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Working-Class Crisis


The byproduct of tighter bottom lines for America’s industry is the big squeeze in health benefits. Those still lucky enough to have employer-based insurance coverage most likely have higher deductibles and co-pays or have been shifted to plans with a limited choice of providers. For those 1.3 million who have become uninsured in the past year, welcome to the growing legions of working class Americans who are “going bare” and hoping for good health.

As the chart below indicates, data just released from the government shows the steady and relentless rise in our country’s uninsured population.


2001 - 41.2 million

2002 - 43.6 million

2003 - 45.0 million

2004 - 45.3 million

2005 - 46.6 million

This past year we have added 1.3 million new Americans to this very vulnerable group. And many of these people work full time.

Rethinking Your Stereotype of the Uninsured

Let me help you discard your stereotypes regarding the uninsured. Many are the working poor. They are caught in that dangerous economic wasteland between poverty and unemployment with the benefits of Medicaid and the ability to purchase affordable health insurance that will leave them with enough left over to feed, clothe, and house their families.

There are 37.8 million Americans of working age without insurance, and 27.3 million of them actually had paying jobs for some or all of last year. Even more astounding, the number of uninsured full-time workers grew by 1 million, from 20.5 million in 2004 to 21.5 million in 2005. Only 27.3% of uninsured Americans did not work at all.

This is not solely a problem for the poor and uneducated. More than 5 million of the uninsured had a college degree, more than 15 million had attended college at one time, and 22.6% had household incomes of more than $50,000 a year.

This is a particular problem for young Americans. Almost 70% of the uninsured are under 35 years of age. Even more disturbing, the number of children without insurance coverage rose from 7.9 million in 2004 to 8.3 million in 2005. This phenomenon occurred despite a number of legislative efforts to cover children and the allocation of extra resources in many states for sign-up drives organized to enroll more children.

The racial makeup of the uninsured population may surprise you as well. More than 22 million uninsured are non-Hispanic whites. In an emergent trend, however, an increasing percentage of the uninsured are Hispanic. There are now more than 14 million uninsured Hispanics in this country, representing a growing percentage of the Hispanic population in states such as California and Texas.

The time has come for those of us who think and act on the nation’s health problems, who should have a longer term and more global view, to step out and step up to change a system that is currently leaving almost 50 million Americans on the side of the road.

Implications for Hospitals and Hospitalists

Like emergency department physicians, hospitalists are hospital-based and ready to take all comers—regardless of insurance coverage or ability to pay the bills. On the clinical side, it is well known that those without insurance coverage generally avoid outpatient services that might have prevented an acute hospitalization. In addition, there is more often a chance for a falloff in post-discharge medical follow-up in those who lack insurance and a supportive outpatient physician. This can lead to unnecessary morbidity and readmissions.

For hospitals, finding a specialist to manage the patients in the emergency department or to co-manage with the hospitalist upon admission creates an additional strain. Depending on the hospital’s locale and patient mix, any increase in patients who are “self pay,” or uninsured, creates a financial strain that can affect the hospitalist service, as well as other hospital-supported clinical functions.

Implications for Patients

Some people with no insurance coverage just won’t get healthcare until they are in extremis—a costly choice for the patient’s well being and longevity, as well as for the entire health system.

More recently, alternative care choices have popped up that may meet the short-term needs of this population. In some Hispanic areas, “medical” clinics that operate on a cash basis have cropped up in garages and homes. The very nature of these clinics has placed them outside of traditional regulatory scrutiny, putting this fragile population further in jeopardy.

In the true tradition of American enterprise, new “minute clinics” are starting to show up in supermarkets (e.g., ShopRite, Piggly Wiggly, Wal-Mart) and in pharmacies (e.g., Rite Aid, Walgreens, Duane Reade). In these locations—for a set fee of about $39-$49 per visit—patients can get quick, straightforward care where they shop, usually from a physician assistant or a nurse practitioner, with physician supervision offsite. Estimates are that there are currently more than 150 such retailed-based health clinics, treating non-urgent health conditions, around the country today. And with demand high, it is expected that these will continue to blossom.

Implications for Primary Care and the Health System

Will these minute clinics become the treatment choice for the cash patient? Will they encroach on traditional primary care? Will an ever-increasing part of the population see healthcare in bursts, in snapshots of care provided in shopping malls, or—for the acutely ill—in emergency departments and subsequently in hospitals? When so much is known about the economies of preventive care—not to mention the value in reducing morbidity and mortality for the individual—and with the predictive value of the genome on the horizon, does the trend to push so many people out of the traditional system, simply because of lack of funding, make sense to anyone?

Implications for Business and America’s Future

Businesses are caught in a bind. They do not have the revenue to absorb double-digit increases in insurance premiums. They are faced with the difficult choice of either reducing benefits to their workers or reducing their work force. By reducing or eliminating health insurance benefits, however, they potentially damage the very workforce they need to keep healthy—and not distracted by the health of their families—in order to be competitive in a global market.

American businesses have shouldered the burden of paying for healthcare in many ways. They pay directly for employee health benefits and workers’ compensation. By paying taxes, they fund Medicare and Medicaid. Many businesses shoulder additional burdens from previous union contracts for benefits for retired employees. All of this comes about in a global market in which many of their foreign competitors cover a much smaller portion of their countries’ health bills.

In the end, I am convinced that hospitalists and all hospital professionals, along with many other physicians, will step into the breach and provide the best healthcare quality they can, regardless of the patient’s ability to pay for the care. That is just what we do. But the time has come for those of us who think and act on the nation’s health problems, who should have a longer term and more global view, to step out and step up to change a system that is currently leaving almost 50 million Americans on the side of the road.

I simply ask the question, “If not us, who?” TH

Dr. Wellikson has been CEO of SHM since 2000.

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