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Expert Perspectives on the 2005 Biennial Health Insurance Survey Findings

James Mongan Fernando Guerra Helen Darling Gerald Shea

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By James Mongan, M.D., President and CEO, Partners HealthCare, and Chair, Commonwealth Fund Commission on a High Performance Health SystemTo learn that a growing number of people in moderate- and middle-income households are going without health coverage is disheartening, but not surprising. As the head of a large hospital system serving a major metropolitan area, I see the impact of more and more families going without medical care due to the combination of eroding health insurance coverage and rapidly rising health care costs.

Many people assume that individuals without health insurance get all the care they need through hospital emergency rooms. That's just not true. People without health insurance frequently do not get basic preventive care such as blood pressure or cholesterol tests or have the ability to treat their chronic health conditions. Having access to a regular source of affordable care is critical to good health since delaying or going without care can have serious consequences.

This study, Gaps in Health Insurance: An All-American Problem, not only raises concerns about the ability of U.S. families to obtain timely medical care, but also about protecting their finances from catastrophic health care costs, and saving for retirement. Leaving millions of Americans without health insurance coverage makes it difficult to achieve a high performance health care system for everyone. This problem affects all of us.

The study also finds that uninsured people with chronic health conditions like diabetes and asthma are much more likely to skip medications for their conditions and to visit emergency rooms or be admitted to the hospital than are those who are insured. This fact alone should set off alarm bells about the ability of the health care system to manage and moderate the catastrophic costs associated with chronic diseases. In addition, the finding that people with unstable coverage are more likely to receive duplicate tests or experience delays in obtaining abnormal results reveals the inefficiency of the nation's fragmented insurance system.

Medical debt and bill burdens also affect many families. Many adults, regardless of insurance coverage and income, are accumulating substantial amounts of medical debt from unpaid medical bills. But the uninsured are the worst affected. Even uninsured adults with higher incomes report medical bill and debt problems at very high rates. Medical debt is another deterrent to seeking needed health care services.

Real solutions that build on group forms of coverage already in place, including employer plans, Medicare, Medicaid, the State Children's Health Insurance Program, and state and federal employee benefits programs, can help to fill insurance gaps with meaningful, affordable coverage that helps link families and providers. The new law here in Massachusetts is one example of how government, employers and individuals can share responsibility for a problem affecting a growing number of people.

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By Fernando Guerra, M.D., Director, City of San Antonio Metropolitan Health District and Member, Commonwealth Fund Commission on a High Performance Health System

As the director of a large metropolitan area public health department and a practicing pediatrician, I witness the impact that the high cost of health care has on families and communities. The new Commonwealth Fund report, Gaps in Health Insurance: An All-American Problem, crystallizes issues that I come across on a daily basis in my practice and in my city.

Every day, I see working families that are struggling to pay for food, housing, clothing, and transportation, and that don't seek care until an illness has progressed to the point where hospitalization, surgery, and expensive medicines are required to treat it. Recently, I saw a four-month-old baby with a six-day-old staph infection—if I had seen her four days earlier it would have cost $150 to treat her, but because of the delay, it cost five times that much.

Chronic illnesses like asthma and diabetes consistently go undiagnosed or untreated because families can't afford the high costs of doctor visits and medicines—I have seen siblings sharing asthma medicines, one child taking them one day and the other the next. This doesn't have to be. We know what medicines work, but that doesn't do any good if people can't afford to come to their refill appointments, refill their prescriptions, and take their medicines.

The uninsured continue to struggle with access to health care. Preventative care, family planning services, mental health care, and dental care are all essential to the complete health of a person, yet we consistently see whole populations going without them.

For example, in San Antonio, we're seeing an increase in the number of women coming in for prenatal care late in their pregnancies. Late access to prenatal care is linked to less than optimal outcomes for a pregnancy, especially if there are such associated conditions as poor dentition and gum disease, which is associated with prematurity or low birth weight. If these women are waiting to come in for prenatal care, you can imagine that they are not necessarily taking care of their teeth—but uninsured people can't even think about dental care.

