Flatlined

The Uninsured

A Personal Story

For several years I bought delicate jewelry made of Venetian glass and fine mineral stones for my wife, my mother, and my daughters from a delightful middle-aged woman named Anne Casey (I have changed her name). Her craft supplements her income as a caregiver to the elderly. I would sit in her home studio in downtown Houston on a Saturday morning and pick out materials, and then she would create striking pieces. Not only did the women in my family like my gifts, but I looked forward to the process because I enjoyed chatting with her over coffee about her materials. I was introduced to Anne by my wife’s close friend, Phyllis (I have not changed her name), who was Anne’s high school classmate. I was disturbed when Phyllis told me this story.

One day in early 2007 a black lump appeared on Anne Casey’s neck—she had the fair Irish skin that is prone to cancers. Since she could not afford insurance, she paid cash for a dermatologist to biopsy it. The dermatologist was notably agitated after he looked at the biopsy under a microscope (he saw malignant cancer cells) and told her she needed surgery right away but he could not do it. Anne had malignant melanoma, a potentially fatal skin cancer that is normally removed as rapidly as possible to prevent its spread throughout the body. Her problem was that the down payment alone for a hospital admission would have been $10,000--which she did not have. I suspected that this was why the doctor could not do the surgery. Fearing for her life, Anne Casey began the process of obtaining a “gold card” which permits her to enter the public hospital system in Houston. Four weeks later she got the card, and four weeks after that, a clinic appointment. In order to find out how extensive the cancer was, the doctors needed an MRI and other tests before doing surgery. The larger of Houston’s two public hospitals sits in forlorn isolation in the back of the massive Texas Medical Center, like the servant’s entrance to a large Victorian house. It contains the only MRI in the county’s public hospital system. Anne was admitted to the hospital for the MRI and other tests normally performed as an outpatient. She lay in the hospital for six days waiting for an MRI as the hospital diverted ambulances because it had no available beds.

Phyllis, who each day was growing more anxious about Anne, called a doctor friend who owns an MRI facility and he agreed to perform the MRI for free. Ms. Casey left the hospital to undergo the donated MRI scan. Meanwhile the black cancer was getting larger every week as the two watched in horror, helpless. After weeks passed without the anticipated call to come in for surgery, Phyllis, desperate to help her friend, called the doctor who had performed the biopsy and insisted that he telephone the doctors at the public hospital to expedite the process. Calls were made on Anne’s behalf directly to the CEO of the hospital district by Phyllis and her friends.

Four months after the diagnosis of a life threatening malignancy Anne Casey finally underwent surgery to remove a visibly growing cancer. She told me that she felt she received excellent care and was glad for it. She could not know that the delay had increased her chance of dying of the cancer.

Anne had the advantages of being educated and having influential friends—her care was expedited. I knew that her doctors had done the best that they could with the resources available to them but her care would have been medical malpractice if she been insured and surgery delayed for four months for any preventable reason. Yet in present day America, Anne Casey’s care was better than many of the uninsured can expect.

When I returned home to Houston from Washington for Thanksgiving I found that there was no longer any need to use a pseudonym. Anne Casey’s real name was Patricia Mackie and she died of malignant melanoma metastatic to her brain on Thanksgiving Day, 2008. Her story is not unique--delayed diagnosis and treatment is the reason that 22,000 uninsured Americans die prematurely each year

The uninsured problem has grown so large that it is now fully in the middle class. Everyone regardless of income knows someone who has played by the rules, like Patricia Mackie, and yet is without health insurance. Given current health care cost trends, the public should care about the uninsured, because they may be next.

Who are the Uninsured?

There are more uninsured people in the US on any given day than the entire population of Central America, forty-one million. There are more uninsured than the combined populations of the three largest metropolitan areas in the US--New York, Los Angeles, and Chicago.

Fifteen percent of the population or forty-seven million Americans are uninsured on any given day.(1) Eighty-two million people, one-third of the non-elderly population, lose insurance some time within a two-year period.(2) According to Jeffrey Passel at the Pew Hispanic Center, only 12.5 percent of the uninsured are illegal immigrants, with that percentage much higher in states such as Arizona, Texas, and California.

Mostly, the uninsured are the working poor. Eight in ten uninsured live in working families.(3) Over half cannot afford to purchase insurance and their employers do not provide it. Twenty percent earn enough money to purchase insurance but choose not to do so.(4)

Twenty-five percent of the uninsured are eligible for public programs but are not enrolled. Most low-income parents know about Medicaid, the federal/state program that provides health insurance for poor children in all states and for their parents in some states, but many fail to sign up either because they think they are ineligible or because they cannot manage the enrollment hassles. For example, leaving work on a weekday every six months to spend all day at the Medicaid office would cost a janitor a day’s pay or his job. Contrast this with Medicare where everyone eligible for Social Security receives an enrollment package in the mail at age sixty-five.

States do not go looking for people that are eligible for public programs such as Medicaid and the State Children’s Health Insurance Program, and many states deliberately erect barriers, such as frequent face-to-face re-enrollment. The states pay thirty to forty percent of the cost of these programs, the federal government paying the balance, and full enrollment is a state budget-buster. The year 2003 was the first time that total state health care costs ever exceeded the cost of elementary and secondary education.(5)

It’s not only the working poor who are uninsured. In fact, moderate-income adults (annual incomes of $20,000 to $34,999 per year) now account for most of the increase in the uninsured, their percentage rising from twenty-eight percent to forty-one percent of the uninsured from 2001 to 2005.(6) About half of personal bankruptcies involve illnesses, and they are primarily in insured, middle-class families.(7)

How does Lack of Insurance Affect Health Status?

