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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.
Reynolds TA. Do the Math. JAMA. 2003;289(9):1162. doi:10.1001/jama.289.9.1162-a
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