UNINSURED AMERICA

December 24, 1998
		A report on the growing problem of those without health insurance. It comes from Susan Dentzer of our health unit, a partnership with the Henry J. Kaiser Family Foundation.

Nov. 3, 1998: Some HMO's pulled out of Medicare. June 22, 1998: The rising prices of HMO's May 5, 1998: Taking legal action against HMO's Feb. 5, 1998: Should there be a health care bill of rights? Nov 20, 1997: Clinton endorsed a bill of rights. Browse the NewsHour's Health coverage.     The American Medical Association	SUSAN DENTZER: The United States is in the midst of one of the longest periods of economic growth on record. Yet, even so, the number of Americans without health insurance keeps rising, and the tally has exploded or the past decade. Dr. Nancy Dickey is the president of the American Medical Association. DR. NANCY DICKEY, American Medical Association: We have gone from 32 million uninsured to more than 44 million uninsured. More than a million people a year added to the ranks of the uninsured, and that is after a decade of the best economic times we've had that I remember. SUSAN DENTZER: Solving that problem is one of the goals President Clinton had in mind back in 1993 and 1994, when he launched his ill-fated attempt to mount a government-led reform of health care. PRESIDENT CLINTON: If you send legislation that does not guarantee every American private health insurance that can ever be taken away, you will force me to take this pen, veto the legislation, and we'll come right back here and start all over again. (applause.) SUSAN DENTZER: Although the president's perform attempt failed to pass Congress, the health-care system has been reforming itself ever since; as companies have sought to limit the growth of health-care costs, millions of Americans have been nudged into managed-care plans. Back, in turn, has prompted an effort in Congress and state legislatures to reform managed-care. But now the AMA is calling on Congress to pick up where the Clinton effort left off and pass broad measures to spread coverage among the uninsured. DR. NANCY DICKEY: You know, those folks who are uninsured don't have a PAC; they don't have an organized voice. As physicians, it's up to us to be their voice. And I don't think any group needs our help, needs the nation's help more than those who are shut out of the system.
	Understated tallies.
	SUSAN DENTZER: Experts say that the official tallies of the uninsured may understate the severity of the problem. Millions more Americans may actually go without coverage from time to time. Health economist Deborah Chollet says the reason so many are being shut out of the system is simple. DEBORAH CHOLLET, Health Economist, Alpha Center: Money, money, money - it's affordability. People don't have insurance because they can't afford to buy it. SUSAN DENTZER: And, in fact, two out of three of the uninsured are in families with relatively low incomes - less than $32,000 a year for a family of four. Most of the uninsured aren't households headed by workers to simply don't have employer based coverage. DEBORAH CHOLLET: The employer can't afford to buy the coverage, or the worker can't afford to take the coverage, given the amount the employer requires the worker to contribute. SUSAN DENTZER: Since the collapse of Clinton's health reforms, Congress has undertaken some steps to spread coverage. (Applause.) In 1997, Congress passed the Children's Health Insurance Program - or CHIP - as part of the Balanced Budget Act. The $24 billion, five-year program is aimed at expanding coverage among the nearly 11 million children without health insurance. So far, 45 states have received federal approval of there are CHIP plans. These programs are expected to cover just 2 ½ million uninsured kids. DEBORAH CHOLLET: The states had hoped that by opening the doors to children who are uninsured they would - you know - flock in those doors. And, in fact, the rate of take up in those plans is less than everyone had hoped. SUSAN DENTZER: The AMA has called for lawmakers to make a concerted effort to tackle the problem of the uninsured. For example, it urged the creation of health insurance purchasing cooperatives. These would allow small businesses and others to buy coverage at attractive group rates. The AMA also proposed giving millions of America's tax credits based on their level of income to help pay for coverage. Forecasters say that unless action is taken, the number of uninsured will continue to rise, perhaps to as high as 53 million people by 2007.
	A profile.
	PHIL PONCE: And with me is Susan Dentzer. PHIL PONCE: Susan, give us a profile of the uninsured. Who are they? SUSAN DENTZER: Phil, they really cut across a broad swathe of the U.S. population. They come from all different income groups, all different parts of the country, all different racial and ethnic groups as well, but, buy and large, they can be low-wage a minimum wage workers. For out of five of those without health insurance are actually in households headed by workers, and three out of five of the uninsured are full-time, full year workers, so again they tend to be people who are working but who are in low-wage jobs and in jobs that don't have - tend to have health insurance attached to it. PHIL PONCE: This is a group that's been referred to as what, the working poor? SUSAN DENTZER: The working poor and the working low income and the working low paid. PHIL PONCE: So, folks say if you're elderly and poor, then you tend to be covered by Medicare, and if you're - and if you're very poor, then you tend to be covered by Medicaid. These are the folks that sort of fall in between. SUSAN DENTZER: Very much so.
