It is no wonder that the national debate in the early 1990s over universal health insurance was so acrimonious and contentious. The debate covers virtually all of the human condition. The debate is not just about access to health care; it is about the broadest of social issues, who is responsible for whom, to what degree, and in what ways. The debate happened to focus on health care.
Health is a fundamental requisite for a good life. Much of one’s health comes from doing what is known to keep one healthy: eat right, drink right, sleep enough, and avoid dangerous situations. That largely works. But some individuals have genetic predispositions toward certain conditions; others live in conditions such as poverty that makes doing the right thing for one’s health more difficult; and accidents do happen. For other individuals, however, health issues commonly derive from poor judgment. We rely on health care to help steer us to better health decisions and to fix what ails us, regardless of the cause.
Often times health care can heal us, but occasionally only at great expense. Because of the possible extraordinary expense, we have created a health care insurance system that protects most of us by sharing the financial responsibility for health care expenditures. The vast majority (84.5%) of Americans participate in that system, usually through their employer. But not everyone has a connection to work, and some employers either do not offer health insurance or offer insurance that requires a large financial commitment by the employee. Certain individuals elect not to make that financial commitment, choosing instead to take a chance that they will not need medical assistance. Still others are served by government programs.
In Wisconsin the percentage covered by medical insurance (91.4% in 1996) is even higher than nationally. But there still remains a segment of the population that has no insurance. That uninsured population makes tremendous financial demands on the health care system when its members do seek treatment. And this medically uninsured population can, and periodically does, make problems for the population at large, either because of the diseases they spread or because of the additions to health insurance premiums they require insurers to charge to compensate for serving the uninsured. If the size of this medically uninsured population could be further minimized, it would benefit not only the uninsured individuals but also the many health care providers in the health care system and our collective health. The issue is how to best reduce the number and negative impacts of the medically uninsured.
Health care is very expensive. It can absorb virtually any resources that may be aimed at it. There is no set limit that is enough. The debate then must focus on what is the minimal amount of health care our society should provide to all of its members. The US has spent many resources targeting specific groups whom it has felt deserve health care. For example, it serves poor children and poor mothers through Medicaid. It serves the elderly through Medicare. It serves Veterans through the Veterans Administration hospital system. It serves the disabled through Social Security Insurance (SSI). These populations have been deemed deserving. But these populations, plus those who pay for health insurance for themselves or have it paid for by their employers, are not inclusive. There are millions of Americans who do not have health insurance either by choice or because they are not offered it. These are the populations in the national debate. These are largely the individuals who locally are putting stress on the health care system. These are the individuals whose presence and demands on the health care system have precipitated this and numerous other studies.
The basic question before us is how can we best deal with the medically uninsured. Some of these individuals are clearly deserving of assistance by most standards. One example is those individuals who are working and are offered medical insurance through their employers but who do not participate because their incomes are not high enough to cover the basics of life and the insurance premiums. But what of others? What of those who are offered health insurance at work but who decline, choosing instead to spend the money that could go to premiums on a boat or a better car? Do they deserve assistance? What of those who abuse their bodies with alcohol, tobacco or drugs or who just eat badly and never exercise, even though they have been told numerous times that these habits need to be changed? These are tough questions.
There are more. Should we decide that health care providers should bear the responsibility for serving the uninsured? We could argue that there is so much money being spent on health care that providers can easily handle the modest demands this uninsured population can put on them at any point in time. But is this fair? Will it work in the long run? Probably not. Health care organizations need to at least balance costs and revenues; paying out more than they take in will only mean the erosion of health care for others.
If we cannot put the health care burden on the health care providers, that then suggests the burden should be on the individual, so that each individual is responsible for making him- or herself healthy and pay a portion of the cost of any medical treatment received. This is the ideal model in our market economy. It includes incentives for
keeping oneself healthy. But many lower income individuals simply do not have the resources to pay for insurance premiums, much less all of the health care costs. And others elect not to pay, forcing the rest of us to pay more. What incentives, if any, might be created to increase the percentage of the population that has a monetary as well as a personal incentive to lead a healthy life and to contribute to whatever costs may be associated with their own health care? That remains to be determined.
The issue of the medically uninsured in previous decades was not as large as it is today. Health care has traditionally been provided to those who needed it, regardless of ability to pay. Health care institutions provided care in part because of mission, in part because of ethics, and in part because the scale of giving was not unreasonable (medical care was less costly). Money from paying customers provided sufficient income to keep the institutions healthy, despite their largess for the uninsured.
But the evolution of the health care has changed this. The ability to cross-subsidize the provision of health care to the uninsured has been shrinking as HMOs and the federal health programs have forced care providers to reduce their costs and accept even lower payments for services provided. Many public hospitals that used to serve the indigent have closed. And with consolidation in the industry and changes in health care delivery, many private hospitals have also closed. The result is that the remaining providers have less ability to give away services and face greater demands to do so. Most still do give them away, but the trend is one that threatens some providers with the inability to continue for much longer to provide health care to the enlarging, medically uninsured population.
As we begin to examine the many different components of this issue of serving the medically uninsured, it becomes increasingly clear that this is a very complex issue, one that can stimulate many varied, yet perhaps valid, solutions. Our intention in this report is to organize the issue in a fashion that others might better address it, as well as examine a number of alternatives that have been or could be proposed. The end state is not to make a case for one particular approach, since a final solution can only be one that is negotiated by many involved actors. But it should help to steer discussion to alternatives that stand a chance of contributing to a solution. We do not pretend to think that we have the answer: many others have approached this issue and failed. But we hope that our systematic examination will draw us closer to some answers to this very critical question for our community, its institutions, especially its health care institutions, and its residents.