Congress passed legislation last week to expand funding for the popular State Children's Health Insurance Program (SCHIP) by about 7 billion dollars per year over the next five years. The vote sets up a fight with President Bush, who has promised to veto the legislation. The 67-29 vote in the Senate was enough to override any veto, but the House bill was about two dozen votes short of the amount needed to do the same. Both chambers would need to reach the two-thirds majority to void the veto.
With that stage set, Bark Back contributor Thomas May, director of graduate studies and associate professor of bioethics at the Medical College of Wisconsin, examined the question of universal health coverage in an excellent Op/Ed in today's Milwaukee Journal Sentinel.
By Thomas May
With a controversial vote on renewal of the federal Children's Health Insurance Program looming, the importance of health insurance for America's children has perhaps never been more relevant.
Although it is one of the wealthiest societies in history, the United States is one of the few industrialized nations not to offer universal coverage for its citizens, with more than 45 million Americans lacking health insurance. This has resulted in a relatively poor level of health for the U.S. population overall, compared to other industrialized countries.
For example, the World Health Organization ranks the U.S. 37th among global health systems, with a ranking of 23rd in infant mortality and 18th in life expectancy. Despite widespread consensus on all sides that the problem of the uninsured is one that must be addressed, potential solutions disintegrate when political issues, especially funding, are faced.
A significant reason for this is that while the moral ideal of universal access is widely lauded, it is difficult to see how devoting greater tax resources to this problem will directly benefit those who are already insured (and who are more likely to vote).
The problems leading to poor rankings by WHO measures, for example, are felt most significantly by the uninsured.
The benefits of addressing the health insurance crisis, however, are significant even for those who already are insured. This is because the impact of the insurance crisis is felt in many areas that affect the health of the entire community, insured and uninsured alike.
The high number of uninsured people means that for a very large segment of the population, access to the health care system will come only as a last resort and then, much later than those who are insured would enter the health system for similar ills.
A review of the literature relating insurance coverage to utilization of health care services finds numerous studies demonstrate that insurance coverage increases utilization of health services, including outpatient primary care as well as acute ambulatory care and inpatient services.
This is significant not only for those who lack access to health services, but also for those who do have access.
For example, because the uninsured do not utilize early detection services in an effective manner, a high number of uninsured people means that early detection of pandemic disease like bird flu (or even the release of a bio terrorism agent) will be undermined.
This is especially true since infectious diseases spread most rapidly in urban areas, where the concentration of uninsured people is greatest.
This affects children disproportionately: Children are recognized "super vectors" for the spread of infectious diseases like flu because of their close interaction in schools and day care facilities and their lack of attention to sanitary precautions.
Perhaps the best example to illustrate the benefits of public funding for access to health services, especially for children, lies in the mandatory childhood vaccination program for entering the U.S. school system - widely recognized as one of most successful public health programs in history.
The program has resulted in the eradication of smallpox, the elimination of polio and a radical reduction in the number of cases of diphtheria, measles, pertussis (whooping cough), rubella, mumps and a number of other serious diseases.
The success of this program depends on enough children receiving vaccination so as to achieve a phenomenon known as "herd immunity." Herd immunity is a concept that is at the foundation of the U.S. vaccination program.
Lack of access to vaccination, would then threaten both those who do have access to this health service, as well as those who do not have access.
Most importantly, and for this reason, the success of this program is the direct result of public funding for vaccination of those children who would otherwise not have access.
These are but two among many potential examples of how access to health services directly impacts the health of the insured and uninsured alike.
The lack of health insurance coverage also poses indirect effects that are nonetheless significant.
Since the costs of treating the uninsured are largely absorbed by hospitals, these costs have contributed to fewer facilities and personnel for those who are insured.
The increasingly competitive health care marketplace has resulted in less ability to "cost-shift" expenses associated with care for the uninsured and increased financial burdens on hospitals where there are high numbers of uninsured patients.
This, in turn, has contributed to rigid streamlining for hospitals in attempts to cut costs. While less a problem in areas like Milwaukee, it is significant at a national level:
A March 2003 report released by the Institute of Medicine concludes that "hospitals in urban areas with higher uninsured rates have less total inpatient capacity, offer fewer services for vulnerable populations, and are less likely to offer trauma and burn care."
In addition, because those who lack health insurance also tend to lack a regular source of primary care, lack of insurance has also been linked to overcrowding of emergency rooms (required to see patients regardless of ability to pay under the Emergency Medical Treatment and Active Labor Act), who often inappropriately use ERs as a primary care outlet.
The lesson of these examples is simple. Health is largely a community good, and the effects of an individual's lack of access to health services extends well beyond that individual's immediate circle of family and friends, to the community as a whole.
If we are not motivated to address the health insurance crisis by morality, then, perhaps we will be motivated by the self-interested reasons of protecting our own health by recognizing the broader community effects of the growing health insurance crisis.
Thomas May is director of graduate studies and associate professor of bioethics at the Medical College of Wisconsin.