Most poor folks who don’t have health insurance would if they could afford it. We’ve settled that.
But that’s the problem – health insurance is just not affordable – today. And costs are not going down, in fact the latest data indicates employers will see another 10%+ jump next year – which will certainly lead to fewer employers offering coverage, fewer employees opting for coverage, and more folks without health insurance.
We’ve seen in Massachusetts that reducing insurance premiums does increase coverage, but the premium levels are still too high for some.
Leaving aside the uncomfortable realities of the real world, what is the correlation between ‘price’, defined as a percentage of family (not household) income, and insurance coverage takeup?
Here’s one data point from one of Bob Laszewski’s posts on Massachusetts –
“The state has seen a gain of only 18,000 Massachusetts residents with incomes above 300% of the poverty level in the Commonwealth Choice plan. That’s because it costs $7,000 – 12,000 a year for a family of four to buy the baseline health plan that includes a $2,000 single/$4,000 family deductible before most benefits are available. A family of four with an income of at least $61,000 (300% of the federal poverty level) would not qualify for a subsidy.”
One study suggests that family income should not be the only metric used when assessing ‘affordability’, as total financial assets, home ownership status, and other indicators may strengthen the correlation with take-up rates.
A paper on the topic was authored by Kate Bunford and Mark Pauly in 2002. (full version here) They used two different methods to determine affordability, one based on income and the other on the coverage purchased by similar folks with similar incomes. Perhaps unsurprisingly, there’s a wide discrepancy in the results obtained from the two methods.
Here’s an excerpt from a summary of their report.
“the insurance-adjusted poverty rate for adults aged 25-64 in 2000 was 10.5 percent; on that basis, health insurance is unaffordable for 10.5 percent of adults aged 25-64. For the whole sample, using the poverty line as a benchmark, 71 percent of the currently uninsured population could afford health insurance coverage…
…Using the threshold that 80 percent of similar households purchase insurance, they find that around 25 percent of the uninsured could afford coverage based on peer comparisons.”
Pauly and Bunford conclude that “Depending on the parameters chosen in our definition, we find that health insurance was affordable to between 24% and 55% of the uninsured in 1998.”
I’d note that the the summary states the “affordability of health insurance, measured in various ways, is not a particularly accurate predictor of whether a person will obtain coverage. It is certainly not the only explanation of observed patterns of insurance coverage.” I’d also note that Bunford and Pauly’s methodology is the basis for that conclusion; they looked at insurance takeup rates and analyzed similar populations, while other analyses relied on survey research.
What does this mean?
More research needs to be done.

There’s more recent data to refine our understanding of who is uninsured – and more apropos to earlier posts here, why. Sorry, libertarians, it’s not because they don’t want health insurance.
When asked why they don’t participate in their employer’s program, 1% of survey respondents said it was because didn’t think they needed insurance.
One percent.
The survey, conducted by the Washington Post, Kaiser Family Foundation and Harvard University provides a “detailed look at the real life experiences and views of low-wage workers”, with ‘low wage’ defined as less than $27,000.
Given the cost of health care and insurance premiums, it is not surprising that for many respondents health care is becoming unaffordable. When asked how easy or difficult it is to afford health care and health insurance, 1/3 of the respondents said ‘very difficult’, and 29% ‘somewhat difficult’. A significant majority would also settle for lower pay if the job had health insurance (56%, compared to 39% who would prefer better pay and no health insurance).
And fewer and fewer are getting insurance through their employer. 69% of the respondents’ employers offer insurance, but only 60% sign up (most because they already have coverage through another source, e.g. via a spouse’s plan, Medicaid or Medicare). Adding up all those with coverage, 72% have some form of coverage, and the remainder does not.
Some claim that a hefty portion of the uninsured don’t have coverage because they just don’t want it. Could be; like I don’t have a place on a lake in New Hampshire because I ‘just don’t want it’. Actually, that’s not true; I also have three college educations to pay for, a mortgage and individual health insurance, so I ‘want’ the lake house, but I can’t afford it.
Here’s a passage from the American Enterprise Institute’s magazine on the issue:
“more than 17.6 million uninsured live in households earning more than $50,000 a year, and household income is above $75,000 for more than 9 million uninsured. However, those numbers overstate the actual income available to those uninsured individuals, because household units are defined more broadly than are insurance purchasing units. As the composition of “households” changes, their income isn’t the same as family income available for spending on health insurance. The rising cost of coverage remains the primary barrier to insurance coverage for the uninsured, and in some cases, its value just may not be “worth it” [emphasis added] for those in higher income families. But a more narrow and consistent measure of the higher income uninsured is closer to 2 million, involving people with regular incomes over $50,000 who lack insurance for spells of more than a year. [emphasis added]”
My sense is that’s what’s really going on here. Poor people can’t afford coverage, and thus don’t have insurance. People of greater, but still modest means, also can’t afford health insurance, so they ‘choose’ to go without.
But most don’t ‘choose’ to be uninsured; the cost:expense equation makes that choice for them.
The question is – at what cost level would people buy coverage?
I’m going to take a shot at that tomorrow.

