"Going Bare"

Uninsured Portion of US Population Is Growing Rapidly, Survey Discloses

Public Citizen Health Letter, February, 1999

Sidney M. Wolfe, Editor


Eight years ago, the federal government adopted a policy statement called HealthyPeople2000, which set a goal to "improve the financing and delivery of clinical preventive services so that virtually no American has a financial barrier to receiving at a minimum, screening, counseling and immunization services"-in short, to guarantee that no one would be completely uninsured for health care when the new millennium began. This declaration was occasioned by a distressing if not scandalous situation: More than 35 million residents of the U.S. lacked access to rudimentary health care.

Seven years later, in September 1998, the Census Bureau estimated that "43.4 million people in the United States were without health insurance coverage during the entire calendar year of 1997 . . . up 1.7 million from the previous year," and there is no sign that since then the increase has stopped or even slowed. It is clear that "going bare"-the jargon for lacking access to health care-is becoming a way of life for more and more Americans, and that the Universal Declaration of Human Rights (to which the U.S. pays lip service) continues to be ignored in the richest nation in the world.

That declaration states that "everyone has a right to ... health and well being of his family, including ... medical care and the right to security in the event of ... sickness [or] disability." By the year 2000-less than a year from now-a situation that was bad a decade ago and bad now will be even worse.

The spotlight on what should be a mark of shame for the only advanced industrialized country without comprehensive health care has been focused by a statistic-packed paper in the January 1999 issue of the American Journal of Public Health entitled "Going Bare: Trends in Health Insurance Coverage, 1989 through 1996." Prepared by a group of doctors from the Harvard Medical School (including Steffi Woolhandler and David Himmelstein, frequent collaborators with Public Citizen's Health Research Group) on the basis of annual Census Bureau estimates, the paper concludes that "despite economic prosperity, the number and rates of the uninsured continued to rise [during that period, and that those] principally affected were children and young adults, poor and middle income families, blacks, and Hispanics."

By 1996, the terminal year of the Harvard study, the number of Americans going bare had increased from 33.4 million in 1989 to 41.7 million, leaving by that time 15.6 percent of the population-almost 1 in 6-out in the cold. "Rising numbers of uninsured during this period of prosperity ... may portend even steeper increases should the economic situation cool." Strongly implied here was a corollary: There is no reason to expect that the rate of increase will abate if good times continue.

The purpose of the Harvard study was not to "play the blame game," as former President George Bush used to say, but to issue a plea for strong and prompt action to bring the millions who are bare into the health care fold. There is plenty of blame to go around, however, including the inept and ill-advised effort early in the Clinton administration to prepare a "reform" package behind closed doors-a policy apparently adopted in desperation because early efforts to bring order out of chaos through open negotiation had been ground up in the Washington lobbying mill.

The picture painted by the Harvard study is almost uniformly dark. Nationally, the health care picture is an unalloyed disaster by standards of other developed countries. Only 10 states, most of them small, had lower percentages of uninsured people in 1996 than seven years earlier. Even Wisconsin, with the most comprehensive coverage in the United States, left 8.4 percent of its population (one person in 12) without coverage. The least comprehensive coverage is in Texas, where 24.3 percent (almost 1 in 4) went bare.

Geographically there is an unbroken swath of misery more than 3,000 miles long running through the western and southern reaches of the nation from California through Arizona, New Mexico, Texas, Louisiana, Mississippi, Florida, Georgia and South Carolina that embraces nine of the 10 states with the highest uninsured percentages. (Arkansas, which abuts on Texas, Louisiana and Mississippi, is the 10th state in what might be termed the "shame belt.") As of 1996, 47.3 percent of Americans going bare lived in these 10 states.

While the sheer numbers of uninsured persons and percentages are concentrated in southern and western states, the Harvard study leaves small room for gloating by other regions. "Aside from Arizona, some of the largest increases in uninsurance rates from 1989 through 1996 occurred in northeastern states, including New Jersey, New York and Massachusetts, and north central states such as lowa and Ohio; all of these states showed increases of 3 percentage points or greater in their uninsured population."

It might have been worse, the study indicates. "Without the Medicaid expansions from 1989 to 1993, another 11 million low income Americans would have been uninsured," it reports. "The leveling off of Medicaid levels after 1993 has likely also contributed to the rising number of uninsured. For example, although young adults had the largest increases in uninsurance, since the end of Medicaid expansion rates of uninsurance for children have also risen sharply."

What of the future? As someone with a wry sense of humor once remarked, "In the short run I am pessimistic; in the long run we are all dead." With fine understatement, the Harvard doctors comment, "Without a reverse in the trends of uninsurance, many of the goals set forth in Healthy People 2000 will not be achieved, particularly in those goals set for special populations. In fact ... minorities were more likely than the general population to be moving in the opposite direction of specified targets."

As the present article was being prepared, Chief Justice William Rehnquist was about ready to drop the gavel opening the Senate impeachment trial of President Clinton. If anything is left of the executive and legislative branches of the U.S. Government after all this is over, perhaps we will be able to get around to putting some real meaning into the Universal Declaration of Human Rights' guarantee of health care to all. According to the Harvard study, "more than 80 percent of Americans [believe] that health care, like education and social security, is a right and not a privilege."

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