	Clinton health reforms.
	PHIL PONCE: And, again, all these folks that are working - employers are not required to give health insurance or provide health insurance? SUSAN DENTZER: No, that's right. Of course, in the Clinton health-care reform proposals there was a proposed so-called employer mandate that would have required firms to provide insurance to their workers, but that collapsed along with the rest of the Clinton health reforms. And now whether you get health insurance are not along with your job is really appear employer's volition. PHIL PONCE: And since the collapse of the Clinton health-care effort in the first term, what have people come to realize about the complexity of the system? SUSAN DENTZER: That it's huge; that this represents one of the major public policy quandaries that lies in front of us. After the collapse of the Clinton reforms, there was a consensus that we would not solve the solution of the uninsured in a big government-wide system reform -- one fell swoop -- that any changes that would be made would have to be incremental. As a consequence, we have made incremental changes. It turns out of the problem incremental changes is that they are just that -- incremental. You can pick up a million people here, a million people there, but you can't really do something to -- in a concerted way -- get health insurance coverage into the hands of many people. This becomes particularly difficult in the current environment, where health insurance premiums are once again rising in many cases very steeply. If the primary reason people don't have health insurance is that they can't afford it, that problem is obviously not helped -- indeed, it's made much worse as health insurance continues to grow more and more expensive. PHIL PONCE: So, if incremental approach isn't working, as some people believe, does that mean that it's time for - that people are now being - are now being called upon to look at more of a systematic-wide - wide-ranging kinds of changes? SUSAN DENTZER: Well, that was exactly what lay behind the AMA's proposal. The AMA is concerned that this story has in a way become -- as journalists refer to it - an evergreen; it's out there, it's been around forever, it's at the point where it's so big and so omnipresent that the irony is people aren't dealing with it. The AMA wants to get this back on journalists' agenda, on the nation's agenda, and that's why they called for this broad systematic approach, basically going back and looking at some of the features of the Clinton health care reforms, putting them together with other proposals to come up with a concerted way of making sure that we - in effect - distributed the ability to pay for health insurance across the broad population. PHIL PONCE: Well, because it's not on anyone's agenda, is it too early to say which of the AMA's proposals might garner the most support? SUSAN DENTZER: I think the only thing that we can say is that if Washington ever digs its way out of some of the other issues that are uppermost on the agenda, and it gets around to looking at this, it will of necessity have to come back to looking at the grab bag of proposals that were on the table in 1993 and '94, and that the AMA has presented us with again. Again, the notion of creating some kind of voluntary health insurance purchasing cooperatives, where people could go and get group insurance rates, also in making a tax-based assistance, tax credits available to individuals, to help them purchase insurance, taking a look at some of the current tax breaks that we apply to insurance and redistributing the effects of those in some way, all of those are very obvious things that were on the table in '93 and '94, and must be on the table again and the AMA again wants that back on the agenda. PHIL PONCE: What's the likelihood of any of those options being seriously explored the next year or so? SUSAN DENTZER: Within the next year I think explored possibly. Dealt with and passed into law probably not very likely at all. If other issues come onto the agenda, like Social Security, those will be of such overwhelming magnitude that they'll drive things like this off the table. But what a lot of people are saying is, look, we're in a period of unprecedented economic expansion, yet, the number of health - of those without health insurance coverage has grown. What is going to happen if this trend continues, and if we get into another economic downturn, theoretically we're looking at perhaps 60 million people or more without health insurance coverage. At that time it will be virtually impossible to muster the funds to deal with the problem. So the time to deal with the problem is now when economic times are good. PHIL PONCE: But, ironically, are some people worried that it's going to take a recession say to get this back on the agenda? SUSAN DENTZER: It did in the early 1990s, and I think a lot of people's expectation is that's what it will take again to get people to focus on it, and get it to vault over the other list of problems that Washington has been front of it. PHIL PONCE: Susan, thank you very much. SUSAN DENTZER: Thanks, Phil.