AAMC Reporter: December 2005

Arthur Garson, Jr., M.D., M.P.H., Vice President, University of Virginia; Dean, U. Va. School of Medicine

Viewpoint: "How We Can Help the Uninsured: A New Proposal"

This we know: People without health insurance become the responsibility of academic health centers. Every day they come to our emergency departments, our clinics, and our wards. So the need is clear. Yet we must deal with some competing realities.

On one hand, our altruistic mission dictates that, insurance aside, we must welcome these people and give them the best possible care. On the other hand, our physicians and hospitals often confront serious financial challenges of their own and must search for new ways to afford caring for the uninsured. For the moment, at least, altruism is still winning.

Let's look at some numbers. About 46 million Americans do not have health insurance. That is a lot of people — more, for example, than the number of people covered by our Medicare system, and more than the combined populations of 24 states. Who are these people? They are the people we meet every day — clerks at the dry cleaners, waiters and waitresses. Nearly three-fourths of them belong to families with at least one paid worker. But many small businesses do not offer health insurance; only 52 percent of companies with three to nine workers do so. Meanwhile, a high proportion of the uninsured earn less than $20,000 a year and simply cannot afford to pay for health coverage.

To put it another way: Two minimum-wage earners (combined income: $21,424), working in a small business that does not provide health insurance, cannot come up with premium payments that range from $2,300 to $10,000 a year. And people living in poverty have perhaps 3 to 5 percent of their income left after paying for food, housing, transportation, and child care. Health insurance? Not likely.

The reason so many people are in that situation is that they have no "safety net." For people between the ages of 19 and 64 — no matter how poor they are — there is no support. In most states, unless they are completely disabled, they get no support from Medicaid.

So what can be done? A national solution is not on the table. But there may well be some hope in the states, which have shown themselves to be innovators in providing health care systems. What has been lacking is a mechanism for structured learning among the states, with eventual opportunities for wider application.

With that in mind, a few of us have been helping to draft legislation that would provide federal support for health care innovation in the states. Formal introduction of the bill — known by its working title, the "Health Partnership Act" — was pending last month in the U.S. Senate. The idea is that efforts to expand health insurance cannot occur in isolation or allow the quality of health care to suffer. Only by controlling health care costs can we afford to provide more coverage. Under the plan, states would apply for five-year federal grants to reach goals in four areas:

• Coverage. States could use various methods to reduce the number of uninsured people, including reliance on tax credits or health savings accounts, to subsidize individuals or small businesses in providing insurance. States also could create purchasing pools, or could expand public programs like Medicaid or the State Children's Health Insurance Program.


• Quality. Goals and indicators would be established to ensure the quality of health care, with measures for such things as the incidence of myocardial infarction or errors made in the use of medications.


• Efficiency. States would set targets for reducing the administrative costs of any new programs below those of current public and private programs.


• Technology. States would seek to improve the technology infrastructure for collecting health information and for using electronic health records, billing, and prescriptions.

In addition, representatives of the states would meet each year to discuss how they could learn from each other as they progressed. The states could change their approaches as they learned — but not their goals. The grants would be renewable and, over time, more states would apply for grants. Eventually there would be a few well-tested systems that could work for many states, or even for the entire country.

The major obstacle here is the money. The country has a lot on its mind right now, with expensive recovery efforts and a continuing war. But it is worthwhile to recall that compulsory public education began in some states in 1865 — another difficult point in our history.

We keep hearing that "the system is broken" and "we must do something." Both views are correct today, and we can expect the situation to worsen. By 2013, the ranks of the uninsured are expected to grow to 56 million, or about one in five.

So how can academic medicine help? Most medical deans and hospital CEOs have excellent relationships with officials in our state governments, and over the past several years many of us have talked about the need to increase health insurance coverage. The ideas were sound, but the money dried up. Now, if states could get some additional money from the federal government and other sources, we in academic medicine could surely help develop appropriate policies for our states — and advocate for them.

This is a new, incremental approach, and we have much to offer in helping it succeed

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