If we are going to make true progress for the hardworking uninsured families in our communities, we must put a higher priority on the importance of a medical home; begin to value the relationship between health care professionals and their patients; make routine health care affordable for working families; and ensure that essential preventative care is accessible. If we don't commit to these things, the cost to the health and economies of our communities will be more than we can afford.

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By Helen Darling, President, National Business Group on HealthMillions of workers in the United States have access to health insurance through their employers, yet millions of others remain uninsured in large part because of the growing cost of health insurance and health care services.

With health spending increasing by more than 7 percent per year and the cost of family health insurance premiums averaging over $10,000 per year, it is sad but not surprising that a growing number of people in this country do not have health insurance and cannot afford health care.

This new study, Gaps in Health Insurance: An All-American Problem, is a reminder that we have a terrible mess of a health care system. It doesn't work well for most people, but is much worse if you are uninsured.

The problem of "uninsurance" is not new. What is new is the growing number of working individuals earning well over minimum wage who cannot pay for insurance and who go without basic health care. Debt from medical bills is growing, even for people who do have health insurance.

In my opinion, the problem is affordability. Employers want to do their best for their employees by providing health care coverage but as the costs of health care and health insurance doubles every six or seven years—keep in mind that we are already starting at a base that is almost twice the cost of other high standard of living countries—employers are finding themselves increasingly stretched too thin.

No economy can support the current rate of growth in health care costs. Business owners both large and small work hard to offer coverage to their employees but in order for them to remain effective and competitive, health care costs must be brought under control. Until systemic problems driving the high costs of health care in the U.S. are solved, we are unlikely to see improvement and this problem will continue to affect everyone, hurting the low- and moderate-income uninsured the most.

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By Gerald Shea, Assistant to the President for Government Affairs, AFL-CIO

The Commonwealth Fund's latest report on uninsured and underinsured Americans provides shocking evidence of the downward spiral in working families' health coverage.

This report deserves a response from public officials; we hope it gets it.

Those elected officials who wring their hands about the uninsured but do nothing to significantly expand coverage should be shamed by this report.

Those who support coverage expansion should think hard about how much of the financial burden should fall on working families, as the Massachusetts governor and state legislature recently did.

To be affordable to working families, the lion's share of the costs of work-based coverage needs to be borne by employers or government. And both have to combine forces to shoulder the high costs of coverage, to improve efficiency, and rein in health costs.

There is no other way that people of modest income can afford family coverage that runs upwards of $10,000 a year.

Often, the problems of the uninsured and underinsured are attributed to the difficulty small firms have in subsidizing health benefits for their workers. While this is undoubtedly true, given the unsustainable cost of health insurance today, it obscures the coverage problem in large corporations. This report documents the extent to which coverage problems exist in large businesses that reject a shared responsibility approach, where the company provides significant funding for health care and workers contribute as well. In fact, 32 percent of those uninsured at some point in 2005 worked for firms with 100 or more employees, according to the survey.

The Fund's biennial survey is also the leading national study on the medical and financial consequences experienced by families that go without health coverage. Nearly half of uninsured respondents reported that they used up all their savings to pay health bills and 20 percent said they couldn't afford to pay for basic costs like rent, food, or heat because of those bills. Nearly 60 percent of the uninsured with chronic illness reported going without prescribed medications or skipping doses because they couldn't afford their drugs.

These are horrifying statistics that show the extent of the threat that lack of coverage poses for individual Americans and for our country as a whole.

This Commonwealth Fund report is a reality check that every elected official and policymaker needs to understand and come to terms with.

The views presented in these commentaries are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.

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Publication Details



J. Mongan, F. Guerra, H. Darling, and G. Shea, Expert Perspectives on the 2005 Biennial Health Insurance Survey Findings, The Commonwealth Fund, April 2006