cracks in the health-care safety net

At any given time, 33 million Americans are uninsured

THE story of the Young family of Tennessee is a tale of how much hustle and enterprise it can take to win access to medical care.When doctors recommended surgery for his daughter, Tommy Young had been laid off from work and the family had no health insurance. So to qualify for Medicaid, he and his wife filed for trial separation. Mr. Young packed his clothes and moved in with his sister for six months until the treatment was complete. ll do what I have to do to make sure my kids are covered," says Pamela Young. And she has had to do quite a bit. Trouble returned when an emergency-room nurse in Nashville recommended surgery for their son. The family was earning a middle-class income of $40,000. But they were still uninsured, so the hospital would not take him in. No one else in town would either - not even a clinic for the homeless - since the first hospital had begun the treatment by performing an emergency operation. Mrs. Young was about to drive back to her hometown doctor in Indiana when a lawyer arranged for the original hospital to take the boy. After that, Mrs. Young left her $17,000-a-year job in hotel management to earn half as much stocking shelves at a K-Mart, because K-Mart offers family health insurance to its employees. The Youngs have clawed and crashed their way into the health-care system when their family was in need. Now the family pays $350 a month for health insurance offered through Mr. Young's employer, but they hold little confidence it will really help them when they need it. This kind of health-care insecurity is nearly epidemic. As the cost of medical care surges, vast numbers of Americans are worried about slipping through their health safety nets. Political pulse-takers hear it in "focus group" discussions of public issues. Surveys show that surprising numbers of people - about 20 percent - have avoided changing jobs for fear of losing their employer-based health insurance. The plight of the uninsured extends far beyond the 14 percent of the population without health insurance. Many more share a growing insecurity about their access to health care. They worry that their health insurance will fall short in an emergency and that they will face financial catastrophe. At any given time, 33.1 million Americans under age 65 (about two of every 13) have no health insurance. That number grew 24 percent in the past 12 years. But the snapshot number can be misleading. Many people roll through a spell with no health insurance while they are between jobs or separated from a spouse who holds the household insurance policy. Half of these spells last less than four months, according to a study by the Urban Institute. Perhaps one in 10 Americans was actually without insurance all of last year, but perhaps twice that number were uninsured at some point during the year. Thirty-six percent of the uninsured are voluntarily without coverage, according to a Republican congressional study. Almost half of the voluntarily uninsured are young, between the ages of 18 and 34.

Hospital stays average $900 a day One risk for the uninsured is financial. A coronary bypass operation costs about $40,000 (although a private insurance policy might be billed twice that). Hospital stays average $900 a day. Aetna Life and Casualty has found that in the course of a year, one in 700 of its policyholders runs up $50,000 or more in medical bills. Without insurance, those bills can mean financial catastrophe. Another risk is to health. The uninsured tend to delay and avoid treatment, and doctors say their health often suffers. A study of nearly 600,000 hospital cases published in the Journal of the American Medical Association (JAMA) this year found that - even comparing patients in similar condition when admitted to the hospital - those without insurance died 1.2 to 3.2 times more often than the insured. One difference: The uninsured receive different treatment in the hospital, including a fraction as many high-cost procedures or diagnoses as the insured. Whether certain procedures are refused by the cost-conscious patient or skimped on by the doctor is not clearly understood, says Jack Hadley, lead researcher in the JAMA study and co-director, Center for Health Policy Studies at Georgetown University.

Uninsured getting less medical care Uninsured people visit doctors fewer times per year, enter hospitals less often, and stay fewer days when they do enter hospitals, according to a number of studies. They also, according to Dr. Hadley's research, arrive at the hospital in worse condition. People without insurance rate their own health more poorly than do the insured. According to the 1986 federal Health Interview Survey, 61 percent of the uninsured rate their health very good or better, compared with 72 percent of the insured. The problem, as Health and Human Services Secretary Louis Sullivan has pointed out in speeches, is not lack of insurance itself. The problem is when people delay or avoid practicing effective health care. That happens far more often with the uninsured. For most people, health care is nearly synonymous with medical care. Health insurance is largely a post-war amenity. In 1949, about 40 percent of Americans had hospitalization coverage. Surgical insurance was sold separately. By 1965, 3 out of 4 Americans were covered for hospitalization. Coverage became increasingly universal through the 1970s, then dropped slightly. The dramatic rise in medical costs has made insurance both more important and harder to hold on to. Insured or not, 27 percent of Americans told Gallup pollsters they were short of money for health care last year, nearly twice the percentage of 1977. All in all, health care amounted to 13.1 percent of all personal consumption in 1989, up from 4.6 percent in 1950. If a family cannot join a group health insurance plan offered by an employer, then the same policy can cost twice as much purchased individually. Democratic political consultants Stanley Greenberg and Celinda Lake sum up attitudes of potential voters this way: "People with insurance doubt they are truly covered. They worry that when they really need health insurance, they will fall through some loophole, find they have reached the ceiling of their coverage, need longterm care, lose their job, or change jobs only to find they are not covered for a 'preexisting condition.

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