Tracey Koehlmoos: Life without health insurance in the US

Tracey Koehlmoos If you are a UK citizen, you probably think we are barbarians. Go ahead and say it, “How can you be a wealthy nation spending so much on healthcare and everyone does not have the right to go to the doctor when they are sick?” I hear this all the time. However, the wheels of change are starting to roll as different elements of the Affordable Care Act (a.k.a. Obamacare) are brought to life, although the changes are not without controversy.

According to the US census of 2010, some 49 million Americans do not have health insurance in the United States. Although these are old data—from 2007—we know that approximately 60% of Americans have health insurance coverage through their employer and another 9% directly purchase their health insurance [1]. However, purchasing health insurance is an expensive and optional undertaking so that those who might have insurance have the freedom to turn it down.

In the US health insurance coverage does not directly equate to access but more generally it is an important aid to getting people into the healthcare system. The vast majority of US hospitals receive federal funding by treating our Medicaid (mostly elderly) population. These hospitals are required to treat patients who enter through the emergency room. Thus, the baby’s earache or the management of diabetes enable the uninsured to walk into the healthcare system at the single most expensive point of care. We know that uninsured people in the US are less likely to receive medical care, more likely to be in poor health and more likely to die early. It limits where and when most people get healthcare and burdens them with large medical bills. [2, 3]

I have been fortunate to have health insurance through the military but am always curious when I run into someone who does not have it.

Typically I have met young seemingly healthy people who do not have insurance. These are young people with full time jobs—although often at small companies so that the company is not required to offer health insurance. (Of course all of this will change as varying aspects of the Affordable Care Act kick in over the next two to three years).

Most of the people I encounter would describe themselves as being fine and not needing health insurance. However, where this issue pops onto my radar is in discussions of what happens when they did have an accident or illness. An accident on a bicycle or a slip on the ice that leads to a broken arm can result in thousands of dollars. [4] Years ago I worked with a young television producer who told me that when he first joined the work force, he had been injured in a bicycling accident and broken his leg. The procedure and the recovery had required surgery, pins, and medical equipment. He was contemplating the declaration of bankruptcy after being unable to pay his way out of the hole which was exacerbated by college tuition debt. He was painfully aware that he was just starting out in life with a lifetime of debt, bad credit ratings, and an amazing level of duress.

Sometimes people will stay in a job that they hate in order to maintain their access to routine care for themselves and for their family. I once worked with a nurse who was experiencing an episode of mental illness. She felt that the demands of her job were making her sick and she dreaded coming to work every day. However, she would have lost her ability to pay for counselling services and medication if she left her job and left her insurance. There is a federal provision which is known as COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) that allows those with a health plan to keep it when they leave their job for up to 18 months. However, the premium goes up significantly so that COBRA is not an option for someone leaving a job for an undefined period of unemployment.

On the other end of the spectrum, I have female friends in their 40s and 50s who stayed at home for decades to raise the children or worked as volunteers or did consultancies. As their marriages fell apart—and the couples went through painful, even horrific periods of legal separation and rebuilding different lives—they would suddenly stop at the signing the final divorce document. Why? Right at the end, it came down to staying married just a little longer so that the non-working or under-employed soon-to-be-ex-wife could keep her health insurance coverage through her husband’s policy. While I am a big believer in marriage being forever, my observation is that “staying married for the health insurance” does nothing to improve the wellbeing of either party and prevents them from moving on in their lives.

Some parts of the Affordable Care Act have already been rolled out and I have already noticed the improvements. For example, children (or “adult children”) are now permitted to remain on their parents’ insurance plan until they turn 26 years old—even if they do not live with their parents, are not in school, or are married. This is a huge change and has impacted the lives of more of my acquaintances than any other thus far. In the past I was frequently approached by desperate parents wanting to discuss the options available for college age children who had manifested an illness (often a mental illness) and had to drop out of university in need of expensive medical care. However, dropping out of school meant that these young adults were no longer able to be covered by their parents’ health insurance just when they needed it most.

Thus, while not perfect, the Patient Protection and Affordable Care Act (PPACA), also known as Obamacare, or the Affordable Care Act (ACA) became the law in the US in March 2010. It is a great leap toward piecing together universal coverage in the US through our mosaic of public and private insurance options. Further, in the years ahead part of the ACA will enact an individual mandate that requires most individuals to carry at least a minimal level of insurance coverage, which will hopefully put an end to some of the horror stories.

While still controversial between political parties and various health system stakeholders, I think that most of the voices speaking the loudest in this debate are well employed people with health insurance and in groups that are well funded and well organized. However, if we take the time to listen to the solitary voices of the uninsured, we will hear a tale that compels us toward implementing change.

Tracey Pérez Koehlmoos is the special assistant to the assistant commandant of the Marine Corps and senior program liaison for community health integration for the US Marine Corps.
The opinions expressed in this article are her own and in no way reflect the opinions of the US Marine Corps, the Department of Defense, or any other agency.

1. Income, Poverty, and Health Insurance Coverage in the United States: 2007.” U.S. Census Bureau. Issued August 2008.
2. Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073-84.
3. Insuring America’s health: Principles and recommendations. Acad Emerg Med. 2004;11(4):418-22.