Republished with the permission of the Tennessee Medical Association and Tennessee Medicine, ©2008

When using our northern neighbor or America’s former colonial monarchy as an example of the ideal healthcare delivery system, one must first look closely at the history of those governments and their people. Both nations are strongly steeped in the history of the crown and centralized control. Canada did not gain coherent statehood until 1867 – two years after the end of America’s Civil War. Independence from the crown was not achieved until 1882, even though Canada had an opportunity to join the American Revolution and free itself on two separate occasions. Before and after its independence, Canada maintained a strong identification with the crown. Similarly, Britain to this day maintains a parliamentary-monarchy whose monarchic influence still insinuates itself into the government. This tacit power of the monarchy manifests itself in how a prime minister resigns from office–to the reigning monarch, instead of to the electors. We won a revolution to free ourselves from this type of system, but we are now at risk of descending back into this centralized-socialist system if Americans are continually lied to about America’s uninsured and deceived into a national healthcare system. After close examination of the British alternative, America’s system is a clearly better choice.

Regardless of how bad critics make America’s healthcare seem, the truth surrounding America’s 45-47 million “uninsured” has never really been revealed. The number is used only as a negative talking point. Politicians would rather use this figure as an inflammatory “fact” to rally their support base into irrational action, rather than tell the truth. So, from where does this 45-47 million number come? The statistic has its origins in a Congressional Budget Office (CBO) and U.S. Census Bureau survey that counts those people or workers who are without insurance at some point in time during a four-month period. Many are between jobs but have no reason to be uninsured. An examination of these statistics reveals that over one-half of the uninsured are re-employed and re-insured within a four-month period. More than half of the surveyed make $50,000 a year or more. The most recent U.S. Census survey (2007) notes that 75.1 percent of households with incomes less than $25,000 have insurance, and that 91.5 percent of families with incomes of $75,000 or more are insured.

The figure of 45 million uninsured seems surprisingly large given the significant programs already in place to assist the disadvantaged. If there are 45 million Americans without insurance, children should not be among them. If you qualify financially (means-tested), your children are covered by Medicaid or SCHIP. For those who qualify financially, pregnancy is covered by Medicaid, providing prenatal care through delivery. A woman in this financial category would also qualify for the Women and Infant Care (WIC) support programs. If you are disabled, you are eligible for Medicare and Medicaid. If you are 65 or older, you have Medicare and are eligible to purchase secondary insurance to cover other costs. If you qualify financially, Medicaid becomes your secondary. Meanwhile, working-age employees receive group insurance from many businesses. For employees at a small business without a group plan, cost-effective private policies provide limited-through-comprehensive hospitalization and physician and emergency services based on your ability to pay. In many states, small businesses also have the option to purchase insurance products through collective purchasing alliances. Many states even have special sales taxes that fund policies for the uninsured who qualify financially.

It is important to understand the CBO number chosen to quantify the uninsured is a misleading “red herring” statistic that lends itself to being exactly what it has become, a politically inflammatory talking point that does not reflect the reality of the problem. It is also important to remember that “illegal aliens” reportedly represent up to 21 percent of the 45 million “uninsured Americans.” Illegals consume medical resources without paying the taxes to fund them. In North Carolina, for example, 43,391 illegal immigrants used the state’s Emergency Medicaid Spending (EMS) program over a four-year period. These illegal aliens used EMS primarily for pregnancy-related conditions and deliveries, but that is shifting toward elderly care, disability and healthcare needs of a broader illegal demographic. The federal government has made one billion dollars available to states to help offset medical expenses incurred from illegal aliens.

Perhaps the most important detail of the CBO’s report is this: the same variables that put someone at risk for being labeled poor by the federal poverty guidelines are also the same variables that lead to someone being at high risk for becoming one of the temporarily uninsured. Understanding that the indicators for the lack of insurance and poverty are the same, it seems reasonable that addressing the causes of poverty will be more successful in helping to reduce the number of uninsured than just giving them a health insurance policy.

