Counting the Uninsured in the U.S.

We know from the Census’ report yesterday that there are 46.3 million total people as of 2008 who lack health coverage from an insurance company or a government-run program, including 36 million American citizens and 9.5 million people who are either legal immigrants, green card holders, or undocumented immigrants here illegally. But the closer we come to solving the problem, the more challenges you’ll hear to any and all of those numbers by those arguing against reform. Yes, there are larger questions of who we think should be covered in a responsible, just society and of what our methodology for counting is. These questions are worth discussion and debate. But it shouldn’t move us off a more fundamental question: how is a system in which millions and millions of people -- no matter how you count them -- lack basic health coverage acceptable?

So what are the distinctions? The largest one is documentation status. It’s not clear to me what the difference is between “more than 30 million American citizens”, to use President Obama’s formulation, or the “more than 46 million people” that is more frequently cited. It makes no difference in terms of public health or the economics of our unsustainable health care costs in which the burden of paying for the uninsured is borne by all of us. Communicable disease and emergency room trip-inducing calamities don’t care whether you’re insured or not, of what country you're a citizen, how much money you do or do not have, or your documentation status. It is a pure political wedge issue, agnostic to substantive health and economic concerns, and one on which I’ll have more to write about tonight.

But the strangest argument I’ve heard lately from Orrin Hatch and other conservatives is that we should also throw out any household making above $50,000 a year from the count. The argument is that those people should be able to afford insurance, because they’re solidly middle-class. That just shows how frustratingly naïve the conventional thinking on who is uninsured truly is.  It is precisely the middle-income working class that is being put through the ringer by our out-of-control health care costs. The income group between $50,000-$70,000 is actually the fastest-grown segment of the uninsured population. It accounts for most of the increase over the last decade. The reason why has been pointed out by many other writers today –- private, employer-based health insurance is already eroding because of escalating costs. Over the past seven years, we have seen a net loss of 5 million people covered by their job -- a fact usually ignored by those arguing that we shouldn't be in a rush to reform -- and the number of uninsured would, ironically, look much worse if it hadn’t been for the expansion of government-run Medicaid and SCHIP.

As someone who is in that income group myself, there is no mystery as to why these people who should have insurance (at least according to the Orrin Hatches of the world) don’t. The average family plan on the individual market here in New York is not that far off from the national average -- $12,254 according to America’s Health Insurance Plans. That represents 17-24% of income for a family in that range. For comparison’s sake, the Swiss and Japanese utilizing private insurance pay 8-9% of their income on premiums. Combine premiums that have nearly doubled since 2000, making an individual market plan increasingly unaffordable to the middle-class, with an increased likelihood that you will not have benefits offered by their employer, and the numbers explain themselves.

Now combine that with an economic crisis where unemployment shoots up several percentage points, leading to an estimated 6 million people have lost their insurance in 2009, and you have a recipe for disaster. No wonder those arguing against reform don’t want you to pay attention to this income group -- it’s the perfect snapshot of what’s going wrong.

So that opens the door to a different question. How many people should be uninsured in the United States of America, a land many of us to believe to be the greatest country on Earth, where we hold ourselves to a self-evident truth that all men and women are created equal? That answer is easy: zero.

(Photo credit: http://www.flickr.com/photos/aussiegall/ / CC BY 2.0 )