Campaign 2000: Insuring the Uninsured - Statistical Data Included

Healthcare Financial Management, Dec, 1999 by Jeanne Schulte Scott

"This is our nation's scandal. It is something that we should be ashamed of."

--Patrick Hays, president of the Blue Cross Blue Shield Association, commenting on reports that more than 44 million Americans are without health insurance.

"The medically uninsured have always been with us. Yet, they have not always been a cause for civic alarm."

--Jacob Hacker, the author of The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security, a book severely critical of any attempt to establish a universal health system in the United States.

Twenty-seven of the world's 28 industrialized nations guarantee health care for all their citizens, according to the United Nations. The United States, which spends more per capita on health care than any other nation, does not. A U.S. Census Bureau report issued in October shows that 44.3 million Americans are currently without insurance, and this number is growing by more than 1 million every year. The Census Bureau estimates that 13 million of these uninsured individuals are children under the age of 18.

Politicians have been talking about implementing universal health insurance for most of this decade while hospitals have been running the de facto universal healthcare system--the emergency department--and the public has been attending to other matters. This situation, however, is due to change. The uninsured population already has emerged as a major issue for the 2000 elections. According to a bipartisan poll conducted through Cornell University and released in October 1999, 70 percent of Americans claim they would pay higher taxes to help establish universal health insurance.

Someone who blasted off for Mars at the time the Clinton administration's healthcare reform efforts began in the summer of 1993 and returned now couldn't be blamed for thinking, "Isn't this where I left things?" In reality, however, healthcare reform is reemerging under conditions almost exactly the opposite of those prevailing in the early 1990s. At that time, there was a sense that a healthcare crisis loomed; now this crisis is seen as an opportunity--depending upon how the politics of the issue play out.

Many experts cite three major reasons for this renewed sense of urgency about the uninsured. First, despite the nation's long economic boom, the ranks of the uninsured continue to expand. Second, many Americans have been personally touched by the problem in some way. Twenty-nine percent of respondents to the bipartisan poll said they had been without insurance at some point in the last three years, and 43 percent said a family member or someone they knew had been without insurance. Third, most of the uninsured who responded to the poll were not "deadbeats," but instead members of low-income families.

More critically, according to the poll, 54 percent said "they would be more likely to vote for a presidential candidate who wants to extend health insurance to all." That number grabbed the immediate attention of every politician, whether they are running for office in 2000 or not.

It's interesting to consider how the leading candidates for the office of President of the United States view this issue. Vice President Al Gore has proposed a program to reach out to virtually all of the nation's children, but especially to the estimated 11 million children of the so-called working poor whose families are most likely to lack insurance. Under his proposal, the nation would begin to underwrite coverage for the children in working families earning up to 250 percent of the poverty level. For a family of four, this figure represents an annual income as high as $41,000. For the estimated 2 million uninsured children in families earning more than 250 percent of the poverty level, Gore proposes tax incentives and a new 25 percent "tax credit" for buying private health insurance.

Former Senator Bill Bradley is more generous. He would subsidize the purchase of health insurance for working families with incomes as high as 300 percent of the poverty level--the equivalent of as much as $49,200 a year for a family of four. Additionally, his program would cover the entire family, not just the children. Under this proposal, the Medicaid program would all but disappear. The states would be left only with the responsibility of providing long-term care support for the aged and the disabled. Acute care and most outpatient and physician office care would be covered under Bradley's plan.

The leading Republican presidential candidate has been more circumspect. Texas Governor George W. Bush's position is somewhat compromised by the fact that about 23 percent of Texas residents are without coverage--the highest percentage in the nation. [a] Nonetheless, Bush has announced his endorsement of premium support for Medicare and a broad range of new tax incentives and medical saving accounts (MSAs) to expand the availability of coverage to the uninsured. Under Bush's plan, premium support would involve a voucher system whereby beneficiaries would receive funds from the program to pay for coverage from privately operated insurance plans. Lower-income beneficiaries would receive more support than more-affluent beneficiaries. Other Republicans, as well as Reform Party candidates, support variations on MSAs and a variety of vaguely defined tax incentives to address extending healthcare coverage to more Americans.