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With the level of uninsured Americans now at its highest rate in eight years and the percentage of people who receive job-based coverage at its lowest rate since 1993, all Americans recognize they are at risk for losing their health insurance protection. But some individuals are more vulnerable than others when they lose health insurance coverage, either because they suffer from illness or for other reasons. Recent efforts to expand coverage, though, may not truly be helping the most vulnerable.

Interview with Harold Pollack, Ph.D., Associate Professor at the University of Chicago 's School of Social Service Administration

  University of Chicago Associate Professor Harold Pollack studies the linkage between poverty policy and public health. His recent research focuses on HIV and hepatitis prevention efforts for injection drug users, drug abuse and dependence among welfare recipients and pregnant women, infant mortality prevention, and child health. His work has appeared in a variety of leading journals, including the Journal of the American Medical Association, the American Journal of Public Health, and Health Services Research. Pollack, who holds master's and doctorate degrees in Public Policy from Harvard University's Kennedy
School of Government, was a Robert Wood Johnson Scholar in Health Policy Research at Yale University and taught Health Management and Policy at the University of Michigan, School of Public Health. Pollack talked to ERIU about the challenges of being uninsured, the effect that lack of health insurance has on vulnerable populations, and what steps are needed to provide health insurance security to millions of people who are at high risk of illness.

How do you look at the problem of the uninsured?

POLLACK: When we think about the importance of health insurance and targeting health insurance policies towards key populations, we have to think about how health insurance coverage intersects with other challenges people face. So, I think about the problem in two ways: who are the people for whom health insurance is most critical for their health and well-being, and which population is at greatest risk for having a variety of social problems because they lack coverage? Looking at it this way helps people realize that we need to focus on policy solutions that more effectively help people who have other vulnerabilities that accompany their lack of coverage. The problem of health services and health coverage is related to a series of other social challenges.

Can you give an example?

POLLACK: The most obvious vulnerability is having a low income. Lack of health insurance has become a much more universal problem in the low-wage sectors of the American economy. Health insurance is becoming more expensive and eating up a bigger part of a worker's compensation, particularly among low-wage earners. For a family of four, the cost of health insurance is a very large percentage of their take-home pay. So, the most obvious vulnerability is economic vulnerability. This is an issue facing recent immigrants and others who earn low wages and have limited job skills.

Beyond income, can you highlight other vulnerable groups when it comes to health insurance and why?

POLLACK:Policymakers have viewed children as a priority, and have done a pretty good job of expanding children's coverage. That's valuable and important, yet children tend not to have, on average, the kind of health vulnerabilities that make health insurance critically important in the finances of people's lives. The "near elderly," or older adults in their late 50s who are seeing health problems emerge, are more vulnerable in this way. In 2003, I moved to Chicago's south suburbs. I was struck by the number of flyers hanging in local shops advertising a raffle or bakesale raising money for some very sick person facing large medical bills. Many were working-age adults who were too young to retire and ineligible for public assistance programs, but who required costly care.

Another group includes very severely disadvantaged populations whose lack of health coverage is of great interest to the public health community, because without health insurance it's very hard to meet a whole range of health and social needs. For instance, in Chicago, 600 people are on the waiting list for methadone treatment. Many people with substance abuse disorders are uninsured. Many are uninsured because their disorders interfere with their ability to get and keep a high-wage job with benefits or to purchase individual coverage. Lack of health insurance for individuals with other kinds of chronic health problems is a very large problem for obvious reasons. Recent immigrants are a vulnerable group. You find high concentrations of uninsured people in immigrant communities, and that creates great burdens on safety net providers, and the entire system.

In looking at the issues of the uninsured via vulnerable populations, how has your thinking of the uninsured changed?

POLLACK: I've always believed universal coverage would carry significant costs, and would bring daunting public management and economic challenges. We are talking about one-sixth of the U.S. economy, a very complicated sixth.

But in recent years, my thinking has shifted; there is no effective alternative to a more aggressive set of public policies that move us towards universal coverage. The costs will be large - both budgetary and in terms of our ability to successfully manage and implement such a system. But the current system is no longer able to accomplish important things we expect from our health care system. The large number of uninsured people is also making it harder to meet key public health and policy objectives. Here in Chicago, we have perhaps one million uninsured people. This does profound damage in so many areas.

We are all being touched by this problem. None of us can be sure that we won't develop a chronic illness. Many of us know family members who have lost jobs or are between jobs and who are anxious about whether their health insurance coverage will be there for them. The combination of a changing economy and rising health care costs has made the current system of health care coverage less effective or reliable for millions of Americans. I think some form of implicit or explicit public subsidy is essential to achieve broader coverage. I'm agnostic about the best institutional arrangements to achieve this. The costs will be real and will be large. The costs we sustain now are also real and large.

So, what's your optimistic prediction?

POLLACK: I don't know exactly, but policymakers at the state and federal levels are showing renewed interest in finding ways to meet people's needs and finding ways to get out of the logjam that we're now in. In the short-run, I am pretty pessimistic. Precisely because the problems are so glaring, I am optimistic in the long run that we will eventually improve the health care system to provide much more security than people have today.

What's happening in Massachusetts now is an interesting model for heath policy. It's not a coincidence that a Republican governor in a Democratic state is coming up with that type of an attack on the problem. My guess is that programs that combine progressive goals and some element of market-oriented approaches are most likely to be accepted.

ERIU has supported much research that explores the best ways to accomplish this. I'm convinced that in the next ten years we'll see more radical changes in health policy than what seems politically feasible now. People on all sides of the political debate are seeing the glaring defects of current systems.

How far would universal coverage help reduce barriers for vulnerable populations? Even if we had universal health coverage, what kinds of things would still leave people vulnerable?

POLLACK: If we had national health insurance today, we would still face enormous challenges in figuring out how to address the needs of vulnerable populations. So we have to have a realistic sense of what universal coverage will and will not accomplish. The pathways between health insurance, medical care, and health are complex. Health coverage is by no means sufficient to improve health. Vulnerable people interact with many systems within the social and health care network. The social services vulnerable people receive are often substandard. The health system is actually much more competent and generous than the other systems that the people turn to in addressing their vulnerabilities. But, with universal coverage at least we would not have people who can't access basic care, or who get basic care and then suffer severe financial consequences. Universal coverage would also provide a financial foundation for safety-net services which are now provided through a patchwork facing severe financial strains.

What's the takeaway here for policy makers from your research?

POLLACK: With the introduction of the SCHIP program in 1997, administrative reforms made it easier to sign up and retain coverage. I think the evidence suggests that changes were generally successful. More recently, with budget problems and high enrollment prompting fiscal consequences, states looked to reverse some of those reforms and thin the rolls to save money.

Research suggests about 5 million kids are eligible for public coverage but aren't enrolled. Why aren't they enrolling?

POLLACK: Lack of coverage is a particularly serious problem when it occurs in combination with other personal and family vulnerabilities and with poor health. Policymakers are understandably concerned about reducing the overall number of uninsured people in America. This is important, but I am more concerned about the nexus between coverage and vulnerability than I am about overall counts of the uninsured. A focus on vulnerability suggests somewhat different priorities for public policy. As I mentioned, states and the federal government have made real progress in extending coverage to poor and near-poor children. Less progress has been made to extend coverage to low-income adults who are in poor health or face other difficulties. The same might be said of high-priority populations facing special vulnerability such as individuals with substance use or psychiatric disorders.

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Funded by The Robert Wood Johnson Foundation, ERIU is a five-year program shedding new light on the causes and consequences of lack of coverage, and the crucial role that health insurance plays in shaping the U.S. labor market.