Philosophy Versus Practice

Despite both rhetoric and law, access to care is hardly universal in the United States. To be fair, access to care is undoubtedly compromised, to one degree or another, in every nation on earth, because of lack of facilities, difficult terrain, poor transportation, poverty, weather, and other factors. The United States is no exception.

However, at least three factors make the United States unique with regard to access. First, unlike those of other developed nations, its federal government has never made a political commitment to universal access. Second, the key to access, generally speaking, is insurance coverage—and with few exceptions, the provision and acquisition of insurance is voluntary on the part of employers and individuals. Third, there is no political or societal consensus that access to care should be a right.

The most obvious evidence of resultant access problems is that a significant portion of the population lacks coverage. As of 2001 (the last year for which complete data were available), 16 percent of non-elderly Americans were uninsured; that represents 40.9 million people (U.S. Bureau of the Census, 2002b). Among them were 8.5 million children younger than eighteen and 272,000 people over sixty-five. Furthermore, members of minority groups were far more likely to lack coverage: Although 13.6 percent of whites were uninsured, 19 percent of African Americans and 33.2 percent of Latinos were uninsured (U.S. Bureau of the Census, 2002a).

There were also significant variations in the rate of lack of coverage among states, ranging from 23.5 percent in Texas and 20.7 percent in New Mexico to 7.5 percent in Iowa and 7.7 percent in Rhode Island and Wisconsin (U.S. Bureau of the Census, 2002c).

It is often argued that coverage is not equivalent to care, and that although it might be less convenient and will likely consume more time, the uninsured are usually able to obtain care when they need it. Some proponents of this position cite the system of public hospitals, operated by counties and cities and occasionally by states and even the federal government; the legal obligation of non-public hospitals to treat the seriously ill and injured; and hundreds (if not thousands) of subsidized clinics, public and private. Millions of people receive care through these avenues every year.

However, the network of public hospitals has contracted in recent years, and often those that remain are severely stressed financially, leading to long waiting times and delays in preventive and nonemergency care. Voluntary and for-profit hospitals vary significantly in terms of how much free care they can and do provide, and many limit what they do beyond the requirements of law. And although clinics often provide excellent and timely primary care, they are unable to offer the technology and specialty care that are available in hospitals.

Seeking to explore the validity of the argument that coverage does not determine access, in 1999 the Institute of Medicine of the National Academy of Sciences undertook a study of the interrelationship of coverage, access, and health status; the results were released in May 2002. The report estimated that 18,000 or more people die prematurely each year because of lack of coverage and a resultant lack of care.

The report concluded, "As a society, we have tolerated substantial populations of uninsured persons as a residual of employment-based and public coverage since the introduction of Medicare and Medicaid more than three and a half decades ago. Regardless of whether this is by design or default, the consequences of our policy choices are becoming more apparent and cannot be ignored" (Institute of Medicine, p. 15-16). But the United States has demonstrated on many occasions that for the most part, it can and will ignore them, at least as a matter of policy. Indeed, even when there was widespread awareness of the coverage crisis on the part of policy makers in the late 1990s, as well as a federal budget surplus, they focused most of their efforts on improving access to care for members of health maintenance organ-izations—who were already insured.

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