Middle class families will not like what they find when they seek care without coverage. Nationally, half as much is spent per capita on the health care of the uninsured as on the insured and for the chronically ill only one-third as much.(8), (9) These trends are worsening. Federal spending on the uninsured fell by nine percent per person between 2001 and 2004, pushing the costs off to municipalities that do not have the tax base to make up the differences.(10)

The health outcomes of the uninsured are predictably poor, embarrassing in a country as rich and educated as the US. The lack of health insurance alone results in preventable deaths, estimated to account for 22,000 deaths in 2006.(11) The effects of poverty and pre-existing illness are factored in, so the deaths are not just from being poor. In the ten years before people turn sixty-five, the risk of death from lack of insurance is nearly doubled.(12), (13) The reasons are lack of preventive care, lack of early diagnosis, and substandard treatment. For example, the uninsured are less likely to have Pap tests for cervical cancer, breast exams and mammography for breast cancer, colonoscopy for colon cancer, blood pressure check-ups, and measurement of blood cholesterol.(14) Their high blood pressure goes out of control when they lose insurance.(15) One-fourth of uninsured diabetics do not even have a routine check up every two years, and twelve percent of non-elderly adults with diabetes are uninsured.(16), (17)

The uninsured suffer high cancer mortality from late diagnosis and under-treatment. Nationally, uninsured women with breast cancer are thirty to fifty percent more likely to die.(18) The mortality rate for colorectal cancer is increased by sixty-four percent.(19)Uninsured men with prostate cancer are more likely to be diagnosed late and to die with advanced disease.(20) Patients with malignant melanoma are more likely to have advanced disease when they are diagnosed.(21)

People are uninformed about how bad the problem is, and not mean just average people. On July 10, 2007 President of the United States, George W. Bush, said “The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you can just go to an emergency room.” (22)

  1. “Income Climbs, Poverty Stabilizes, Uninsured Rate Increases,” US Census Bureau News, August 29, 2006.
  2. “One in Three: Non-Elderly Americans Without Health Insurance, 2002-2003,” Families USA Publication no. 04-104, June 2, 2004.
  3. “The Uninsured, A Primer,” Kaiser Family Foundation, October, 2006. Accessed online 2007: http://www.kff.org/uninsured/7451.cfm.
  4. Lisa Dubay, John Holohan, and Allison Cook, “The Uninsured and the Affordability of Health Insurance Coverage,” Health Affairs Web Exclusive, November 30, 2006.
  5. 2004 State Expenditure Report, National Association of State Budget Officers. Accessed online 2007: http://www.nasbo.org/Publications/PDFs/2004ExpendReport.pdf.
  6. Sara R. Collins, Karen Davis, Michelle M Doty, et al., “Gaps in Health Insurance: An All-American Problem,” The Commonwealth Fund, April 2006.
  7. David U. Himmelstein, Elizabeth Warren, Deborah Thorne, et al., “Discounting the Debtors Will Not Make Medical Bankruptcy Disappear,” Health Affairs Web Exclusive, February 28, 2006.
  8. Jack Hadley and John Holahan, “How Much Medical Care Do the Uninsured Use, and Who Pays for It?” Health Affairs Web Exclusive, February 12, 2003.
  9. Marc L. Berk and Alan C. Monheit, “The Concentration of Health Care Expenditures, Revisited,” Health Affairs 20, no. 2, (March/April 2001).
  10. Jack Hadley, Matthew Cravens, Terri Coughlin, et al., “Federal Spending on the Health Care Safety Net from 2001-2004: Has Spending Kept Pace with the Growth in the Uninsured?” Kaiser Commission on Medicaid and the Uninsured, November 2005. Accessed online November 2007: http://www.kff.org/uninsured/7425.cfm.
  11. Stan Dorn, “Updating the Institute of Medicine Analysis of the Impact of Uninsurance on Mortality”, Urban Institute, accessed at http://www.urban.org/url.cfm?ID=41158
  12. Karen Davis, “The Costs and Consequences of Being Uninsured,” Medical Care Research and Review 60, no. 2 (June 2003): 89S-99S.
  13. J. Michael McWilliams, Alan M. Zaslavsky, Ellen Meara, et al., “Health Insurance Coverage and Mortality Among the Near-Elderly,” Health Affairs 23, no. 4. (July/August 2004).
  14. Care Without Coverage: Too Little, Too Late, Institute of Medicine (Washington, DC, The National Academies Press 2002) 48-49.
  15. N. Lurie, NB Ward, MF Shipiro, et al., “Termination from Medi-Cal Benefits: A Follow-up Study One Year Later,” New England Journal of Medicine 314, no. 19, (May 8, 1986).
  16. Maureen I. Harris, “Racial and Ethnic Differences in Health Insurance Coverage for Adults with Diabetes,” Diabetes Care 22, no. 10 (October 1999).
  17. John Z. Ayanian, Joel S. Weissman, Eric C. Schneider, et al., “Unmet Health Needs of Uninsured Adults in the United States,” JAMA 284, no. 16 (October 25, 2000).
  18. Care without Coverage: Too Little, Too Late 54.
  19. Richard G. Roetzheim, Naazneen Pal, Eduardo C. Gonzalez, et al., “Effects of Health Insurance and Race on Colorectal Cancer Treatments and Outcome,” American Journal of Public Health 90, issue 11 (2000).
  20. Care without Coverage: Too Little, Too Late 54.
  21. Richard G. Rotzheim, Naazneen Pal, Colleen Tennant, et al., “Effects of Health Insurance and Race on Early Detection of Cancer,” Journal of National Cancer Institute 91, no. 16 (August 18, 1999): 140901415.
  22. White House press release on President George W. Bush’s speech to Cleveland Chamber of Commerce, Cleveland Ohio, July 10, 2007. Accessed online October 2007: