U is for Understanding the Uninsured

Most agree that not having health insurance is a bad bet. How big a gamble and what can be done to improve the odds are questions being asked - and now being answered - by a number of UCSF researchers.

"These researchers are not just looking at individual slices of the question and being unaware of other issues and problems and approaches," says Hal Luft, the director of the Institute for Health Policy Studies (IHPS). "They're communicating with each other, developing a broader and more textured set of analyses and approaches to policy than what often appears in other universities." In short, the IHPS, along with the Center for Health and Community and other organized groups on campus, are fostering research that takes aim at the problem from different perspectives - and explores for creative solutions.

The frightening scale of the problem is well known. Nationwide, about 42 million people are uninsured, which translates into an estimated 17,000 premature deaths annually. Over the years, Paul Newacheck, professor in residence at the IHPS, and his colleagues have documented the value of health insurance. "Clearly, health insurance plays a major role in both improving access to and use of preventive and sick care health services," he says. Uninsured people are more likely to end up being seen at a more advanced stage of chronic conditions or cancer, and are more likely to have unmanaged chronic conditions like diabetes and asthma that then become acute. As Luft sums up, "People without health insurance have worse health."

The problem is even more pronounced for dental care, says Jane Weintraub, director of the Center to Address Disparities in Children's Oral Health. About 108 million people nationwide do not have dental coverage, in some cases because they are unaware that such insurance even exists. And for those who do have coverage, it's almost always part of an employment package. "Oral health is very tied to overall health," says Weintraub, "so we really would like to see dental insurance included in any kind of overall health insurance plan."

Health Quandary

The bottom line is that having health insurance matters. "It matters with respect to the ability of people to be able to get into the physician, or dentist, and to get preventive services," says Luft. "It matters much less for their ability to get in the hospital if they need it, but of course they may leave with a very large bill." He adds that the California county hospitals see a lot of people who don't have health insurance, so they have designed programs to try to fill in the gaps. "They don't get coverage for people," says Luft, "but they do get them care."

Andrew Bindman, chief of the division of general internal medicine at San Francisco General Hospital, sees the human consequences of the insurance gap every day. "Here we have the primary care clinics that we think are a wonderful resource, but we're still having tremendous problems meeting the level of need." Many people are hospitalized with chronic conditions because medical providers are not able to care for those conditions in a timely, ongoing way. The challenge is particularly daunting in San Francisco, which has the highest rate of uninsured residents of any county in California. Con-sequentially, Bindman says, SFGH is trying to do better outreach to the underserved communities to improve the quality of medical care. Says Bindman, "It's not sufficient to just have a safety net."

When it comes to universal health coverage, James G. Kahn, associate professor at the IHPS, and UCSF colleagues, including Kevin Grumbach, long affiliated with IHPS, are advocating a plan that includes long-term care and requires a low co-payment. As proposed, it would cover everyone in the state, including the undocumented, and be financed with existing program funds, a small individual income tax (0.3 percent) and an eight percent payroll tax on businesses, which is similar to what they pay if they offer health insurance already. The proposal was evaluated - and praised - by independent analysts advising the government of California on solutions to the state's uninsured problem.

Not only does the plan project large savings in administrative costs for marketing and enrollment, claims and referral processing, and denials and appeals, "a single payer also has another huge benefit," says Kahn. "The cost-control measures do not depend on case-by-case, patient-by-patient, doctor-by-doctor oversight, which can be very intrusive. Single payer manages to control costs in other ways and leaves the patient and provider to make decisions based on clinical assessment."

Although many businesses are beginning to see the benefit of a mandated tax that will cap their ever increasing costs for providing insurance, Kahn realizes that it will never be easy to get a proposal such as his implemented. "The political issues are extremely complex and there are lots of barriers to doing something like this," he says. "No one, not even the most true believer, thinks this is a cakewalk politically."

Signs of Hope

Politics and healthcare are indeed intertwined, often clashing, but the news is not all bad. For example, Newacheck points out that in the last decade, many health services researchers around the US, including those at UCSF, have helped build the momentum for improving health insurance coverage for children. "We've seen pretty significant expansions in publicly provided insurance for low-income families, although there are still about 10 million kids in the US without coverage," he says.

Of those 10 million uninsured kids in the US, Newacheck says that about two-thirds are eligible for public programs, but for one reason or another are not enrolled. He and Dana Hughes, associate professor at the IHPS and the Department of Family and Community Medicine, are independently looking at why these programs are underutilized. Hughes is examining how to simplify and streamline children's insurance eligibility processes in the state - processes that often include long applications and lots of documentation. "If we were successful in enrolling those kids in the programs, we would make a huge dent in the problem," says Hughes. Toward this end, she has implemented the CORE (County Outreach, Retention and Enrollment) intervention, applying a "quality improvement method," similar to a business model, to the health insurance processes of six California counties. This two-year program is now at its midpoint, and although results have yet to be analyzed, so far it appears that "there are a huge number of programs available and it's very, very confusing." Her systematic analysis should eventually lead to recommendations to make the county enrollment processes more user-friendly. Newacheck says that Hughes' work "can lead to improvements down the line if policymakers pay attention to it."

All predictions will turn cloudy, though, if the state's current financial woes begin to preoccupy budget-conscious policymakers. Bindman is particularly worried. "We're getting into this lose-lose situation of fewer people being covered by private insurance through their employers as well as less money available from taxes to extend public insurance systems." Health care providers can be a bulwark, Bindman believes, if they don't turn their back on the plight of the uninsured as the government retreats from the issue. "We are reaching a crisis point and it's ultimately going to have to be a shared public/private solution to care for the uninsured. I don't think the government will be in a position to solve it by itself."

by Mitzi Baker