The report, which says 46.3 million people lacked coverage as of the end of 2008, makes the case for reform stronger than ever by punching holes in arguments that minimize the plight of the uninsured.

By Michael Hiltzik
LA Times
September 17, 2009

Pity the medically uninsured in America. As if they don’t already have enough to worry about, now they’ve become a political football.

Opponents and supporters of healthcare reform toss assertions about them back and forth. Their number is debated — are they 46 million people? 30 million? Eight million? Their motivations for not having health coverage are questioned: Are they “young invincibles” who think they’re too healthy to need it? Too rich to need it? Or just cheapskates?

And let’s not ignore the aspersions cast on their character: “A citizen who accepts personal responsibility for his welfare has no real problem getting health insurance,” one reader wrote me recently.

Moral fiber and a clean lifestyle are all that’s needed to secure adequate healthcare, apparently.

But efforts to minimize the plight of the uninsured don’t stand up to scrutiny. The latest figures, setting the number of uninsureds at 46.3 million people as of the end of 2008, were released last week by the U.S. Census Bureau, and they make the case for reform stronger than ever.

“That’s a solid and respected estimate,” Timothy D. McBride, a professor of public health at Washington University in St. Louis, told me.

He called the figures “alarming,” because one trend they underscore is the decline in employer-sponsored health coverage. The percentage of the country covered by workplace plans dropped last year to 58.5% — down from a peak of 64.2% in 2000 and the lowest level since 1993. Taking up some of the slack was the government, which expanded the number of persons covered by Medicaid by 44% to nearly 43 million.

The census data effectively punch holes in the most common misrepresentations that reform opponents make about the uninsured. The anti-reform lobby says the group comprises mostly illegal immigrants; people who can afford insurance and forswear it; candidates for public assistance who don’t bother to sign up; and people who are uncovered only for brief periods and thus (presumably) don’t warrant our concern.

Let’s take these assertions one by one.

First, uninsured illegal immigrants. Many opponents of healthcare reform raise their concern that illegal immigrants might benefit from publicly funded elements of healthcare reform to the level of a fetish. The issue was behind the now-infamous outbreak of hooliganism on the floor of the House of Representatives during President Obama’s healthcare speech last week, for example.

As for how many uninsured illegal immigrants there are, I’ve seen estimates as high as 12 million. No data support that figure. The Pew Hispanic Center, crunching the census figures, concluded that about 49% of all non-citizen permanent residents of the U.S. are here illegally. Applying that ratio to the Census Bureau’s estimate of 9.5 million noncitizens among the uninsured would suggest that the number of illegal immigrants among them is about 4.7 million.

The draft legislation in the House already bars public money from being spent to help illegal residents buy health insurance. As for the attempt by some members of Congress to mollify the anti-immigrant lobby by forbidding illegal immigrants to buy health insurance even with their own money — a position unaccountably endorsed by President Obama — there’s little to say about it except that it should go into the dictionary as a new definition for the word “pusillanimous.”

More pertinently, to oppose healthcare reform because a few of these people might slip through the sieve and end up getting a public handout to pay for health insurance is almost comically counterproductive. Reforming our healthcare system is a matter of the utmost urgency, with huge implications for our economy, our industrial competitiveness and the health of millions of American men, women, and children. Holding it hostage to a minor issue like public assistance to a few million illegal immigrants who probably wouldn’t benefit anyway is like allowing the fear of a paper cut to keep you from ever cracking open a book.

How about the well-heeled, voluntary uninsureds? Consider a 2007 “fact sheet” by Julia Seymour of the Business & Media Institute, an appendage of the right-wing Media Research Center.

Citing the 2005 edition of the census report, Seymour stated that “there are 8.3 million uninsured people who make between $50,000 and $74,999 per year and 8.74 million who make more than $75,000 a year.”

In other words, she said, “that’s roughly 17 million people who ought to be able to ‘afford’ health insurance because they make substantially more than the median household income of $46,326.” She repeated this claim again in June.

In fact, the 2005 census report said nothing of the kind. It said 17 million uninsured people lived in households with household income of $50,000 or more, a very different matter. (The figure in the latest census report is 17.7 million.)

You see, a single household can have one person in it, or four, or 10. It can be one family, or two or four. If one wage earner pulling down $50,000 shares an apartment with a spouse and three children, that’s not five people each earning $50,000 as Seymour, in her confusion, would conclude — it’s a low-income family, which in many states would qualify for Medicaid.