Two examples of regional health programs demonstrating the lack of need for an even-broader national program are Maine’s Dirigo Health Insurance Program and Alachua County, Florida’s Choices Program. Both are tax-based or employer-mandated, and were started to provide insurance products to the working uninsured. Early estimates suggested tens to hundreds of thousands of people would be eligible and in need of the program; the reality has fallen far short of that number. In Maine, of an estimated 136,000 potential enrollees, only 2,000 people had enrolled by 2005–less than 1.5 percent of the expected number. Currently, there are 12,000 enrollees–less than nine percent of the expected number. So disappointing are the results that a blue-ribbon panel has been established to consider elimination of the program altogether. In Alachua County, enrollments are only in the hundreds, as collected tax dollars go unused. Enrollment after two years was so low, the county commission broadened the eligibility window to 200 percent of the federal poverty level and reduced work-hour requirements to 28 hours per week. Even with this liberalization of eligibility requirements, few people qualify for insurance coverage. The Alachua County program has collected over $24 million to serve only 900 enrollees. The program would be better used as a helping-hand program instead of a handout program. Instead, there is no expectation that enrollees undertake education or self-improvement, and the benefits never run out. In essence, Alachua County has broadened eligibility into brackets based on wages that can support a private policy without any expectation that the recipients help themselves. Both programs languish today, collecting tax dollars for a minute number of enrollees. The 1990s lessons of the Republican legislature and President Clinton’s “Workfare” have been overlooked, as local and state governments establish welfare programs that disincentivize recipients to improve their economic situation.

Again, it is important to note the demographics of those who are uninsured, temporarily or long term, are the same as those who are rated as welfare-eligible in most categories. Just as important, the government does not require recipients of state monies to improve their ability to earn more and come off the state dole.

After examining the numbers, it seems the true number of America’s uninsured is much smaller than has been advertised and politicized, because current public and private programs provide for the overwhelming majority of the needs of the briefly uninsured. Even if someone falls between the eligibility requirements and is in immediate need of healthcare, many resources are still available. A perfect example of the availability of free healthcare services is the Alachua County (FL) Medical Society’s We Care program, which provides free healthcare for those who qualify. In 2006, We Care was calculated to have provided over $4.7 million in dental and medical care to those who qualified. This program has expanded to every county in Florida, and recently to Georgia. We Care and all the other high-quality, free healthcare programs in Florida have provided over $961 million worth of free medical and dental care since the inception of Florida’s Voluntary Health Services program. This number does not include any federal or state programs such as the public health department, Medicaid programs or state-funded agencies. In 2005 alone, over $100 million worth of free medical care was provided to Floridians. These numbers alone make it clear that there is no reason not to receive health care in Florida unless someone chooses not to have access to it. Florida has demonstrated that free market solutions to care for the temporarily or long-term uninsured are available and need to be expanded.

The demographics of those served by Florida’s outreach programs are surprisingly familiar. Of those who qualified, 70 percent were women and 62 percent were between the ages of 45-64. Some 53 percent were Caucasian. Over 50 percent of the women were unemployed and had been denied disability benefits or they were pending (and would be Medicare-eligible, if qualified). About 75 percent of the total recipients were unemployed. Only 25 percent worked part time or at all, and many lacked a high school or equivalent education. Whites followed by blacks were the two largest groups of recipients. On closer examination, Florida’s uninsured population is among the same group of Americans who are at risk for falling into the federal poverty welfare group and being uninsured.

Sadly, it cannot be left unsaid that included in the cadre of those at risk of becoming or being uninsured are America’s single mothers (divorced with a deadbeat dad or never married) and their children. It has been documented that this progressively enlarging group of Americans is at high risk of becoming trapped in poverty. Accordingly, they are at risk for being uninsured. Mechanisms to prevent this are unpopular but there is definite evidence that a complete nuclear family lifts families out of poverty and allows access to insurance and opportunity.

Even with the success of Florida’s outreach programs, policy-makers across this state and country have continued to ignore the real reasons that any uninsured Americans exist–the demographics of poverty. The demographics of the recipients of Florida’s free healthcare benefits and the so-called 45 million uninsured Americans are remarkably the same demographics as those who receive state and federal welfare benefits.

Benevolence is one of the hallmarks of American society, but we have to be careful that this benevolence does not breed dependence. America has overlooked the fact that the risk of being uninsured is remarkably similar to the problem of poverty. Both have the same root causes, yet we are not outraged at those causes. Through shortsighted programs such as nationalized healthcare, we would constrain our freedoms and centralize government’s control over our lives. Let us instead work toward solving the problems of poverty, not encourage it by providing open-ended benefits with no expectation for improvement in the recipient’s personal and family responsibility. America is about opportunity and the willingness to work hard to achieve the success that opportunity and education bring. It takes hard work, family values, education and commitment to community to achieve the success of personal, welfare-free independence. By giving people the tools through free-market principles, charity becomes a helping hand, not an anchor.