The consequences of a â€œnoâ€ vote in the halls of Congress and the possible quashing of health care reform will only propel the erosion of health care coverage in the United States, say experts in the New England Journal of Medicine (NEJM) Online First.
In the NEJM Perspective piece – titled â€œThe Consequences of â€˜Noâ€™â€ – authors Arthur L. Kellermann, MD, MPH, associate dean for health policy, Emory University School of Medicine, and Lawrence S. Lewin, MBA, say health care costs and coverage are tightly intertwined.
Kellermann says, â€œAlmost all the focus has been on analyzing the implications of the two remaining bills â€“ the one passed by the House and the one that is about to be debated in the Senate. But there is a third option that warrants equal scrutiny – it is a â€œNoâ€ vote. If it were a bill, its sponsors could call it â€˜The Status Quo Act of 2009.â€™â€
The authors write that for more than four decades health care costs have grown faster than our national economy. As a result, health care consumes a steadily growing share of federal and state budgets and the budgets of American families.
The authors point to a recent Institute of Medicine (IOM) committeeâ€™s analysis of the current trajectory of the U.S. health care system. It looked at the dynamics driving downward trends in insurance coverage and examined the health consequences of the lack of insurance for individual adults, children and communities. The IOM committee report, released earlier this year, built on and updated the previous IOM efforts resulting in six reports on health care between 2001 and 2004. The authors, who chaired these committees, say the reports paint a compelling picture of the harmful health and financial effects of the status quo – not only for people without coverage but also for people who have health insurance.
In addition, say Kellermann and Lewin, relentless cost growth threatens employer-sponsored insurance, undermines publicly funded programs such as Medicare and Medicaid, and renders individual insurance policies inadequate or unaffordable. Most Americans get coverage through their workplace, but the proportion is falling.
Kellermann notes, â€œIf nothing is done, all the indications are that employer-sponsored health insurance will continue to erode, public insurance programs like Medicare and Medicaid will become unaffordable, the private insurance market will be priced out of sight and the number of uninsured will grow to an unsustainable level. And these changes arenâ€™t decades away, they are happening right now.â€
Several factors are driving the decline in coverage, say the authors. Fewer workers, particularly among low wage earners, are being offered health insurance. Manufacturing jobs, which traditionally provided generous benefits, have been replaced by service jobs such as wholesale and retail trades that typically cover fewer employees. Rising premiums are encouraging employers to hire more part-time workers and contractors who donâ€™t receive benefits. More employers are dropping coverage; others are shifting a larger share of insurance costs to their employees through decreased wages, higher premiums and steeper copayments. As a result, fewer workers can afford employer-sponsored insurance.
Adults who canâ€™t get coverage through work, are too young for Medicare and donâ€™t qualify for Medicaid have only one option â€” individual health insurance, continue Kellermann and Lewin. Consumer Reports describes the individual insurance market as a â€œnightmareâ€ for consumers, say the authors. In recent years, several states have attempted to reform the individual health insurance market, with little success.
â€œCoverage matters,â€ say Kellermann and Lewin. â€œOn average, uninsured Americans get about half the preventive services and medical care that insured Americans receive. Studies have shown that uninsured people with cancer, heart disease, stroke, lung diseases, and other conditions are more likely to have poor health and to die prematurely than similar people with coverage. The available safety-net services are insufficient to overcome the gap between those who have health insurance and those who do not.â€
As a result, adds Lewin, the argument that we need not expand access to insurance as there is plenty of free care available, is contradicted by the dramatic difference in health outcomes for those without insurance coverage.
The economic consequences of a lack of insurance are equally grim. If even one family member lacks coverage, the entire family is exposed to the financial burden of severe illness or injury. In 2009, 20 percent of uninsured adults used up all or most of their savings paying medical bills. If states cut their Medicaid programs when American Recovery and Reinvestment Act funding runs out, uncompensated care will increase sharply, say the authors.
â€œThe burden this increase will impose on health care providers will be more than some can bear,â€ say Kellermann and Lewin. â€œIf many safety-net clinics and hospitals close their doors, the patients these institutions served will have nowhere else to go. When they end up in private hospital emergency departments and inpatient beds, it could trigger additional facility closures. Access to care will be diminished for the insured and uninsured alike.â€
The authors conclude by saying a vote for the status quo may be politically tempting, but it wonâ€™t stop the steady erosion of coverage in the United States.
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