The recent CONCORD report on cancer survival rates has been used by some on the right to support their contention that the US health care system is superior; according to Catron, the “much-maligned U.S. health care system is the best in the world.” Catron and his fellow travelers’ use of the researchers’ findings has been, to be kind, selective at best.
The study looked at populations around the world, including 16 US states and a half-dozen metropolitan areas that represented 42% of the US population. (Not all state data was available due to collection issues and standards). Four types of cancer, including breast (women), colon, rectum and prostate, which comprise a majority of all newly diagnosed cancers in adults were examined.
From this, Catron concluded:
“Nowhere is this [the superiority of the US health care system] more obvious than in the area of cancer treatment. John Goodman reports on another study published in Lancet Oncology showing that the U.S. has the best cancer survival rates:
[this is a quote from Goodman, not from the Lancet] “A new study of cancer survival on five continents lays to rest the theory that Americans fare poorly compared to other developed countries … in almost every category Americans survive cancer at higher rates than patients in other developed countries.”
Here’s a chart showing U.S. survival rates for breast and prostate cancer compared to the survival rates of four countries whose health care systems are often touted as superior to ours”
Here are a few of the problems with Catron’s argument.

• Catron used two types of cancer, not the four that were studied. And the two he used were (surprise!) the ones that favored the US. Rectal and colon cancer survival rates were statistically similar in the U.S., Japan, Canada, France, the Netherlands, Sweden, and Australia
• There’s no doubt the US survival rate for one of his examples – prostate cancer – is very high. There’s also no doubt that this cancer is way over-hyped in the US, with much more screening and testing, lots of which identifies cases that are unlikely to be fatal. Prostate cancer is quite common among older men. It usually grows very slowly, so slowly that most of us end up dying from something else. So we’re paying way more for screening that is marginally useful from a population perspective.
• The incidence of diagnosed prostate cancer in the US is much higher than in other countries
• Catron may have meant to say that the US health care system is much better for white folks. In the US, there’s a wide disparity in survival rates between blacks and whites. For breast cancer, survival for white women in the USA (84.7%) was 14% higher than for black women (70.9%). For colorectal cancer, white patients in the US had survival rates 10% higher than for black patients (60% compared with 50%). For prostate cancer, However, there was a 7% difference in survival between black and white men (92% compared with 85.8%).
• The US stats covered less than half of the population; we don’t know if survival rates in the other 58% of the population are better/worse/the same

The leaps of logic in Catron’s argument would do credit to gymnasts with Olympian aspirations. First that the data is complete (it is not); second that survival rates for two types of cancer is a fair evaluative basis (what about other maladies?): and third that the US has a better health care system because of breast and prostate cancer survival rates.
The logical errors in Catron’s analysis, combined with his faulty arguments, would be laughable if they weren’t representative of how some actually ‘think’. Their approach to any issue is to try to scare the bejesus out of folks, ignoring data and evidence contrary to their opinions. This does them no credit, and over the long term likely undermines their attempt to influence the dialogue on health system reform.
Looking at data from the Commonwealth Fund, and employing Catron’s logic (better survival rates = better health care systems), we find that the 5 year survival rate for kidney transplant patients was 94% in Canada, 86% in the UK, and 83% in the US in 2001. Does this mean that the Canadian system is better than the US system? Of course not – and I’d bet that Catron and his ilk would be quick to point out the problems inherent in drawing such a conclusion.
What does this mean for you?
If you torture numbers long enough, they’ll say anything you want them to. Catron’s misuse of the CONCORD statistics is Exhibit One in the case against this horrifying practice.

There are those on both sides of the political debate (and some who fancy themselves in the middle) who use anecdotes, scary stories, hyperbole and highly elastic versions of ‘true’ stories to support their solutions to our present health care insurance disaster.
While both sides are guilty, I’d have to say the free marketers look to be ‘guiltier’. Case in point – I’m on the distribution list (at least at the time of this writing) for a few PR firms that have been hired by conservative types to get bloggers to espouse the libertarian, it-ain’t-broke-that-bad-so-don’t-fix-it perspective on health care reform. And they tend to try to scare the crap out of everyone with horror stories of waiting lists in Canada, patients expiring in the UK on transplant lists, and folks with furrin accents invading American hospitals as they try to get kidneys or MRIs or gall bladder surgery without waiting till three years after they’re dead. And these are the reputable folks – there’s also a lot of misinformation circulating in the webosphere about bad Canadian health care.
Not to say this doesn’t happen – there’s no perfect health care delivery/reimbursement system anywhere on earth (although the VA looked closer than most before it was underfunded).
Are there waiting lists in Canada? Yep – but they’re not intolerably long. Are there waiting lists in the US? Yep. Which one is shorter? Depends. Do you have insurance? If you aren’t insured and live in the US, the wait is really really long. If you are a workers comp patient in Massachusetts and need a neurosurgeon, the wait is really really long (the fee schedule is so low very few docs will take WC patients).
And let us not forget that American health care system has a pretty poor reputation for delivering consistently good care…
Ignoring the politically-biased reports on waiting lists, it is likely that Americans don’t have to wait as long as Canadians for some specialty care, and some Canadians may actually not get certain services. For that rapid access, Americans pay almomst twice as much.
You can get it cheap, fast, or good – pick one. We Americans have picked fast, ignored good, and certainly ignored cheap. The Canadians picked cheap, are at least as good, and have accepted slow.
Before you vote, consider what you could do with $750 billion a year in the US – because that’s how much we’d save if our costs mirrored our friends to the north.