Health insurance premiums are not the only things on the rise. Although the cost of health care has increased less rapidly in recent years, it is still increasing, and the number of uninsured and underinsured Americans also continues to increase. According to the Agency for Health Care Policy and Research, 27% of uninsured families had difficulty obtaining health care; the biggest barrier was cost. These statistics suggest that fewer people can obtain basic health care without difficulty, and many cannot do so at all.

Troubling Trends

• Additional statistics illuminate trends in the uninsured population:
  
• In 1996, almost 15% of children younger than 8 years of age (10.6 million) were uninsured.
  
• Many Hispanic families (1.4 million) reported having difficulty obtaining health care; 70% of those families attributed the problem to cost.
  
• Most uninsured and underinsured people are employed.
  
• About one fifth of workers are uninsured or underinsured.
  
• Seventy-five percent of people who have difficulty paying their medical bills have some kind of health insurance.
  
• Between 1988 and 1996, the average deductible for family coverage nearly doubled (from $370 to $688).
  
• In 1994, private health insurance accounted for one third of health care costs ($313 billion of $950 billion).
  
• In 1997, over 11 million Americans whose annual incomes were at or below the poverty level had no health coverage.
  
• In 1998, two thirds of uninsured persons earn less than half of the amount designated as the federal poverty level; if a person whose income is at the poverty level purchased health insurance, the cost would comprise approximately one quarter of his or her annual income and one third for a family of four.
  

Traditionally, the number of Americans lacking insurance would decrease in accordance with a decreasing unemployment rate. That is no longer the case. Unemployment has reached record lows in recent years, but the number of uninsured persons continues to climb steadily. One reason is that fewer employers are offering insurance.

Employer-Based Health Insurance

According to Uwe Reinhardt, PhD, MA, MPH, James Madison Professor of Political Economy at Princeton University, the employer-based health insurance system will probably cease to exist. Reinhardt, who recently co-edited The Future of the United States Health Care System: Who Will Care for the Uninsured?, observed that employer-funded health insurance began during World War II when Congress enacted wage controls. Because take-home pay was capped, employers started offering workers nonmonetary compensation, such as health coverage. Eventually, health insurance became an expected employer-provided benefit and has been one for so long that employees did not realize how much insurance cost until recently.

Leon Reinstein, MD, of Johns Hopkins University School of Medicine and the University of Maryland School of Medicine, commented that employees have been seeing an isolated part of the big picture: their portion of the cost, which was once a small contribution. Employers that once provided 100% of health care benefits for employees have been raising employee contribution percentages as premiums increase. In 1988, employees of small companies (those that employ fewer than 200 people) contributed an average of $34 per month. In just 8 years, this amount increased to $175 per month, an average increase of 23% each year.

Reinstein has been involved with the American Academy of Physical Medicine and Rehabilitation since 1981 and served as its president for the 1992-1993 term, when the Clintons presented their health care reform proposal. Reinstein testified before the Subcommittee on Health of the House of Representatives Ways and Means Committee and presented the Academy's stance on health care reform, including its belief that patients with physical disabilities should receive medical care regardless of their financial or insurance status.

Needed Reforms

The inability of the government to enact much-needed health care reforms has helped to perpetuate the current system's failure. Instead of revising the system from the inside out, politicians are focusing on providing insurance for high-priority groups. The Children's Health Insurance Program (CHIP), a federal and state program created in 1997, reserves $24 billion over 5 years for expansion of health insurance coverage for uninsured children. The Health Insurance Portability and Accountability Act (HIPAA), created in 1996 to make health insurance more available to working families, provides protection for persons who are between jobs, have preexisting medical conditions, or are self-employed. The HIPAA was passed as part of the Balanced Budget Act of 1997.

Reinhardt does not believe that these measures are adequate. "[The] HIPAA never really did much. The children's insurance is better than nothing but is again quite limited," he commented. Reinstein agreed, but added, "I think it's politically the best that can occur at this time." A piecemeal approach to the problem is less than ideal, but as Reinstein pointed out, "another 5 or 10 million uninsured will have health insurance." Further incremental expansions are planned, such as President Clinton's proposal that persons between 55 and 64 years of age be allowed to purchase Medicare coverage.

Robert D. Reinecke, MD, President of the Philadelphia County Medical Society and Professor of Ophthalmology at Jefferson University Medical College, believes that "there's a real need [for government to] make available Medicare-type coverage for individuals." Reinecke was instrumental in putting health insurance coverage at the forefront of the 1992 senatorial election, comparing a citizen's right to accessible health care with the constitutional right to be defended by an attorney. The Philadelphia County Medical Society, one of the oldest societies of its type in the country, is dedicated to enabling every resident of Philadelphia to see a physician regardless of insurance status. The Society believes that getting the patient to the physician is the challenge; once that is accomplished, it is thought that physicians will follow through and provide appropriate care. "The present system is collapsing," Reinecke stated, "and something has to take its place."

Reinstein agreed, explaining what he feels are the benefits of adopting a system similar to Canada's, which would guarantee all American citizens health insurance that could never be taken from them. This may sound idealistic, but Reinstein noted that Americans have banded together on similar issues. "We've already started by saying we'll provide an education for every citizen from kindergarten through 12th grade," he asserted. And because health insurance companies spent about 20% on administrative costs and profits, the implementation of a national health plan would allow most of the money to be spent on actual health care "and not indirectly on giant insurance companies' bureaucracies, stockholders, and CEOs' bonuses every year," Reinstein commented.

The State of the U.S. Health Care System

Table 1 Although other barriers to obtaining adequate health care exist (for example, difficulty in getting transportation or referrals), the high cost of health insurance and its lack of availability to much of the population appear consistently as the key factors. Reinstein pointed out that the United States is the only industrialized nation besides South Africa that does not provide national health insurance for all of its citizens. He remarked that despite the numerous advantages of adopting a national health insurance system, significant barriers continue to block the way, primarily the general unwillingness (on the part of both politicians and taxpayers) to provide the needed funding through an overt tax and the poor opinion that Americans have of government-operated programs. Reinstein also cited a lack of unity and said that the country needs to come together on this issue and agree to guarantee health care for all citizens. He commented that health care is a privilege in this country but added, "I think it should be a right. The highest quality of health care in the world is in the United States. The problem is, it's not available to everybody."

Linda Gundersen