Mass Failure

In 1966–just before Medicare and Medicaid
were launched–47 million Americans were uninsured. By 1975,
the United States had reached an all time low of 21 million without
coverage. Now, according to the Census Bureau’s latest figures,
we’re back where we started, with 47 million uninsured in 2006–up
2.2 million since 2005. But this time, most of the uninsured
are neither poor nor elderly.

The middle class is being priced
out of healthcare. Virtually all of this year’s increase was
among families with incomes above $50,000; in fact, two-thirds
of the newly uncovered were in the above-$75,000 group. And full-time
workers accounted for 56 percent of the increase, with their
children making up much of the rest.

The new Census numbers are
particularly disheartening for anyone hoping for a Massachusetts
miracle. In the Commonwealth, 651,000 residents are uninsured,
65 percent more than the figure used by state leaders in planning
for health reform. Their numbers came from a telephone survey
done in English and Spanish. But that misses people who lack
a land-line phone–43.9 percent of phoneless adults are uninsured,
according to other studies.

It also skips over the 523,000
non-English speakers in Massachusetts whose native language isn’t
Spanish (e.g. Portuguese, Chinese, or Haitian-Creole), another
group with a high uninsurance rate. In contrast, the Census Bureau
goes door-to-door for its survey and has translators for almost
every language. It gets a more complete picture.

In sum, Massachusetts health
reform planners have been wishing away a quarter of a million
uninsured people. Recent Patrick administration claims that health
reform is succeeding are based on cooked books. According to
the state’s figures, almost half of the previously uninsured
gained coverage under the health reform bill by July 1. But according
to the Census Bureau, the new sign-ups amount to less than one-quarter
of the uninsured. Moreover, it’s likely that much of that gain
has already been wiped out by shrinking job-based coverage–a
longstanding and nationwide trend.

Why has progress been so meager?
Because most of the promised new coverage is of the “buy
it yourself” variety, with scant help offered to the struggling
middle class. According to the Census Bureau, only 28 percent
of Massachusetts uninsured have incomes low enough to qualify
for free coverage. Thirty-four percent more can get partial subsidies–but
the premiums and co-payments remain a barrier for many in this
near-poor group.

And 244,000 of Massachusetts
uninsured get zero assistance–just a stiff fine if they don’t
buy coverage. A couple in their late 50s faces a minimum premium
of $8,638 annually, for a policy with no drug coverage at all
and a $2,000 deductible per person before insurance even kicks
in. Such skimpy yet costly coverage is, in many cases, worse
than no coverage at all. Illness will still bring crippling medical
bills–but the $8,638 annual premium will empty their bank accounts
even before the bills start arriving. Little wonder that barely
2 percent of those required to buy such coverage have thus far
signed up.

While the middle class sinks,
the health reform law has buoyed our state’s wealthiest health
institutions. Hospitals like Massachusetts General are reporting
record profits and enjoying rate increases tucked into the reform
package. Blue Cross and other insurers that lobbied hard for
the law stand to gain billions from the reform, which shrinks
their contribution to the state’s free care pool and will force
hundreds of thousands to purchase their defective products. Meanwhile,
new rules for the free care pool will drastically cut funding
for the hundreds of thousands who remain uninsured, and for the
safety-net hospitals and clinics that care for them. (Disclosure–we’ve
practiced for the past 25 years at a public hospital that is
currently undergoing massive budget cuts.)

Health reform built on private
insurance isn’t working and can’t work; it costs too much and
delivers too little. At present, bureaucracy consumes 31 percent
of each healthcare dollar. The Connector–the new state agency
created to broker coverage under the reform law–is adding another
4.5 percent to the already sky-high overhead charged by private
insurers. Administrative costs at Blue Cross are nearly five
times higher than Medicare’s and 11 times those in Canada’s single
payer system. Single payer reform could save $7.7 billion annually
on paperwork and insurance profits in Massachusetts, enough to
cover all of the uninsured and to upgrade coverage for the rest
of us.

Of course, single payer reform
is anathema to the health insurance industry. But breaking their
stranglehold on our health system and our politicians is the
only way for health reform to get beyond square one.

Dr. Steffie Woolhandler
and Dr. David Himmelstein
co-founded Physicians for a National Health Program and are primary
care doctors at Cambridge Hospital.