December 2010

Less than a year ago, Francis Campos-Dunn was still working at a county hospital in the San Francisco Bay Area, helping patients navigate the often-maddening bureaucracy required to draw on their health insurance. These days, she has a new set of problems to navigate: how to manage her own care without any insurance of her own, having slipped into an unfortunate but fast-growing slice of the population–Americans who have lost their jobs and now lack health coverage. Back when was still working, Campos-Dunn, 42, earned $4,000 a month, enough to make her co-payments for regular medical care. These days, she depends on $300 a month contributions from her 16-year-old son–money he earns at a part-time job–just to pay to the rent. When a recent seizure left her with two broken teeth, she skipped the required treatment and opted to have the teeth pulled instead, because she lacked the funds–a choice that would have previously seemed unthinkable. As the Great Recession has sown unemployment and downgraded work even for those people who have held on to their jobs, the number of Americans lacking healthcare has swelled beyond 50 million, according to a sobering new report from the Kaiser Foundation . Among the report’s most troubling findings: The number of Americans without any health care coverage grew by more than four million in 2009. That left almost one-fifth of non-elderly people uninsured. Among those between 19 and 29 years old, nearly one-third lacked coverage. The study underscores the degree to which the recession has accelerated the loss of basic elements once viewed as inextricable pieces of a middle class life. The number of Americans lacking medical coverage now exceeds the population of Spain. Nearly all Americans over 65 are insured by Medicare, the government-run health care plan, but those beneath that age are increasingly vulnerable to losing health care once provided by their employers or finding themselves unable to afford private coverage, according to the report, “The Uninsured: A Primer.” As those lacking health insurance grow in number, so do those missing out on necessary medical attention. About one-in-four uninsured adults have forgone care in the past year because of costs, compared to only 4 percent of those who have private coverage, according to the report. Those lacking health coverage are vulnerable to what has become a commonplace financial calamity: confronting a medical emergency, and having to pay for care entirely out of pocket. This year, 27% of uninsured adults used up most or all of their savings paying medical bills, according to the study. Half of these uninsured households had total assets of $600 or less. Medicaid covers Americans with the lowest incomes, but that fact merely mitigates conditions for people in abysmal circumstances: Medicaid beneficiaries are typically in much worse health than those with private coverage. They are likely to have incomes that place them well below the poverty line, and to suffer health conditions that impede their ability to work, exacerbating their difficulties. Under the health reforms championed by President Obama, Medicaid is set to expand in 2014 to cover almost all people under 65 with incomes up to 138% of the federal poverty line. That would provide health care to many more Americans who now lack coverage. But until then, many Americans will continue to shoulder the burden of unaffordable health care costs. The soaring number of people falling through the cracks and going without health insurance is in large part the result of the recession, which has eliminated millions of jobs, along with employer-sponsored coverage. Roughly half of all working age Americans with insurance have it through their employer. Even among those who have avoided unemployment, millions have been forced to take temporary or part-time positions for lack of available full-time work, often surrendering their benefits in the process. More than half of those who are officially unemployed have no health coverage whatsoever, according to a Rutgers University study, “The Shattered American Dream: Unemployed Workers Lose Ground, Hope, and Faith in their Future.” Those numbers increase to nearly 60% for those who have been unemployed for over six months. Six in ten Americans have been unemployed for over a year. Yet even if the economy soon adds more jobs and lowers the ranks of the unemployed, the scarcity of health coverage is likely to endure, argues one of the study’s authors, Carl Van Horn, Professor of Public Policy at Rutgers University and Director of the John J. Heldrich Center for Workforce Development . Long before the recession, he noted, having a job conveyed no guarantee of coverage. “Just recovery of jobs isn’t sufficent to address the issue,” he said. “A lot of the jobs that people are getting are part-time jobs and/or don’t have healthcare benefits attached to them.” And even those who are eligible for healthcare in the wake of job loss cannot always take advantage of what is available to them. “It’s pretty obvious that government policies are confusing,” Van Horn said. “A lot of folks are losing their jobs for the first time and they don’t know what they’re even entitled to.” Paying for healthcare can be one of the first things to go for families dealing with constrained finances. Over 50% of those surveyed said that healthcare was one of the expenses they could not afford to pay. “We have an employer-based healthcare system,” Van Horn said. “And if your lose your job, unless you’re old or very poor, you have no health care insurance.” In San Mateo, California, just south of San Francisco, Francis Campos-Dunn understands this fact all too well. For years, she has contended with a variety of often-expensive health problems, making her insurance situation particularly crucial. Her administrative job at the San Mateo County Hospital provided for her needs and also delivered insurance for her son and a granddaughter. But late last year, she was laid off, and so began a painful and bewildering lesson in the particularities of the American health care system. Kaiser, the giant health maintenance organization, offered her the option to continue her health insurance for $1,500 dollars a month. But that outstripped her total income– a disability payment of $1,300 a month. So Campos-Dunn turned to Medical, California’s state-run health insurance–the state’s version of Medicaid. But they told her that her income exceeded the allowable limit by $32 a month and denied her claim, she says. Undeterred, she appealed, was granted a hearing and was subsequently approved for the state insurance. But three weeks later, another letter arrived informing her that once again, she made too much money to qualify for the state’s health insurance. Since her unemployment, she has struggled with this ceaseless back and forth with the bureaucracy, going without care for weeks in between. “I never thought I’d be in this position,” she said. “I used to help families get on insurance. I used to hear all these problems. I used to think anything was possible to try to figure out a way around it so they could get health insurance. Now I have no health insurance.” With her medical condition continuing to require care, her battle to keep up has worn her down past the point where she can even muster the effort to continue fighting. “It got up to a point where I didn’t even try to deal with them anymore,” she said. “If I ended up in the hospital I’d just pay the bill.” She now owes Kaiser over $55,000, she says. She owes the San Mateo County Hospital–her old employer– over $22,000. “I just don’t think it’s right,” she said. “I’ve been working since I was 15 years old and now I can’t access what I need because I make 32 dollars too much.”