A household with $75,000 in income could easily comprise two wage earners each making, say, $37,500, which means they could be part-timers ineligible for employee coverage or full-timers working for small employers who don’t offer it.

Seen in that light, Seymour’s picture of wealthy wage-earners deliberately going insurance-naked withers away. As hard as she and her ilk try to paint a picture of champagne-swilling yuppies playing dice with their health coverage, the facts aren’t on their side.

Next we come to low-income uninsureds who are eligible for public programs such as Medicaid or the Children’s Health Insurance Program, but who haven’t signed up. The critics claim they number somewhere between 11 million and 14 million and shouldn’t be counted among the uncovered 46 million.

They may be right about the numbers. Underutilization of public programs is a well-known problem. Indeed, a strong outreach component is written into H.R. 3200, the Democratic healthcare reform bill, for exactly that reason.

Yet their complaint brims with irony. Many of those who say we shouldn’t label people who don’t make use of public programs as “uninsured” are the same people agitating against the public option in healthcare reform. In other words, they’re saying that up to 14 million Americans wouldn’t be uninsured if they just took advantage of, um, a public option.

Finally we come to the short-term uninsured. The claim here is that as many as 80% of all those who lose coverage regain it after as little as four months. McBride, who has studied this issue, says that’s a misunderstanding of statistical math based on the difference between the flow of people in and out of the uninsured cohort and the status of those without insurance at any given point of measurement.

Citing a study by the Congressional Budget Office, he observed that although half of those who become uninsured in a given year regain coverage within a few months, about 80% of those who lack health insurance at a particular time end up being uninsured for more than 12 months, the definition of “chronically uninsured.”

In sum, the ranks of the uninsured are large, and with every employer who decides he can’t cover his workers anymore and every bump up in the unemployment rate, they grow larger. They can’t be wished away, and if the opponents of reform were committed to an honest debate, they’d stop trying.

Michael Hiltzik’s column appears Mondays and Thursdays. Reach him at michael.hiltzik@latimes.com, read him at www.latimes.com/hiltzik, and follow @latimeshiltzik on Twitter.

Copyright (c) 2009, The Los Angeles Times

latimes.com/business/la-fi-hiltzik17-2009sep17,0,1400353.column

by Sara Marshall
Orcinius.com
Sunday, September 13, 2009

True confessions: I missed the health care speech. While the whole lefty blogosphere was watching and blogging and tweeting, I was sacked out in my attic bedroom high on a mountainside in Vancouver, sleeping off a narcotic haze and the exhausting aftermath of a long night spent in the emergency room at Lions Gate Hospital.

President Obama tried to remind Americans all over again why health care reform matters. I didn’t need a speech: I’d just had an up-close-and-personal encounter with a rational, not-for-profit, single-payer health care system. And it reminded me all over again (as it does every time we see a doctor here) why health care reform is the most crucial battle of our generation.

The health event was new to me, but pretty garden-variety as ER visits go. I had my first gallbladder attack. Not life-threatening, just the worst pain I can remember being in since the last time I was in labor. It started up just before dinner Tuesday night. At 2 am Wednesday, still awake and in worsening pain, I found my keys and shoes, stumbled down to the car (leaving the rest of the family sleeping), and drove the 25 blocks down to the hospital.

Four things in particular stood out about the hours that followed — things that show just how different medicine is when the patients trump profit as the main priority, things that Americans need to understand if they’re going to see through the chaos of this moment to the kind of future that’s possible.

First, the waiting time between walking in the door and being admitted was literally about 45 seconds. American conservatives have filled people’s heads with images of Canadians packed into old, worn-out, badly-lit, overcrowded emergency rooms bustling and echoing with writhing, moaning souls enduring waits that can stretch to days. Sorry to blow the fantasy, but last night, I walked into a newly-remodeled, gently-lit, serenely quiet lobby that I had completely to myself. There wasn’t another human being in sight. Even the receptionist had apparently taken a break.

I doubled over on the counter, breathing through the pain (those long-ago Bradley childbirth classes are still paying off). Moments later, a nurse appeared to check me in. With a quick swipe of my BC provincial care card, my complete medical files glimmered onto his computer screen. He put a thermometer in my mouth, then confirmed the basic data while a printer spit out my wristband. The whole check-in process took under three minutes.

“It’s really quiet tonight,” I noticed, trying to look nonchalant while clutching my stomach.

