto the national agenda.
To be sure, opinions on how best to fix the problem abound, even in this election year when healthcare has receded into the background for Washington lawmakers. Earlier this year, Frist put together a panel, headed by Sen. Judd Gregg (R-N.H.), to look at possible solutions to the uninsured problem. It is expected to report its findings within a matter of weeks. Sen. Edward Kennedy (D-Mass.) also plans to introduce legislation that would require employers with more than 50 workers to provide healthcare coverage and create a program to cover everyone not eligible for other government or employer-sponsored coverage. California passed similar legislation late last year.
And there has been talk in Congress-most prominently by Sens. Chuck Grassley (R-Iowa), chairman of the Senate Finance Committee, and Max Baucus of Montana, the ranking Democrat on the committee-of providing tax credits to unemployed individuals to help pay for their health insurance, and of legislation requiring individuals to buy health insurance in the same fashion that most states force residents to buy auto insurance. So far, neither proposal has gone very far.
Kerry's and Bush's approaches
The issue also is prominent in the upcoming presidential election. Sen. John Kerry, the presumptive Democratic presidential candidate, released a healthcare proposal last year that would ramp up coverage by expanding Medicaid and the State Children's Health Insurance Program to cover more adults and create a "premium rebate pool" in which the federal government would pay for 75% of healthcare costs of individuals when they exceed $50,000. The plan also would provide tax credits to individuals and small businesses. It would cost $653 billion and cover 27 million Americans, according to a recent study by Kenneth Thorpe, a health economist at Emory University.
President Bush's approach to reducing the number of uninsured relies on expanding tax credits available to individuals who purchase health insurance, increasing health savings accounts and creating association health plans to help small businesses provide coverage to their employees. His strategy would cost $90 billion and provide coverage to about 2.5 million Americans, according to Thorpe.
In the different approaches lies a key reason why there has been so little action on the issue-while Republicans traditionally look to the private market for answers, Democrats believe the federal government must play the central role in providing for the uninsured.
"This issue has been captured by the philosophical differences and that has clouded the possibility of (finding) solutions," said the Rev. Michael Place, president and chief executive officer of the Catholic Health Association.
There is even some dispute about the problem's severity. A year ago, a Congressional Budget Office study questioned the 43.6 million uninsured figure because it represents how many people were uninsured at any point in time during 2002. "That estimate, however, overstates the number of people who are uninsured all year," the CBO report said.
"The Congressional Budget Office estimates that between 21 million and 31 million people were uninsured for the entire year," the report said.
Rep. Bill Thomas (R-Calif.), chairman of the House Ways and Means Committee, summed up the finding by saying: "CBO's analysis reveals some good news-fewer individuals are long-term uninsured than previously thought. The characteristics of the uninsured have received little attention to date, so this analysis is helpful in considering solutions to providing healthcare to these individuals."
For a good part of the past 70 years, the topic of the uninsured has consistently been on the political agenda, but the matter has rarely gone beyond talk. To be sure, experts cite the creation of Medicare, Medicaid and SCHIP as great achievements.
However, the last comprehensive attempt at guaranteeing coverage for every American, the healthcare initiative spearheaded by Hillary Rodham Clinton during her husband's presidency, famously went down in flames, and the repercussions of its failure continue to be felt today.
Two mistakes helped unravel the Clinton proposal, said Merrill Matthews Jr., director of the Council for Affordable Health Insurance, an advocacy association of insurance carriers. First, the administration failed to involve Congress in the initial stages of drafting its healthcare proposal.
The administration also took too long to create its proposal and get it to Congress, Matthews said, giving opponents a chance to build their arsenal. And since the drubbing of the Clinton proposal, legislators have been reluctant to move on any fundamental change to the healthcare system, he said.
What has replaced a comprehensive approach are incremental steps such as expanding tax credits for those who have lost jobs because of trade agreements, and granting waivers to states to expand their Medicaid programs. "The danger of doing small things is we become content with small results," Place said.
At last week's launching of Cover the Uninsured Week, Rockefeller said that the "me-first" special interests of the various healthcare trade associations have made putting together a comprehensive approach to the uninsured problem nearly impossible.
"We have to understand that if there's going to be universal healthcare ... there has to be a greater sense of ethos," he told the audience.
Indeed, hospitals have recently faced criticism for their aggressive billing practices of the uninsured and Congress has said it plans to hold hearings on the issue.
Others see more deeply rooted obstacles to creating a system of universal or near-universal coverage. Since World War II, health insurance in this country has been tied to having a job. The problem with such a system, said the Alliance for Health Reform's Howard, "is that it's voluntary. If it gets too expensive, employers can and do walk away from providing coverage."
Matthews said such a system also inevitably drives up healthcare costs since employees are insulated from the true costs. Workers believe a trip to the doctor costs only a $20 copay because they are unaware of how much employers pay in monthly premiums. That in turn can lead to a higher number of uninsured when the costs become too much for employers to bear. In a mobile economy, he added, an employer-sponsored insurance system leaves gaps in coverage when people change jobs.
Some experts said the biggest stumbling block to providing more coverage is a lack of a moral imperative. Many have said that Americans are waking up to the issue now only because they are realizing that losing their own coverage in today's economy is a very real possibility. "Americans had not identified it as their problem," Place said. "It had always been someone else's."
But experts speaking at a panel discussion on the uninsured last week said that Americans, in effect, have been guilty of what Rockefeller called "benign neglect" when it comes to the uninsured.
Judy Feder, dean at the Georgetown Public Policy Institute and HHS' principal deputy assistant during the Clinton administration, said the public suffers from a misconception that giving insurance to everyone will end up hurting those who already have coverage and that costs will go up while benefits will be reduced.
Uwe Reinhardt, a healthcare economist at Princeton University, put it more bluntly: "Americans are uniquely self-righteous and tolerant of enormous misery and pain ... for the losers in society." The uninsured, he said, are among the losers.
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