Health Care Problems in the USA

The following is from the New England Journal of Medicine, November 18, 2009.

Authors: Arthur L. Kellermann, M.D., Lawrence S. Lewin, M.B.A.


Adults who can’t get coverage through work, are too young for Medicare, and don’t qualify for Medicaid have only one option — individual health insurance. Consumer Reports describes the individual insurance market as a “nightmare” for consumers: “more costly than the equivalent job-based coverage, and for those in less-than-perfect health, unaffordable at best and unavailable at worst. Moreover, the lack of effective consumer protections in most states allows insurers to sell affordable plans whose skimpy coverage can leave people who get very sick with the added burden of ruinous medical debt.”5 In recent years, several states have attempted to reform the individual health insurance market, with little success.

Coverage matters. On average, uninsured Americans get about half the preventive services and medical care that insured Americans receive. Studies have shown that uninsured people with cancer, heart disease, stroke, lung diseases, and other conditions are more likely to have poor health and to die prematurely than similar people with coverage. Existing safety-net services are insufficient to overcome the gap between those who have health insurance and those who do not.

The economic consequences of a lack of insurance are equally grim. If even one family member lacks coverage, the entire family is exposed to the financial burden of severe illness or injury. In 2009, 20% of uninsured adults used up all or most of their savings paying medical bills.

When many people lack insurance, everyone’s access to care is compromised. University of Pennsylvania economist Mark Pauly and colleagues have found that in communities with high proportions of people who are uninsured, insured people are more likely than those elsewhere to have difficulty obtaining needed care and to be dissatisfied with the care they receive.1 In such communities, emergency services are strained, access to trauma care is diminished, and a growing number of specialists are unwilling to take emergency department call.

If states cut their Medicaid programs when ARRA funding runs out, uncompensated care will increase sharply. The burden that this increase will impose on health care providers will be more than some can bear. If many safety-net clinics and hospitals close their doors, the patients these institutions serve will have nowhere else to go. When they end up in private hospital emergency departments and inpatient beds, it could trigger additional facility closures. Access to care will be diminished for the insured and uninsured alike.

Voting for the status quo may be politically tempting, but it won’t stop the steady erosion of coverage in the United States. The authors of the 2009 IOM report were blunt: “There is no evidence,” they wrote, “to suggest that the trends driving loss of insurance coverage will reverse without concerted action.”1 Six years ago, the IOM Committee on the Consequences of Uninsurance was equally direct.2 It recommended “that the President and Congress develop a strategy to achieve universal insurance coverage and establish a firm and explicit schedule to reach this goal by 2010.” That deadline is less than 2 months away.