“Actually, we’re pretty full.” This was my first visit since a recent remodel created a huge new ER ward. (They’re expecting the world here: this particular hospital is the closest one to the skiing venues for next February’s Winter Olympics, and also one of the province’s major orthopedic centers. It’s where Canada’s athletes come to get put back together.) There were lots of people here — but they were all already comfortably checked in and settled away in beds, rather than milling around the lobby waiting to be tended. In another three minutes, I was settled in, too.

Second: You don’t realize how much politics — in this case, the war on drugs — has warped medical care until you see how differently non-American doctors and nurses deal with pain management. Since Canada sees drug abuse as a social problem, not a law enforcement one, it’s stubbornly resisted several ham-handed attempts by the American government to get it to crack down on doctors who persist in seeing codeine and morphine as useful medications. While Health Canada does keeps tabs on individual doctors’ prescribing habits, docs are given vastly more discretion in managing their patients’ pain than their US counterparts are. If you’re hurting, the docs here will calmly and generously prescribe painkillers — good ones, serious ones, the yummy kind that really do the job. (And yeah, I guess that would explain why the whole ER ward was so eerily quiet, too.)

So it was that, minutes after my arrival, the ward nurse tucked me in and hooked me up to an IV drip with saline and anti-nausea medications. “Would you like some morphine with that?” she asked, in the same casual and pleasant voice with which a waiter might offer you cream for your coffee. My inside voice, battered after a long evening of agony, jumped up and hollered: “YESSS! Oh, HELL yes!” My outside voice sweetly smiled back: “That would be lovely.” In moments, eight hours long hours of accelerating pain finally subsided — and I went to sleep, waking only occasionally from my opiate bliss to find myself being wheeled out for this test or that as night turned to morning.

Third: About those electronic medical records. I am a fan. A big one. Everybody in the BC health care system has their records in one big database, accessible within seconds in every doctor’s office and hospital in the province. The doctors and nurses never have to waste a lot of time taking history, or guessing at the doses of the meds I’m taking (it turns out that dutifully reporting that “I think I’m taking half of that round green pill now” is surprisingly unhelpful) or wondering where those X-rays disappeared to, or cross-testing my blood type. It’s all there — including digital copies of all the X-rays, ultrasounds, mammograms, and EKGs I’ve ever had here. Every doctor that writes a prescription knows exactly what else I’ve been prescribed. It’s hard to overstate how much this improves the level of care, even as it cuts costs.

(It’s also another reason doctors can be so generous with painkillers. Since all the information from everywhere ends up in the same file, the e-records system automatically notices and flags doctor-shoppers and drug-seekers — which, in turn, allows doctors to be much more confident about giving non-addicts what they need without being worried that they’re enabling somebody they shouldn’t be.)

Beyond the vast improvements in individual care, though, there are also huge public health benefits. Qualified public health researchers can get access to the population-level data in the files — though they need special authorization (and a damned good reason) to access individual patients’ names. They use this data to compare the pool of patients who’ve had treatment A against those who got treatment B; and issue impartial advisories as to which is better. They can instantly track emergent epidemics like SARS, or notice geographic anomalies affecting one area or another, or figure out who got a batch of bad vaccine. As genetics-based medicine emerges (and BC is one of the world centers for this), the growing pile of data in this system will eventually become a global asset in the effort to correlate the various genetic and environmental interactions that contribute to illness or health.

Do I worry about privacy? Not in Canada, much. This is a country that has a national Office of Privacy. The privacy laws are strict enough that the prairie provinces are doing a booming business in storing records for assorted American enterprises, where they’re beyond the long snooping noses of Homeland Security and other public and private buttinskis. In theory, only authorized medical personnel get access to my records. Both provincial and national laws (and the general mood of the country) support the idea that we’ve got privacy rights that deserve careful respect.

At the same time, I’m not at all sure Americans are ready for this. Canada’s system works because the country has a strong culture of privacy, and an even stronger bulwark of laws that back that up. Americans have almost no data privacy to speak of compared to most of the rest of the industrialized world, and no real expectation of having any. Frankly, I wouldn’t trust any American e-records system until our whole cultural and legal framework around data privacy is overhauled. I trust the Canadian government to get it mostly right. I don’t trust any American government not to sell my data to ChoicePoint or hand it over to the NSA. Until that changes, y’all be careful.

