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March 5, 2003

Do the Math

JAMA. 2003;289(9):1162. doi:10.1001/jama.289.9.1162-a

My 59-year-old mother is learning about trinomials and the subjunctive. When she is not working, she goes to algebra class, to French, to programming. As long as she can carry a halftime load at the local college, she is not one of the 41.2 million uninsured in the United States. Because her job does not offer benefits, she has no employer-based care. Because a doctor once wrote in a chart that she might have emphysema (which she apparently does not), she has been refused coverage from the major private carriers. Because she is not disabled or blind, and I am no longer a minor, she is not eligible for Medicaid. Because neither of us could afford the $796 per month "safety-net" coverage she was offered in her state, we pay tuition at the local college, and she sits up late at night doing homework.

Neither her situation nor our absurd solution is typical, and neither is anyone else's. There are many ways to end up uninsured in this country, and just as many ways to be insured. But something is not working. As a nation, we spend more (whether measured in absolute terms, as percentage of gross national product, or per capita),1 and we cover less. The numbers are overwhelming: 15% of the US population is uninsured, and millions more are underinsured.2,3 Lack of insurance is associated with more illness and earlier death.3

There are myriad possible solutions. California alone, in last year's Health Care Options Project, generated 9 proposals aimed at universal coverage. They provide a microcosm of current health policy: 5 involve expanding eligibility for current programs; 2 propose employer-based coverage plans, and 2 are publicly funded "single-payer" plans.4 Which, if any, will be politically plausible remains to be seen.

Because the formulation is shocking and because it is true, people like to say we are the only industrialized nation in the world without a national health care system. (And yet we are not a country without a public health care system—Medicare and Medicaid together cover approximately 80 million people—over a quarter of the population.1) What is left to understand is why, and whether what we do instead is working.

In this issue, Bridget Harrison looks back to the five moments in the last century when we might have created a national system. Asaf Bitton and James Kahn review what we spend now, and where it goes. Jason Etheredge and Paul Uhlig ask how far incremental change to these existing programs can take us, while Joseph Harrell and Olveen Carrasquillo consider the particular combination of factors that leaves 1 in 3 US Latinos uninsured. That too many people are without coverage is clear. That this compromises health has been proven. That we can do better is certain.

Centers for Medicare and Medicaid Services.  2002 Data Compendium. Available at: Accessed February 6, 2003.
Short P, Blanthin J. New estimates of the underinsured younger than 65 years.  JAMA.1995;274:1302-1306.
Committee on the Consequences of Uninsurance.  Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press; 2002.
Lewin Group.  Cost and Coverage Analysis of Nine Proposals to Expand Health Insurance Coverage in CaliforniaFalls Church, Va: Lewin Group; 2002.