Health Insurance Solved
by John Goodman
Issue 116 - September 24, 2008

The Census Bureau has just come out with new figures showing that the number of uninsured has reached an all-time high, causing gnashing of teeth, crying and wailing....possibly driving some people to drink. It will cause apoplexy on the editorial pages of The New York Times.

So I have a solution. And it will cost not one thin dime.The next president of the United States should sign an Executive Order requiring the Census Bureau to cease and desist from describing any American (even illegal aliens) as "uninsured." Instead, the Bureau should categorize people according to the likely source of payment should they need care.

So, there you have it. Voila! Problem solved.

Here is the idea: only people who are denied care are truly uninsured. Everyone who gets care is effectively insured by some mechanism. So instead of producing worthless statistics that people fling around in vacuous editorials and pointless debates, the Census Bureau should produce meaningful numbers, identifying all of the sources of funds people will draw on if they need medical care.

Also, my solution would put the United States on a par, say, with Britain and Canada. Those countries insist that all of their citizens are "insured," whether or not they get needed medical care.

Here are some categories I would use:

• Self-Insured + EMTALA + Free Care. At a minimum, everyone is self-insured up to the extent of his net worth; and it would be a useful Census activity to show the assets people have available to pay medical bills directly. Then, the fact that the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospital emergency rooms to provide emergency care (regardless of ability to pay) counts as additional insurance. It is supplemented by the availability of free care, variously estimated at between $1,000 and $1,500 per uninsured person per year.
• Potential Medicaid. About one in every four "uninsured" persons is eligible for Medicaid or SCHIP (for children), but is not yet enrolled. Enrollment is a mere formality, however. It can be done in the emergency room. In many places it can be done several months after the care has been delivered. Surely this must count as health insurance de facto prior to enrollment.
• Self Insured + Potential Private Coverage. There is also the possibility of buying private insurance after the onset of illness. About one-third of the uninsured are in households earning $50,000 or more, and more than half of those earn $75,000 and up. These people can clearly afford to buy a lot of medical care directly. They also can afford insurance. Six states have guaranteed issue and community rating in the individual market. In other states, many are protected by the Health Insurance Portability and Accountability Act (HIPAA) and many have access to state subsidized risk pools allowing access to private insurance after illness has occurred. Sorting out how many people potentially have access to different types of private coverage would be another useful Census function.
• Potential Employer Coverage. About 80% of the uninsured are living in a household with someone in the labor market. More than one-fifth of them were offered coverage at work but turned it down. If the need arises, they can always enroll. Also, anyone who already has a job can probably land one with employer-provided coverage (if needed), possibly in return for a pay cut. Note: HIPAA prohibits employers from denying people coverage because of their (or a family member's) health status. In general, America has made it surprisingly easy to get someone else to pay your medical bills - even if you don't have a Blue Cross card.

So loyal readers, feel free to weigh in. Shall we get rid of the term "uninsured" on the grounds that it detracts from rational public policy discussion?

John Goodman is President of the National Center for Policy Analysis