Finally, the last thing I noticed about last night was something that wasn’t there. I’m talking about that little meter in the back of my head, the one that whirred and spun and ticked off every charge from the minute I walked into an American ER until the minute I walked out again. The IV. The X-rays. The box of Kleenex, the Tylenol, and the barf pan. The crappy food (if you’re lucky enough to get any). Even with good insurance, the co-pays alone on eight hours in the ER could bust the family grocery budget for the next three months. That big number hanging over my head was always a real distraction from dealing with whatever crisis actually put one of us there. No matter what the presenting condition was when we arrived, I always seemed to have a bad case of heartburn when we left.

Contrast that with last night, when my glorious morphine dreams were completely untroubled by the sound of that mental meter. By the time they checked me out at 10:30 am, I’d had a whole bank of diagnostic tests, including a long and detailed ultrasound exam that found twin bouncing baby gallstones. The ER then handed me off to an internist for further exploration of the issue. (I see her next week — it’s already set up.)

No bills. No worrying about how to pay for the surgery, either — that will be covered, too. The morning nurse (the fabulous and charming Trish) pulled the IV. I got dressed, picked up my purse, and left. And that was it. No pain. No worries. No heartburn.

And that’s all it should ever be. And could be. And will be, if we keep leaning on Congress to get this thing done right.

by Sara Marshall
Orcinius.com
Sunday, September 13, 2009

True confessions: I missed the health care speech. While the whole lefty blogosphere was watching and blogging and tweeting, I was sacked out in my attic bedroom high on a mountainside in Vancouver, sleeping off a narcotic haze and the exhausting aftermath of a long night spent in the emergency room at Lions Gate Hospital.

President Obama tried to remind Americans all over again why health care reform matters. I didn’t need a speech: I’d just had an up-close-and-personal encounter with a rational, not-for-profit, single-payer health care system. And it reminded me all over again (as it does every time we see a doctor here) why health care reform is the most crucial battle of our generation.

The health event was new to me, but pretty garden-variety as ER visits go. I had my first gallbladder attack. Not life-threatening, just the worst pain I can remember being in since the last time I was in labor. It started up just before dinner Tuesday night. At 2 am Wednesday, still awake and in worsening pain, I found my keys and shoes, stumbled down to the car (leaving the rest of the family sleeping), and drove the 25 blocks down to the hospital.

Four things in particular stood out about the hours that followed — things that show just how different medicine is when the patients trump profit as the main priority, things that Americans need to understand if they’re going to see through the chaos of this moment to the kind of future that’s possible.

First, the waiting time between walking in the door and being admitted was literally about 45 seconds. American conservatives have filled people’s heads with images of Canadians packed into old, worn-out, badly-lit, overcrowded emergency rooms bustling and echoing with writhing, moaning souls enduring waits that can stretch to days. Sorry to blow the fantasy, but last night, I walked into a newly-remodeled, gently-lit, serenely quiet lobby that I had completely to myself. There wasn’t another human being in sight. Even the receptionist had apparently taken a break.

I doubled over on the counter, breathing through the pain (those long-ago Bradley childbirth classes are still paying off). Moments later, a nurse appeared to check me in. With a quick swipe of my BC provincial care card, my complete medical files glimmered onto his computer screen. He put a thermometer in my mouth, then confirmed the basic data while a printer spit out my wristband. The whole check-in process took under three minutes.

“It’s really quiet tonight,” I noticed, trying to look nonchalant while clutching my stomach.

“Actually, we’re pretty full.” This was my first visit since a recent remodel created a huge new ER ward. (They’re expecting the world here: this particular hospital is the closest one to the skiing venues for next February’s Winter Olympics, and also one of the province’s major orthopedic centers. It’s where Canada’s athletes come to get put back together.) There were lots of people here — but they were all already comfortably checked in and settled away in beds, rather than milling around the lobby waiting to be tended. In another three minutes, I was settled in, too.

Second: You don’t realize how much politics — in this case, the war on drugs — has warped medical care until you see how differently non-American doctors and nurses deal with pain management. Since Canada sees drug abuse as a social problem, not a law enforcement one, it’s stubbornly resisted several ham-handed attempts by the American government to get it to crack down on doctors who persist in seeing codeine and morphine as useful medications. While Health Canada does keeps tabs on individual doctors’ prescribing habits, docs are given vastly more discretion in managing their patients’ pain than their US counterparts are. If you’re hurting, the docs here will calmly and generously prescribe painkillers — good ones, serious ones, the yummy kind that really do the job. (And yeah, I guess that would explain why the whole ER ward was so eerily quiet, too.)

