published Thursday, January 28th, 2010

Cleaveland: Portrait of America's uninsured

Despite what Congress does regarding health care reform, we must provide relief for up to 50 million non-elderly Americans who have no health insurance. Their numbers have steadily grown in this economic downturn. They represent 17 percent of our population.

This is their profile:

* Job status: Two-thirds are full-time workers, generally employed by companies with fewer than 10 employees. They earn too much to qualify for Medicaid but not enough to afford private health insurance. Eleven percent of the uninsured are jobless. The rest are part-time workers, often working two or more jobs because full-time work is unavailable.

* Education: Forty-four percent did not finish high school; 25 percent are high school graduates; the rest have varying levels of post-high school education.

* Ethnicity: Thirty-seven percent are white, 17.5 percent are black and 38 percent are Hispanic.

* Immigration: As of 2008, 39 million immigrants resided in the United States comprising 13 percent of the population. Seven in 10 are naturalized citizens or have legal-resident status. More than half of the naturalized and legal immigrants are uninsured, often because they work for companies that do not provide insurance benefits. They find private insurance unaffordable.

Age: Twenty percent of the uninsured are children. Thirty percent of young adults, age 20-29, are uninsured. High cost of health insurance is the dominant barrier for the uninsured. Many Americans who have lost their jobs cannot afford to maintain payments that would allow continuation of health insurance previously provided by their employers. Pre-existing health problems makes health insurance unavailable or unaffordable for many Americans.

Expansion of Medicaid and the State Children's Health Insurance Program (SCHIP) is one proposal for providing health coverage for the insured. Medicaid depends upon a formula for funding, with both states and the federal government footing portions of the cost. While the recession has driven enrollment steadily upward, financial contributions from the states have fallen. This restricts both enrollment and services. Federal stimulus funding, which will continue until the end of 2010, prevented even further cuts.

Because individual states determine eligibility and covered services, Medicaid differs widely from state to state. Seventeen states limit eligibility to individuals and families earning less than 50 percent of the Federal poverty level (FPL is $36,620 for a family of three). Tennessee sets eligibility at 100 per cent of FPL and is ranked among the top ten Medicaid programs in terms of services that are covered.

Most states set income levels for SCHIP at a level above that of Medicaid. This results in some children having health insurance, while their parents do not.

If Medicaid were expanded to accommodate significant numbers of the uninsured, the program would need substantial new revenues. Standards for both eligibility and services would need to be regulated by the Federal government. Otherwise some states would continue to provide meager services to a small fraction of those needing insurance and health care. Perhaps poverty levels could be determined for each state to use in its calculations for eligibility.

Unfortunately, in many states, including our own, care givers who accept Medicaid patients must deal with a stiflingly complex bureaucracy. Simplification of administrative procedures is imperative to make Medicaid patient and provider friendly.

A 2009 study in The American Journal of Public Health estimates that as many as 45,0000 Americans die each year as a direct consequence of being uninsured. Most uninsured persons do not receive recommended vaccinations or screening tests for cancer. They are less likely to receive timely, comprehensive care when sick or injured. Too often, they must use expensive emergency rooms as their providers of last resort. Their healthcare bills quickly consume any resources which they may have. They live in fear of illness and accident.

In addition to being a complex economic and political issue, the uninsured represent a profoundly moral issue that Congress must address. Delay translates into lost lives, depleted personal resources and crushed aspirations.

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