Back in 2005, I co-authored an article with Richard Stuhan, a partner at Jones Day. The article was primarily about the concerted and misguided efforts to sue non-profit hospitals for their alleged failure to provide charity care. The plaintiffs contended that such provision of charity care was a legal obligations of 501(c)(3) tax exempt entities. These suits, while striking the public policy cord concerning the plight of the uninsured and the inflation of health care costs and charges, were based upon ill conceived legal theories and, accordingly, failed miserably. But they probably were a precursor of congressional interest in charity care provided by non-profit hospitals and health systems — which is currently playing out and has resulted in some significant changes, most notably the new Form 990s.
One of the items we briefly discussed in that article, an issue that should be a major large part of the health care reform debate, is the scope of the health care insurance (or, more particularly, uninsured) problem in the United States. Who accounts for the uninsured figures and why are they uninsured is critical to forming the debate about solutions. The debate, I would think, is fundamentally different if a substantial portion of the uninsured could afford insurance or could access other forms of insurance (SCHIP, Medicaid, etc.), but decide for personal reasons not to obtain insurance or face administrative, educational or transactional barriers to signing-up for federal or state-sponsored insurance programs for which they would otherwise be eligible. Circa 2003, the uninsured level was approximately 45 million, but a very significant portion of this populations was either eligible for federal or state programs or were from households that were significantly above the federal poverty level and could, technically, afford insurance.
Periodically, this issue has popped up with one study or another discussing the scope of the uninsured problem — addressing who are they, why are they not insured. Of course, with this new round of health care reform, the issue of the uninsured should be front in center in the debate. Recently, a report was issued entitled WHO ARE THE UNINSURED? An Analysis of the Characteristics of Americans Without Health Insurance by the Employment Policies Institute. This seems to be a fairly politicized organization that has written studies before that have been scorned by some. So, with that disclaimer and taking the study with a grain of salt, its conclusions are still notable. Assuming its numbers are correct, approximately 43% of the 2006 18-64 year-old uninsured are in households at greater than 2.5x the federal poverty limit. This is not inconsistent with previous studies I had seen and I would think could be fact checked.
By no means does this take away from the significant and troubling 47% who are involuntarily uninsured. But the number of individuals and households that have the means to, but choose not to, purchase health care insurance is important to the current debate. What impact does this very significant portion of the uninsured have for risks of adverse selection, individual/employer mandatory coverage requirements, the level FPL subsidies and other components of healthcare reform bills being proposed.