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Uninsured Sit At Center Of Emotional Health Care Debate

ARIELLE LEVIN BECKER

September 06, 2009

Chico Rodriguez has no health insurance, so his health plan is simple.

"Basically," he said, "I try not to get sick."

Otherwise, he'll face a bill of several hundred dollars for going to the emergency room, where he gets his medical care. So Rodriguez, 32, of New Britain, tries to avoid it unless the pain from an injury or an illness gets "really, really, really, really, really bad."

Like many of the more than 320,000 Connecticut residents who do not have health insurance, Rodriguez falls into a gap in the system. His job as a maintenance technician pays too much for him to qualify for state assistance programs. But Rodriguez's employer, a small business, can't afford to offer health insurance, and Rodriguez, who also takes care of his grandparents, can't afford a plan of his own.

"It's my everyday struggle," he said.

Rodriguez and a growing number of uninsured state residents stand to gain perhaps more than anyone from health care reform efforts. They face the constant challenge of handling health problems with no safety net and no routine way to get care.

People without health insurance receive less than half the amount of health care as those who have insurance, and pay for more of it out-of-pocket, according to a 2008 study prepared for the Henry J. Kaiser Family Foundation.

They're not the only ones who bear the burden of incomplete insurance coverage.

Taxpayers fund billions of dollars' worth of payments to doctors and hospitals for providing health care to people without insurance. In Connecticut, the state spent $96.3 million on so-called uncompensated care during the past fiscal year.

People who have private insurance also subsidize, through their premiums, the cost of care for people without insurance, though the extent to which that occurs is not entirely clear.

A 2005 report by the consumer advocacy group Families USA estimated that the insurance premium for a family in Connecticut with employer-based coverage included an extra $583 attributable to the cost of caring for people without insurance, or 5.1 percent of the state's average premium cost. The Kaiser study found that uncompensated care accounted for about 1.7 percent of private health insurance premiums.

Who Are The Uninsured?

Most health reform proposals are aimed at making sure the uninsured become insured, although the plans and philosophies differ on how to do it and how far they would go.

Some of the proposals, including plans in the U.S. Senate and House, would make government insurance programs available to more people or create a new public insurance option that the uninsured could join. Others, favored by the insurance industry and opponents of a public plan, would require everyone to buy insurance, with subsidies for those who cannot afford it — a plan that's in place in Massachusetts, with mixed success.

So just who is uninsured in Connecticut, and why?

Like Rodriguez, the majority of uninsured residents — 61 percent — are employed, according to a 2006 survey by the state Office of Health Care Access. A majority were not offered insurance through their jobs; 14 percent were eligible for coverage through their jobs but declined it.

About 25 percent of uninsured Connecticut residents were eligible for a public insurance program like Medicaid, according to the OHCA. Sixty percent fell into the same gap as Rodriguez: ineligible for public or employer health coverage.

Among uninsured state residents under 65 in 2006 and 2007, nearly 17 percent were children and nearly 60 percent were considered low-income, earning less than the equivalent of $41,300 for a family of four, according to the Kaiser Family Foundation. Those numbers could change as more people lose jobs or the ability to pay for health coverage. Families USA projected in July that 48,660 Connecticut residents would lose their health insurance between January 2008 and December 2010 — an average of 310 per day.

Not Enough Doctors

Rodriguez hopes reform will make health insurance affordable for everyone. Despite broad disagreements on how to do it, there are some ways to make inroads right away. The seemingly simple act of signing up everyone who is eligible for public coverage, for example, would remove an estimated 11 million people from the ranks of the uninsured, according to the Kaiser Family Foundation.

But experts say just giving everyone insurance won't be enough.

They say any expansion of health coverage will require increasing the ability of the health care system to see more patients — perhaps an additional 40 million to 50 million.

There already is a shortage of primary care physicians in the U.S. That means encouraging more medical students to go into primary care, continuing to address a nursing shortage, and possibly using other medical workers, like physician assistants, to give routine care that does not require a doctor.

And the type of insurance used to expand health coverage is likely to make a difference in how easy it is for newly insured people to see doctors and receive health care. Medicare and, in particular, Medicaid pay health care providers significantly less than the cost of delivering care, making it less financially appealing for doctors to see patients covered by those programs. Patients in the state's HUSKY insurance program for poor children and their families already struggle to find doctors to see them, in part because the rates doctors are paid under the program are so low.

That dynamic is reflected in an analysis of emergency-room use by the Connecticut Hospital Association, which contradicted assumptions that people without insurance are the heaviest emergency room users.

The association found that in 2007, people without insurance used the emergency room just slightly more than people with commercial insurance, a barely noticeable difference, said Stephen A. Frayne, the association's senior vice president.

By contrast, people enrolled in state insurance programs such as Medicaid went to the emergency room for the "wrong reasons" three to five times the rate of people with employer-sponsored insurance, suggesting that those on state assistance programs lack adequate access to care, Frayne said.

"So while they carry an insurance card, they're not able to seek out care for routine primary care stuff in a physician's office," he said.