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UNINSURED, AND LIKELY TO STAY THAT WAY
To get to the heart of the health-care-reform debate, it helps to steer clear of Washington. Travel instead to the Neighborhood Health Center, a primary-care clinic in Pittsfield, Mass. There, every afternoon, 20 or 30 patients walk in with medical problems--and no insurance to pay the bill.
Collette Dus, 32, is here for a checkup. It's her first since her husband Lino lost his $40,000 machinist's job--and its medical benefits--in 1991. He now does freelance landscaping; Collette works part-time at a nursing agency. Together, they made $19,000 last year--"not dirt poor," Collette says, but not wealthy enough to pay $5,000 for insurance.
Most of the nation's 37 million uninsured are in the same boat. Most live above the poverty line. In fact, three of four uninsured adults are employed but typically hold jobs that offer few or no benefits. Unable to qualify for Medicaid, they negotiate a patchwork of free and subsidized services, delaying care and putting off noncritical tests and drugs.
"WORSE OFF." It doesn't look like Congress is going to do these uninsured much good. Truly universal coverage, and the means to pay for it, has little political viability. Instead, what appears likely is a plan that guarantees nothing, costs many working poor more, and, ultimately, leaves millions without coverage for years to come. "Many people will be worse off," says Lynn Etheridge, a Washington consultant.
The problem starts with individual mandates. In essence, these require that every American buy insurance, with subsidies for families with incomes below a certain level--$29,600 for a two-parent family with kids. The proposed plans call for annual deductibles of $400 to $500 for individuals, plus separate deductibles of up to $500 for drugs and coinsurance payments of up to 25%.
The question: Even with subsidies, how many of the now-uninsured will be able to afford such coverage? Linda Dupuis, a part-time factory worker in Pittsfield, offers a clue. She was covered by a policy until recently but couldn't pay its $500 annual deductible and 15% coinsurance. Her kids get care from doctors who accept a few dollars a month in payment. But "anything for me, I won't go," she says.
Doctors and policy analysts say millions of others will be caught in the same bind, especially lower-middle-class families above the subsidy ceiling. Even more would be shut out by the weak-kneed Senate Finance Committee bill, which would allow Congress to knock down subsidies if enough funding doesn't materialize. (It won't.) An employer mandate presents similar hazards: Small companies forced to pay for insurance probably would fund premiums out of workers' wages.
Other obstacles that prevent the uninsured from getting care aren't addressed by anyone's bill: lack of transportation, poor health education, a dearth of supporting social services. Some patients refuse to see doctors because of language barriers, psychological problems, or simply their shame in taking what they perceive as a government handout. "There's an open question whether providing access to medical care is enough," says Peter Z. Konigsberg, national medical director of Coopers & Lybrand's health consulting group.
PROBLEM POSTPONED. Do we accept a half-solution, or less? Any of the plans on Congress' plate surely will reduce the number of uninsured, giving more people access to a broader range of medical services. And the price will not be terribly great: Rand Corp. estimates that universal coverage would cost $20 billion to $30 billion more--about 3% of total U.S. health-care spending--than what such patients cost the system already.
The risk is that the nation stomachs the coming congressional solution, then assumes the big problem is solved. It won't be. Among Pittsfield's uninsured, there's broad support for a plan that gives everyone the same benefits and some frustration with a political process that appears to be working at odds to their needs. "Whatever Clinton does," says Tina Lefebrve, a part-time hotel chambermaid, "I hope it helps me." She's likely to be disappointed.Commentary/by Keith H. Hammonds