Health data that no critic can deny

Pity the medically uninsured in America. As if they don’t already have enough to worry about, now they’ve become a political football.

Opponents and supporters of healthcare reform toss assertions about them back and forth. Their number is debated -- are they 46 million people? 30 million? Eight million? Their motivations for not having health coverage are questioned: Are they “young invincibles” who think they’re too healthy to need it? Too rich to need it? Or just cheapskates?

And let’s not ignore the aspersions cast on their character: “A citizen who accepts personal responsibility for his welfare has no real problem getting health insurance,” one reader wrote me recently.

Moral fiber and a clean lifestyle are all that’s needed to secure adequate healthcare, apparently.


But efforts to minimize the plight of the uninsured don’t stand up to scrutiny. The latest figures, setting the number of uninsureds at 46.3 million people as of the end of 2008, were released last week by the U.S. Census Bureau, and they make the case for reform stronger than ever.

“That’s a solid and respected estimate,” Timothy D. McBride, a professor of public health at Washington University in St. Louis, told me.

He called the figures “alarming,” because one trend they underscore is the decline in employer-sponsored health coverage. The percentage of the country covered by workplace plans dropped last year to 58.5% -- down from a peak of 64.2% in 2000 and the lowest level since 1993. Taking up some of the slack was the government, which expanded the number of persons covered by Medicaid by 44% to nearly 43 million.

The census data effectively punch holes in the most common misrepresentations that reform opponents make about the uninsured. The anti-reform lobby says the group comprises mostly illegal immigrants; people who can afford insurance and forswear it; candidates for public assistance who don’t bother to sign up; and people who are uncovered only for brief periods and thus (presumably) don’t warrant our concern.


Let’s take these assertions one by one.

First, uninsured illegal immigrants. Many opponents of healthcare reform raise their concern that illegal immigrants might benefit from publicly funded elements of healthcare reform to the level of a fetish. The issue was behind the now-infamous outbreak of hooliganism on the floor of the House of Representatives during President Obama’s healthcare speech last week, for example.

As for how many uninsured illegal immigrants there are, I’ve seen estimates as high as 12 million. No data support that figure. The Pew Hispanic Center, crunching the census figures, concluded that about 49% of all non-citizen permanent residents of the U.S. are here illegally. Applying that ratio to the Census Bureau’s estimate of 9.5 million noncitizens among the uninsured would suggest that the number of illegal immigrants among them is about 4.7 million.

The draft legislation in the House already bars public money from being spent to help illegal residents buy health insurance. As for the attempt by some members of Congress to mollify the anti-immigrant lobby by forbidding illegal immigrants to buy health insurance even with their own money -- a position unaccountably endorsed by President Obama -- there’s little to say about it except that it should go into the dictionary as a new definition for the word “pusillanimous.”


More pertinently, to oppose healthcare reform because a few of these people might slip through the sieve and end up getting a public handout to pay for health insurance is almost comically counterproductive. Reforming our healthcare system is a matter of the utmost urgency, with huge implications for our economy, our industrial competitiveness and the health of millions of American men, women, and children. Holding it hostage to a minor issue like public assistance to a few million illegal immigrants who probably wouldn’t benefit anyway is like allowing the fear of a paper cut to keep you from ever cracking open a book.

How about the well-heeled, voluntary uninsureds? Consider a 2007 “fact sheet” by Julia Seymour of the Business & Media Institute, an appendage of the right-wing Media Research Center.

Citing the 2005 edition of the census report, Seymour stated that “there are 8.3 million uninsured people who make between $50,000 and $74,999 per year and 8.74 million who make more than $75,000 a year.”

In other words, she said, “that’s roughly 17 million people who ought to be able to ‘afford’ health insurance because they make substantially more than the median household income of $46,326.” She repeated this claim again in June.


In fact, the 2005 census report said nothing of the kind. It said 17 million uninsured people lived in households with household income of $50,000 or more, a very different matter. (The figure in the latest census report is 17.7 million.)

You see, a single household can have one person in it, or four, or 10. It can be one family, or two or four. If one wage earner pulling down $50,000 shares an apartment with a spouse and three children, that’s not five people each earning $50,000 as Seymour, in her confusion, would conclude -- it’s a low-income family, which in many states would qualify for Medicaid.

A household with $75,000 in income could easily comprise two wage earners each making, say, $37,500, which means they could be part-timers ineligible for employee coverage or full-timers working for small employers who don’t offer it.

Seen in that light, Seymour’s picture of wealthy wage-earners deliberately going insurance-naked withers away. As hard as she and her ilk try to paint a picture of champagne-swilling yuppies playing dice with their health coverage, the facts aren’t on their side.


Next we come to low-income uninsureds who are eligible for public programs such as Medicaid or the Children’s Health Insurance Program, but who haven’t signed up. The critics claim they number somewhere between 11 million and 14 million and shouldn’t be counted among the uncovered 46 million.

They may be right about the numbers. Underutilization of public programs is a well-known problem. Indeed, a strong outreach component is written into H.R. 3200, the Democratic healthcare reform bill, for exactly that reason.

Yet their complaint brims with irony. Many of those who say we shouldn’t label people who don’t make use of public programs as “uninsured” are the same people agitating against the public option in healthcare reform. In other words, they’re saying that up to 14 million Americans wouldn’t be uninsured if they just took advantage of, um, a public option.

Finally we come to the short-term uninsured. The claim here is that as many as 80% of all those who lose coverage regain it after as little as four months. McBride, who has studied this issue, says that’s a misunderstanding of statistical math based on the difference between the flow of people in and out of the uninsured cohort and the status of those without insurance at any given point of measurement.


Citing a study by the Congressional Budget Office, he observed that although half of those who become uninsured in a given year regain coverage within a few months, about 80% of those who lack health insurance at a particular time end up being uninsured for more than 12 months, the definition of “chronically uninsured.”

In sum, the ranks of the uninsured are large, and with every employer who decides he can’t cover his workers anymore and every bump up in the unemployment rate, they grow larger. They can’t be wished away, and if the opponents of reform were committed to an honest debate, they’d stop trying.


Michael Hiltzik’s column appears Mondays and Thursdays.


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