Uninsured — making a diagnosis

This past week, the Centers for Disease Control and Prevention announced an early release of its estimated findings from the 2006 National Health Interview Survey (NHIS). The report that’s received the most publicity has been the one citing the numbers of people in our country without health insurance.

As with all statistics used to create the perception of a national health crisis in need of government intervention — such as obesity — we’ve learned to look at them carefully. The CDC reported that 43.6 million Americans don’t have health insurance, but the devil is in the details.

Let’s look.

Survey designs. For more than a decade, repeated studies have reported wide discrepancies among population survey estimates of the numbers of uninsured. These problems have not been widely reported in the media, however. Instead, every interest picks the survey with the data most favorable to its agenda. Primarily, we hear the beefed up statistics because they make the best soundbytes, and federal funds to the States and various programs are based on those figures.

At the annual meeting of the American Association for Public Opinion Research back in 2001, two main methodological problem used in traditional population surveys were reported. First, uninsurance is measured as the residual after the respondents have denied all of the possible insurance choices offered. The Census Bureau’s Current Population Survey (CPS) began using a verification question and found that estimates of uninsured were indeed higher without this. The second problem reported was that most health insurance surveys measure as lack of insurance whatever the status is at the time of interview, not lack of insurance for the entire year.

According to the 2003 Congressional Budget Office report, “How Many People Lack Health Insurance and For How Long?”, estimates from population surveys which depend on respondents’ recall “are prone to reporting error and other forms of statistical error.” It also identified the problem of popular surveys overstating the number of people who are uninsured all year. They found that between half and two-thirds of the people who had been without insurance at some point during the year (due to job changes, etc.), actually had coverage for the rest of the year.

Examining federally sponsored national surveys — the Survey of Income and Program Participation (SIPP), the Medical Expenditure Panel Survey (MEPS), Census Bureau's Current Population Survey (CPS), and the National Health Interview Survey (NHIS) — the CBO found that the NHIS and CPS only make a point-in-time estimate, whereas data from SIPP and MEPS note those who are uninsured for an entire year — figures one-half to one-third less.

Two years later, in an effort to get to the bottom of survey discrepancies, two new analyses were commissioned by HHS Assistance Secretary for Planning and Evaluation after four government surveys found the numbers of uninsured in 2003 ranged from 19 million to 45 million! Both extremes in these findings had been conducted by the Census Bureau, but the larger figure is most cited. The first analysis found that 20% of those listed as uninsured actually had had health insurance, and the second analysis found 10% had had coverage. According to Public Health News: “Both studies conclude[d] that the CPS overestimated the number of uninsured because it undercounted the number of residents enrolled in Medicaid programs.”

It’s important to recognize that all of these surveys are “estimates” and not one is 100% accurate. An example of the statistical errors possible was highlighted this past March when the Census Bureau announced that for at least the past decade it had been overstating the number of people without health insurance due to a computer system problem. They are planning to go back and reissue corrected figures for every year from 1995. This major news was barely whispered by the media.

Who are the uninsured?

Regardless of these issues or the problems with health insurers, just considering the term “uninsured” used in all of these reports is not what most of us think of when we envision the uninsured. This is not to suggest there isn’t a problem deserving of our attention, but that it might not be quite the problem we believe it to be — and without clearly identifying the problem, we can’t hope to begin to discuss tenable solutions. Doctors know this: getting the diagnosis right is the first step to getting the right treatment. We hear of a crisis of uninsured in our country, with huge numbers dying and 43.6 million uninsured, as in this week’s CDC report. So let’s break down these figures and try to get a realistic picture of the uninsured in the our country.

Can afford but don’t buy insurance. According to the most recent U.S. Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2005” issued on August 2006: Of the 46.6 million Americans they cited as uninsured in 2005, 17.04 million without health insurance live in households making more than $50,000 a year. That’s 37% of the uninsured in the U.S. Nearly 9 million of those make more than $75,000.