So it was that, minutes after my arrival, the ward nurse tucked me in and hooked me up to an IV drip with saline and anti-nausea medications. “Would you like some morphine with that?” she asked, in the same casual and pleasant voice with which a waiter might offer you cream for your coffee. My inside voice, battered after a long evening of agony, jumped up and hollered: “YESSS! Oh, HELL yes!” My outside voice sweetly smiled back: “That would be lovely.” In moments, eight hours long hours of accelerating pain finally subsided — and I went to sleep, waking only occasionally from my opiate bliss to find myself being wheeled out for this test or that as night turned to morning.

Third: About those electronic medical records. I am a fan. A big one. Everybody in the BC health care system has their records in one big database, accessible within seconds in every doctor’s office and hospital in the province. The doctors and nurses never have to waste a lot of time taking history, or guessing at the doses of the meds I’m taking (it turns out that dutifully reporting that “I think I’m taking half of that round green pill now” is surprisingly unhelpful) or wondering where those X-rays disappeared to, or cross-testing my blood type. It’s all there — including digital copies of all the X-rays, ultrasounds, mammograms, and EKGs I’ve ever had here. Every doctor that writes a prescription knows exactly what else I’ve been prescribed. It’s hard to overstate how much this improves the level of care, even as it cuts costs.

(It’s also another reason doctors can be so generous with painkillers. Since all the information from everywhere ends up in the same file, the e-records system automatically notices and flags doctor-shoppers and drug-seekers — which, in turn, allows doctors to be much more confident about giving non-addicts what they need without being worried that they’re enabling somebody they shouldn’t be.)

Beyond the vast improvements in individual care, though, there are also huge public health benefits. Qualified public health researchers can get access to the population-level data in the files — though they need special authorization (and a damned good reason) to access individual patients’ names. They use this data to compare the pool of patients who’ve had treatment A against those who got treatment B; and issue impartial advisories as to which is better. They can instantly track emergent epidemics like SARS, or notice geographic anomalies affecting one area or another, or figure out who got a batch of bad vaccine. As genetics-based medicine emerges (and BC is one of the world centers for this), the growing pile of data in this system will eventually become a global asset in the effort to correlate the various genetic and environmental interactions that contribute to illness or health.

Do I worry about privacy? Not in Canada, much. This is a country that has a national Office of Privacy. The privacy laws are strict enough that the prairie provinces are doing a booming business in storing records for assorted American enterprises, where they’re beyond the long snooping noses of Homeland Security and other public and private buttinskis. In theory, only authorized medical personnel get access to my records. Both provincial and national laws (and the general mood of the country) support the idea that we’ve got privacy rights that deserve careful respect.

At the same time, I’m not at all sure Americans are ready for this. Canada’s system works because the country has a strong culture of privacy, and an even stronger bulwark of laws that back that up. Americans have almost no data privacy to speak of compared to most of the rest of the industrialized world, and no real expectation of having any. Frankly, I wouldn’t trust any American e-records system until our whole cultural and legal framework around data privacy is overhauled. I trust the Canadian government to get it mostly right. I don’t trust any American government not to sell my data to ChoicePoint or hand it over to the NSA. Until that changes, y’all be careful.

Finally, the last thing I noticed about last night was something that wasn’t there. I’m talking about that little meter in the back of my head, the one that whirred and spun and ticked off every charge from the minute I walked into an American ER until the minute I walked out again. The IV. The X-rays. The box of Kleenex, the Tylenol, and the barf pan. The crappy food (if you’re lucky enough to get any). Even with good insurance, the co-pays alone on eight hours in the ER could bust the family grocery budget for the next three months. That big number hanging over my head was always a real distraction from dealing with whatever crisis actually put one of us there. No matter what the presenting condition was when we arrived, I always seemed to have a bad case of heartburn when we left.

Contrast that with last night, when my glorious morphine dreams were completely untroubled by the sound of that mental meter. By the time they checked me out at 10:30 am, I’d had a whole bank of diagnostic tests, including a long and detailed ultrasound exam that found twin bouncing baby gallstones. The ER then handed me off to an internist for further exploration of the issue. (I see her next week — it’s already set up.)

No bills. No worrying about how to pay for the surgery, either — that will be covered, too. The morning nurse (the fabulous and charming Trish) pulled the IV. I got dressed, picked up my purse, and left. And that was it. No pain. No worries. No heartburn.

And that’s all it should ever be. And could be. And will be, if we keep leaning on Congress to get this thing done right.