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U.S. Census Bureau
September 2010

Health Insurance Coverage in the United States

Highlights

* The percentage of people without health insurance increased to 16.7 percent in 2009 from 15.4 percent in 2008. The number of uninsured people increased to 50.7 million in 2009 from 46.3 million in 2008.

* The number of people with health insurance decreased to 253.6 million in 2009 from 255.1 million in 2008. This is the first year that the number of people with health insurance has decreased since 1987, the first year that comparable health insurance data were collected. The number of people covered by private health insurance decreased to 194.5 million in 2009 from 201.0 million in 2008. The number of people covered by government health insurance increased to 93.2 million in 2009 from 87.4 million in 2008.

* Between 2008 and 2009, the percentage of people covered by private health insurance decreased from 66.7 percent to 63.9 percent. The percentage of people covered by employment-based health insurance decreased to 55.8 percent in 2009, from 58.5 percent in 2008. The percentage of people covered by employment-based health insurance is the lowest since 1987, the first year that comparable health insurance data were collected. The number of people covered by employment-based health insurance decreased to 169.7 million in 2009, from 176.3 million in 2008.

* The percentage of people covered by government health insurance programs increased to 30.6 percent in 2009, from 29.0 percent in 2008. This is the highest percentage of people covered by government health insurance programs since 1987. The percentage and number of people covered by Medicaid increased to 15.7 percent or 47.8 million in 2009, from 14.1 percent or 42.6 million in 2008. The percentage and number of people covered by Medicaid is the highest since 1987. The percentage and number of people covered by Medicare in 2009 (14.3 percent and 43.4 million) were not statistically different from 2008.

* In 2009, 10.0 percent of children under 18, or 7.5 million, were without health insurance. These estimates were not statistically different from the 2008 estimates. The uninsured rate for children in poverty (15.1 percent) was greater than the rate for all children.

* Between 2008 and 2009, the uninsured rate and the number of uninsured for non-Hispanic Whites increased from 10.8 percent and 21.3 million to 12.0 percent and 23.7 million. The uninsured rate and the number of uninsured for Blacks increased from 19.1 percent and 7.3 million to 21.0 percent and 8.1 million.

* The percentage and number of uninsured Hispanics increased to 32.4 percent and 15.8 million in 2009, from 30.7 percent and 14.6 million in 2008.

http://www.census.gov/prod/2010pubs/p60-238.pdf

Census Bureau press release:
http://www.census.gov/newsroom/releases/archives/income_wealth/cb10-144.html

PNHP press release:
https://pnhp.org/news/2010/september/number-of-uninsured-skyrockets-43-million-to-record-507-million-in-2009

Comment:

By Don McCanne, MD

Highlights of the 2009 health insurance highlights:

* Uninsured increased to 50.7 million – 16.7 percent of the population

* Private insurance decreased to 194.5 million – 63.9 percent

* Employment-based insurance decreased to 169.7 million – 55.8 percent

* Medicaid increased to 47.8 million – 15.7 percent

* Uninsured children remain at 7.5 million

* Racial and ethnic disparities in coverage have compounded

Those who oppose government solutions to the health care crisis will likely pass these worsening numbers off as an expected consequence of the sputtering economy and the new age of unemployment. They will pay little heed to the fact that the numbers are still intolerable when the economy is thriving; that isn’t their concern.

Supporters of the Patient Protection and Affordable Care Act (PPACA) will no doubt be disturbed by these numbers, but it is very likely that they will make the most of them in selling PPACA by showing how it will dramatically reduce the numbers of uninsured. That is true. Many will be covered by Medicaid and by private health plans, even if far too many will still remain uninsured.

This Census Bureau report remains silent on one of the most important issues in health insurance – the numbers who are underinsured – those who will face financial hardship should medical needs arise.

PPACA is an underinsurance program. Employers will see little relief and will expand their present trend of shifting more insurance and health care costs onto their employees. Individuals buying plans in the new insurance exchanges will select underinsurance products with low actuarial values (30 to 40 percent of costs to be paid by the patient) with subsidies that are inadequate to avoid financial hardship. Many will move into the Medicaid program which has more expansive coverage, but which reimburses providers at such a low rate that far too many will not be willing to accept patients under this program. With Medicaid chasing away providers, it too has become another form of underinsurance.

Thus the touted increase in insurance enrollment under PPACA will be more than offset by the explosion in underinsurance – affecting the majority of Americans. At this point looking forward, this nefarious outcome is not obvious to most. But as underinsurance sneaks up on us, and more and more individuals are feeling the pain, they’ll be ready. Ready for what? Ready for an improved Medicare that will always be there for us – in both good and bad economic times.

The PNHP press release (link above) provides a reality-based perspective of just what these numbers mean.