In fact, according to the Census Bureau, the biggest increases in uninsured by household incomes over the past decade has been among those making the most money. They are people who generally have access to insurance through employers and can most afford insurance, but prefer to self-insure for whatever reason (perhaps to keep their healthcare decisions out of the hands of their employer or government). Freedom includes the freedom to make choices about our bodies others may not agree with and many will not readily concede to government force.

Even among a larger 45% of the population not regarded as poor because they make above 200% of the Federal Poverty Level, 88% reported being in good to excellent health and 90% paid their health expenses in full. Not a group contributing to a crisis (except to those selling insurer managed care, perhaps).

Not Americans. Another 9.5 million of those listed among our uninsured Americans, according the Census Bureau, are not citizens of the United States. That’s 20% of the uninsured in our country.

Young and healthy. According to the Census Bureau, more than 18 million of the uninsured are people between the ages of 18 and 34, for whom health insurance isn’t a priority and they’ve chosen, wisely or not, to spend their disposable income on other things. Looking at the Bureau of Labor Statistics Consumer Expenditure Survey, young people spend many times more on entertainment and meals and drinks outside the home, than they do on health care. They’re 40% of the uninsured in America.

Of course, not having health insurance is not the same as not having health care. Even among those of limited means, there is a wide variety of clinics across the country that are free, low-cost or charge on a sliding scale based on income. Many young women, for instance, use Planned Parenthood for basic preventive gynecological care. Families go to subsidized clinics and public health departments for preventive screenings, immunizations or urgent care. And regardless of anyone’s ability to pay, under U.S. federal law, commonly called the COBRA law, anyone who goes within 250 yards of a hospital emergency room requesting care, must be treated and stabilized, including women in labor.

Eligible for existing government programs. What may be saddest to learn is that the Congressional Budget Office found that “33% of the uninsured in the U.S. are eligible for public health coverage programs” but had not enrolled. A 1997 study by the American Academy of Pediatrics found 25% of eligible children hadn’t been enrolled, meaning outreach efforts to enroll these children need improvement.

Poor children most pull at our heart strings, and Americans do care about children. The idea that we let vast numbers of poor children die or suffer defies logic and all evidence, which continues to show that children’s health is improving. Those who receive benefits through federal programs, such as WIC (Women, Infants, and Children), also receive some preventive health care and free immunizations from hospitals and charitable institutions, but these children are also listed among uninsured numbers. It is sincerely heartbreaking that there are disparities in care among some poor and minority children in our country, and there are things in need of improvement; but separating the nonuse of healthcare services due to access barriers, cultural views, socioeconomic factors and parent education needs is also difficult.

A Research Corporation report estimated that 14 million Americans without insurance (one-third) were eligible for Medicaid and other free public programs; yet even 9 million of them had been enrolled during the year but were still categorized as uninsured because they hadn’t been signed up for the entire year.

If the idea that significant numbers of those who are uninsured are actually already eligible for existing government programs sounds unbelievable, it doesn’t to officials in Massachusetts. As you may remember, their new law mandating everyone have health insurance went into effect Sunday, although residents won’t get hit with penalties until December 31st. As reported in the New York Times, “most of those who have signed up were poor enough to qualify for free or state-subsidized insurance.” The largest numbers of the state’s uninsured now are healthy young people in their 20s and 30s, said state officials. And they are not rushing to get coverage.

So how many have actually fallen through the cracks through no fault of their own, are unable to find affordable insurance (which includes a lot of fat people or with a multitude of health issues or indices which the insurance companies want to use to deny them coverage) and are in need of our help? Dr. David Gratzer, M.D., a doctor with licenses in both Canada and the U.S. and author of The Cure and Blue Code, believes the number is closer to 7%. Regardless of the exact estimate, clearly, it’s a much smaller number than popularly believed. While no means less important, having a clearer diagnosis leads us to very different and less far-reaching cures to ponder.

© 2007 Sandy Szwarc