Health Reform Failure

In 1966 - just before Medicare and Medicaid were launched - 47 million Americans were uninsured. By 1975, the United States had reached an all time low of 21 million without coverage. Now, according to the Census Bureau's latest figures, we're back where we started, with 47 million uninsured in 2006 - up 2.2 million since 2005. But this time, most of the uninsured are neither poor nor elderly.

The middle class is being priced out of healthcare. Virtually all of this year's increase was among families with incomes above $50,000; in fact, two-thirds of the newly uncovered were in the above-$75,000 group. And full-time workers accounted for 56 percent of the increase, with their children making up much of the rest.

The new Census numbers are particularly disheartening for anyone hoping for a Massachusetts miracle. In the Commonwealth, 651,000 residents are uninsured, 65 percent more than the figure used by state leaders in planning for health reform. Their numbers came from a telephone survey done in English and Spanish. But that misses people who lack a land-line phone - 43.9 percent of phoneless adults are uninsured, according to other studies.

It also skips over the 523,000 non-English speakers in Massachusetts whose native language isn't Spanish (e.g. Portuguese, Chinese, or Haitian-Creole), another group with a high uninsurance rate. In contrast, the Census Bureau goes door-to-door for its survey and has translators for almost every language. It gets a more complete picture.

In sum, Massachusetts health reform planners have been wishing away a quarter of a million uninsured people. Recent Patrick administration claims that health reform is succeeding are based on cooked books. According to the state's figures, almost half of the previously uninsured gained coverage under the health reform bill by July 1. But according to the Census Bureau, the new sign-ups amount to less than one-quarter of the uninsured. Moreover, it's likely that much of that gain has already been wiped out by shrinking job-based coverage - a longstanding and nationwide trend.

Why has progress been so meager? Because most of the promised new coverage is of the "buy it yourself" variety, with scant help offered to the struggling middle class. According to the Census Bureau, only 28 percent of Massachusetts uninsured have incomes low enough to qualify for free coverage. Thirty-four percent more can get partial subsidies - but the premiums and co-payments remain a barrier for many in this near-poor group.

And 244,000 of Massachusetts uninsured get zero assistance - just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases, worse than no coverage at all. Illness will still bring crippling medical bills - but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2 percent of those required to buy such coverage have thus far signed up.

While the middle class sinks, the health reform law has buoyed our state's wealthiest health institutions. Hospitals like Massachusetts General are reporting record profits and enjoying rate increases tucked into the reform package. Blue Cross and other insurers that lobbied hard for the law stand to gain billions from the reform, which shrinks their contribution to the state's free care pool and will force hundreds of thousands to purchase their defective products. Meanwhile, new rules for the free care pool will drastically cut funding for the hundreds of thousands who remain uninsured, and for the safety-net hospitals and clinics that care for them. (Disclosure - we've practiced for the past 25 years at a public hospital that is currently undergoing massive budget cuts.)

Health reform built on private insurance isn't working and can't work; it costs too much and delivers too little. At present, bureaucracy consumes 31 percent of each healthcare dollar. The Connector - the new state agency created to broker coverage under the reform law - is adding another 4.5 percent to the already sky-high overhead charged by private insurers. Administrative costs at Blue Cross are nearly five times higher than Medicare's and 11 times those in Canada's single payer system. Single payer reform could save $7.7 billion annually on paperwork and insurance profits in Massachusetts, enough to cover all of the uninsured and to upgrade coverage for the rest of us.

Of course, single payer reform is anathema to the health insurance industry. But breaking their stranglehold on our health system and our politicians is the only way for health reform to get beyond square one.

Dr. Steffie Woolhandler and Dr. David Himmelstein co-founded Physicians for a National Health Program and are primary care doctors at Cambridge Hospital.

(c) 2007 The Boston Globe

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