Teachers sue over health plan

By Susan Essoyan
Star Advertiser
September 15, 2010

Hawaii public school teachers filed suit yesterday in Circuit Court to block changes in their health coverage, saying that the state’s plan to do away with their health benefit trust fund is unconstitutional.

The suit, Kono et al. v. Lingle et al., seeks to represent more than 15,000 active and retired school teachers with health benefits in the Hawaii State Teachers Association Voluntary Employees’ Beneficiary Association Trust.

The teachers are objecting to the state’s plan to transfer their health benefit plans from “the financially sound” VEBA to the “insolvent or nearly insolvent” Employer-Union Health Benefits Trust Fund, according to the lawsuit.

“The forced transfer of the teachers into EUTF is designed to prop up that failing system on the backs of the teachers,” said Paul Alston, attorney for the plaintiffs. “What they will get if they are forced to transfer is higher costs and inferior benefits. It is clearly unconstitutional to take away the valuable benefits the teachers have.”

The suit contends that the change amounts to a breach of contract and violates the Hawaii Constitution by “diminishing or impairing” accrued benefits in the employees’ retirement system. After the switch, teachers will face higher co-payments and curtailed drug coverage and services, it said.

The lawsuit also alleges that the state improperly took $3.96 million from the VEBA trust surplus, which otherwise would have been used as reserves, and put it into the general fund.

The Legislature passed a law to phase out the VEBA trust on Dec. 31, and assign teachers to Employer-Union Health Benefits Trust, which covers more than 94,000 state and county employees and retirees.

The court filing included an April 12 letter from Gov. Linda Lingle to legislators in which the governor called the Employer-Union Health Benefits Trust “insolvent,” adding that “its governance is untenable.” She noted that Aon Consulting, the trust’s consultant, warned on March 31 that the trust fund would likely run out of money to cover expenses later this year.

Aon Consulting recommended a 26 percent increase in premiums as of July 1, but the Employer-Union Health Benefits Trust’s board of trustees has voted to keep rates and benefits the same through December of this year.

http://www.staradvertiser.com/news/hawaiinews/20100915_Teachers_sue_over_health_plan.html

Comment: 

By Don McCanne, MD

During Q&A at some of my speaking engagements, a common question from the audience: “Under a single payer, Medicare for all program, would I have to give up my excellent retired teachers’ health benefit program that we fought so hard for all of these years?”

That’s a very good question. These programs are often more comprehensive than Medicare. In fact, that is why we specify an improved Medicare as the framework for a single payer national health program. All essential health benefits would be included; deductibles, co-payments and coinsurance would be eliminated, and the administration of the program would be streamlined. There would be no need to maintain the teachers’ health benefit program as a separate entity.

What is alarming about this report from Hawaii is that these sacrosanct programs are now vulnerable. The teachers’ well-funded voluntary employees’ beneficiary association trust (VEBA) is about to be dumped into the near-bankrupt health benefit trust established for other government employees. The double tragedy is that the teachers lose, and other government employees who should have the most secure of health benefit plans are also losing as more of their health care costs inevitably will be dumped on them.

If our best and most stable health insurance programs are facing this uncertain future, what does that say about the security of other private insurance programs within our fragmented system of financing health care?

The Patient Protection and Affordable Care Act (PPACA) rewards employers who dump their health benefit programs by requiring health care assessments that are only a fraction of what they pay in premiums for their existing insurance programs. Their employees then are forced, by mandate, to purchase plans within the exchanges. Though purchased through exchanges, these plans are merely a slightly more regulated reincarnation of the individual market – the least stable and least reliable of private insurance plans. The subsidies for these plans are the equivalent of vouchers, providing a mechanism for shifting ever more of health care costs to those individuals with the greatest health care needs.

The teachers of Hawaii are right to be concerned. They need to fight hard to protect their VEBA, at least long enough for us to enact an even better program for them and everyone else – an improved Medicare for all.

PNHP
September 13, 2010

African Americans with muscular dystrophy die 10 to 12 years younger than their white counterparts, according to research published in today’s (Tuesday, Sept. 14) issue of Neurology, the medical journal of the American Academy of Neurology.

The black-white mortality gap, which was calculated on the basis of 20 years of data, is among the largest ever observed in the annals of research into racial disparities in health care, say Dr. Nicte Mejia and Dr. Rachel Nardin, co-authors of the editorial. “Furthermore,” they write, “white patients with MD [muscular dystrophy] enjoy increasing survival, while survival of black patients with MD barely budges,” leading to an ongoing widening of that gap.

“Inequities in the health delivery system – and the multiple ways in which race constrains access to care – seem the most likely explanation for the observed MD black-white mortality gap,” Mejia and Nardin write in their editorial. But they add that inadequate access to care due to lack of good quality health insurance may also be part of the picture.

“Nonelderly African Americans are 1.5 times more likely than whites to lack any type of insurance and about twice as likely to rely on Medicaid,” they write, noting that lack of health insurance is linked to lack of access to care.

And while Medicaid, the public health program for the poor, compares favorably with private insurance in providing access to primary care, it falls short when it comes to providing access to the standard-of-care treatments needed to manage conditions like muscular dystrophy, they say.

These shortcomings of Medicaid coverage are “particularly worrisome because more than half of the new health coverage under the 2010 National Health Reform will be Medicaid.”

In a separate comment made today, Nardin said, “Replacing the current U.S. health care financing system with a single-payer system that would ensure comprehensive insurance coverage for every American, regardless of race, would go a long way toward reducing this type of disparity.”

https://pnhp.org/news/2010/september/blacks-with-muscular-dystrophy-die-10-12-years-younger-than-whites-new-study-0

Neurology: Widening gap in age at muscular dystrophy–associated death between blacks and whites, 1986–2005
http://www.neurology.org/cgi/content/abstract/75/11/982

Comment:

By Don McCanne, MD

It is shameful that we have tolerated for so long a health care system that has failed to address the inequities and injustices exemplified by a widening black-white mortality gap in patients with muscular dystrophy – an inherited disorder inflicted on blameless victims.

Opponents of true reform (based on principles of health care justice) often blame the victim, implying that it is not the deficiencies in our health care system that are to blame, but it is the patients’ own personal failures that result in their predicaments, and we have no responsibility to intervene.

Even the most callous opponents of reform may acknowledge that there are exceptions in which the victims cannot be blamed, but even in those instances, the unfavorable outcome is often attributed to other socioeconomic factors over which we have no control. The “leave me out of this” mentality certainly contributes to our national inertia.

Maybe we can’t fix everything that’s wrong with our health care system and with society in general, but what we can do is reject the message of the passive obstructionists who contend that we’re each on our own, and join together in solidarity to address our societal deficiencies that have permitted terrible injustices such as sentencing muscular dystrophy patients to die a decade early merely because of their personal circumstances associated with being black.

The Patient Protection and Affordable Care Act will provide many of these unfortunate individuals with access to an insurance program, Medicaid, but as a chronically underfunded welfare program, that in no way ensures access to the actual medical care that they need. Many of them are already on this program, yet it doesn’t prevent them from dying a decade earlier than they might otherwise.

Although we have much to repair in this nation, a very good place to start would be to enact a health care financing system that would ensure that all of us receive the health care that we need – an improved Medicare for all. Furthermore, since collectively we are multi-tasked, we can revitalize and expand simultaneously our work on all of the other social justice issues as well.

By J. William Thomas, Erika C. Ziller and Deborah A. Thayer
Health Affairs
September 2010

In this paper we present the costs of defensive medicine in thirty-five clinical specialties to determine whether malpractice liability reforms would greatly reduce health care costs. Defensive medicine includes tests and procedures ordered by physicians principally to reduce perceived threats of medical malpractice liability. The practice is commonly assumed to increase health care costs.

Across all specialties, reductions in medical malpractice premiums would lead to statistically significant savings in 2.0 percent of the conditions analyzed, but these are high-volume situations, comprising 35.8 percent of all episodes. However, the magnitude of savings that could be realized is small, accounting for less than 1 percent of medical care costs in every specialty. Across all thirty-five specialties, savings associated with a 10 percent premium reduction in medical malpractice premiums would be just 0.132 percent. Even if medical malpractice premiums were to be reduced as much as 30 percent, defensive medicine costs would decline no more than 0.4 percent.

http://content.healthaffairs.org/cgi/content/full/29/9/1578

Comment: 

By Don McCanne, MD

Will bringing an end to defensive medicine reduce our national health expenditures? According to this and other studies, yes, but not by much.

Defensive medicine represents those tests and procedures that physicians order for the purpose of reducing the risk of medical malpractice liability. These are not random tests, but they are tests selected to prevent the patient from suffering harm – an essential component of malpractice.

If there were no liability exposure, why would a physician decide against ordering a test that might prevent a harmful outcome for the patient? Do physicians really believe that it is acceptable to gamble with the health of the patient by omitting potentially beneficial tests, yet is is not acceptable to place that same bet if a malpractice suit might ensue? Are these tests really for the benefit of the doctor and not for the benefit of the patient?

How often have you heard a physician confess to ordering a test that the patient didn’t need, but the test was still necessary to prevent a lawsuit? That is a non sequitur. If the physician could be sued for not ordering the test, then the test was absolutely essential.

The point of today’s message is that we keep looking in the wrong places for ways to try to control health care spending. Though we need malpractice reform for other reasons, we can’t look at it as a source of significant health care savings.

The most important first step to begin to control runaway health care costs would be to replace our wasteful, dysfunctional health care financing system with a single payer national health program – an improved Medicare for everyone – a Medicare that provides us with the financial tools with which we could slow the rate of health care spending increases.