"… the sickest people are most likely to have problems getting the medical care they need. The vast majority of uninsured adults in poor health had difficulty getting care. This finding directly contradicts the conventional wisdom that truly sick people can always get care when they need it."

The problem of health care delivery has become more important in the last two decades as efforts to cut rising health care costs increasingly translate into reduced access for the under- and uninsured. Most of the uninsured are under the age of 65 because Medicare covers virtually all elderly Americans. Those that are insured under the age of 65 are largely dependent upon private health insurance coverage through employment. Sixty-nine percent (69%) of nonelderly Americans in 1993 were insured by a private health insurance plan (61% through employer and 8% through individually purchased plans). Twelve percent (12%) received coverage through Medicaid, 2% received insurance as members of the military, and 17% of the nonelderly population were left without public or private insurance in 1993 (38.4 million people). Most of the uninsured however are not poor, the majority are working families with modest income. Seventy-two percent (72%) are from families with incomes above the poverty level.¹ Children under age 18 account for approximately one-fifth of the uninsured population even though Medicaid provides insurance for one in four children and covers 40% of all births. Unfortunately, the situation for the uninsured is getting worse. Changes in the health care marketplace are likely to perpetuate "the already limited access to care for people without insurance."

 

In 1965, President Lyndon Johnson and his administration considered the enacting of Medicare as an insurance program for the elderly that was only an interim step toward the broader goal of providing universal health care coverage. Before the introduction of Medicare and Medicaid, one-third of the US population was uninsured or underinsured. After the introduction of these programs it gradually fell to about 12 percent of the population in the late 1970s, and since that time the proportion of underinsured and uninsured has risen steadily, to approximately 15 percent of the current population and 25 percent in California. In the absence of changes in public policy, current projections are that 20 percent of the population, or 50 million people, will be uninsured at the beginning of the next century.

Employer-based health insurance spread in the decade after World War II because employers were not allowed to raise wages. Instead, they chose to improve their employees’ fringe benefits, one of which included health care coverage. Between 1945 and 1973, a flourishing economy enabled employers to provide this coverage to their employees. Beginning in the 1960s, health care expenditures grew at twice the rate of general inflation. In the 1980s, health care inflation and a failing economy forced employers to start thinking about reducing health care costs. Many employers elected not to ensure employers at all while others shifted costs to their employees and still others enacted their own insurance plans. Health care inflation continued to rise however, and by 1989 employers’ health expenditures represented 8.9 percent of wages and salaries.⁷ As a result of these economic pressures, health maintenance organizations became more attractive to employers interested in cutting costs by forcing the health care system to become more efficient.

Some argue that every American already has a catastrophic insurance policy, the emergency room of a nearby hospital. Not withstanding, several investigators have demonstrated that the lack of medical insurance is a barrier to health care even for serious medical conditions.^, Franks et al. showed that the risk of premature death among Americans is significantly increased with a lack of health insurance over a long period. Hadley et al. found that the mortality rates among hospitalized patients without health insurance are two or three times higher than those with insurance. People without health insurance are also less likely to seek medical care, less likely to get medical care, and consequently are more likely to experience worse health.

As the number of underinsured and uninsured citizens in this country steadily rises and as health maintenance organizations, under the guise of managed care, continue to emphasize cutting health care costs, we as a society are forced to deal with the prospect of inadequate health care coverage for millions of people. The goal of the 2000 Health care Symposium is to provide a framework for discussion of these issues and insight into the potential for improvements in health care delivery.