American College of Physicians: Internal Medicine — Doctors for Adults ®


46 million uninsured present an intolerable situation

From the March ACP Observer, copyright 2007 by the American College of Physicians.

By Lynn Kirk, FACP

While advances in medicine over the past few decades have greatly enhanced many Americans' quality of life, progress has been clouded by the growing ranks of the uninsured. More than 46 million people in the U.S. encounter significant barriers in accessing our excellent health care system because they lack health insurance. It's a problem that affects not only the uninsured and their families but that reverberates throughout communities, the economy and the country.

How to best care for the uninsured and expand access to health insurance have long been debated at the local, state and national levels. In addition to the 46.6 million uninsured in the U.S.—representing 16% of the population—an estimated 16 million are underinsured and thus at significant risk for being severely adversely impacted by a health crisis. A significant portion of personal bankruptcies in this country are attributed to health care expenses that have spiraled out of control.

There are several factors that contribute to the expanding number of uninsured:

  • Fewer employers are offering health insurance to their employees due to rising costs.
  • Fewer workers can afford the insurance that is available to them.
  • More people are being denied affordable insurance for often insignificant pre-existing conditions.

The Institute of Medicine (IOM) has clearly documented that those without insurance are less likely to receive regular care or preventive services, more likely to suffer from preventable complications of illnesses, and more likely to die prematurely. Internists know this because we provide a large proportion of care for these patients.

The College has long been involved in actively advocating for the uninsured. Most recently, in 2002, ACP developed a proposal for health insurance coverage for all Americans within seven years. Most of the steps outlined in that proposal have not been achieved. The College continues to advocate for dedicated federal funds to support state-based programs to reduce the number of uninsured and for federal legislation to implement a plan to provide health insurance coverage to all Americans by a defined date. Proposed mechanisms to achieve these goals include changes in federal entitlement programs, tax credits and other subsidies to allow low-income working Americans to buy into benefits programs.

The public is becoming more vocal about the need for change, and for improved access to the health care system. The Citizens' Health Care Working Group authorized by Medicare legislation in 2003 has summarized the input from a wide variety of stakeholders collected at six hearings, 31 community meetings across the country and multiple surveys. Their conclusions echo many put forward by ACP, the IOM and other organizations. They include:

  • Health and health care are fundamental to the wellbeing and security of our country.
  • It should be public policy, established by law, that all Americans have affordable health care coverage.
  • All Americans should have access to a set of core health care services across the continuum of care throughout their lifespan.

Rising health care costs and the increasing number of Americans lacking health insurance are likely to keep this topic on the political agenda. Several states are trying to tackle the problem. Massachusetts, for example, has mandated that everyone in the state purchase health insurance by July 1, 2007 or face financial penalties. Under that plan, low-income residents would receive subsidies to purchase health insurance and those living below the poverty level would not be required to pay premiums. There would also be a mechanism for connecting individuals and small businesses to affordable insurance products, among other features. Other states, such as California, are working on their own innovative strategies. These efforts should provide valuable information for future state and federal action.

As health care providers, we face daily the personal toll that lack of health insurance takes on our patients, their families and our health care system. Because of internists' unique perspective on health care, I propose that we have a particular responsibility to advocate for the health care policies that we feel would most benefit our patients and our society. This advocacy should comprise, at minimum, understanding the various options for expanding health insurance coverage, being aware of the implications of proposals for health care reform and using this information when making our decisions in the voting booth. For many of us, this responsibility will also include educating others, speaking directly to our elected officials about the changes required to improve our health care system and campaigning for those candidates we feel are most likely to help achieve our vision.

With so many people still unable to access quality health care, it is imperative that we all take action. However we choose to participate in the debate, we must not continue to tolerate the intolerable.


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