"Health Insurance – What Would Dr. King Do?"

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The Rev. Suzelle Lynch
January 20, 2008

READING

from “Uninsured In America: Life and Death in the Land of Opportunity,” by Susan Starr Sered and Rushika Fernandopulle – page 4-5, Introduction

The “Problem” of the Uninsured

The familiar phrase “the problem of the uninsured” conjures either an image of troubled, “problematic” individuals or the notion that these unfortunate persons constitute a “problem” for the rest of society. The real problem, however, begins at a far more basic level. The inability of a large portion of the U.S. population to access health care services in a systematic and medically competent manner is a consequence of social and economic developments that predate and underpin individual life histories.

Unlike the medical systems of most Western countries, America’s health care structure centers on an increasingly for-profit system of employment-based private insurance. Employer-sponsored health coverage expanded rapidly in the United States during World War II, when the shortage of civilian workers encouraged employers to look for creative ways to attract and retain employees. In order to prevent inflation, the War Labor Board put a ceiling on all wages. It rules, however, that unions could bargain for health care benefits without violating the wage freeze. At the same time, the Internal Revenue Service ruled that health insurance premiums would be treated as a nontaxable business expense.

During the postwar era of economic growth, employment-based health insurance became the norm in the United States, and it indeed worked reasonably well for many Americans. During this period, millions of blue-collar workers held long-term union contracts guaranteeing health care benefits, and white-collar workers expected to remain with and rise through the ranks of the companies in which they built their careers.

In recent years, however, the relationship between employment and health care has become increasingly problematic. First, as the nature of employment has changed globally, fewer people are able to stay in the same job for many years. As a result, jobs no longer serve as stable platforms for health care arrangements. Second, the fragmented nature of the American health care system, together with the political dominance of the medical, insurance, and pharmaceutical industries, has allowed health care costs to soar far above the costs for comparable products and services in Canada, Great Britain, and continental European countries. As the cost of health care rises, more employers look for ways to avoid providing insurance to their employees. The millions who find themselves uninsured are now priced out of the health care marketplace. (end reading)

SERMON

I’m not an expert in the area of health insurance, and I’m not an expert on the thought of the Rev. Dr. Martin Luther King, Jr. either. But I cannot help but think, given his profound work on behalf of those who experienced discrimination, that if he were alive today, Dr. King would be encouraging us to get to work on the issue of America’s health insurance system, for there is something terribly wrong.

Despite the fact that we spend twice as much as other industrialized nations on health care ($7,129 per person), despite our advanced medical technologies, forty-six million Americans – or about one in seven under the age of 65 – have no health insurance (2006 numbers http://www.kff.org/uninsured/index.cfm). Another 17 million are under-insured (2003 numbers), which means that they have insurance, often provided by their employers, but their medical expenses amount to ten percent or more of their after-tax income (or five percent or more of their income if that income is below 200 percent of the federal poverty level). (http://www.pbs.org/newshour/indepth_coverage/health/uninsured/underinsured.html )

If you are not one of the uninsured or the under-insured, you may be breathing a sigh of relief right now. I know I am. And for me, it’s both a sigh of relief, and a sigh of gratitude to all of you, for as an ethical and compassionate employer, Unitarian Universalist Church West does provide adequate health insurance coverage for me and for our staff.

And yet I cannot help but be disturbed by the knowledge that in the United States we treat health care as a commodity distributed according to a person’s ability to pay, rather than as a social service, a common good, distributed according to medical need. In our market-driven system, health insurance businesses compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to their employers (or other payers) so that they can make money for their investors. This creates a paradox: a health care system based on avoiding taking care of the sick. It generates huge administrative costs, which, along with profits, divert resources away from providing medical care and towards business expenses. (paraphrased from http://www.pnhp.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance.php )

We just heard words from Dr. King, “Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny.” I have always found a profound parallel between that quote and the seventh principle of the Unitarian Universalist Association – that we affirm and promote respect for the interdependent web of all life, of which we are a part. Sighing with relief because I am not being treated unjustly is not an adequate response for a Unitarian Universalist when so many are forced to go without what they need.

And boy, do they ever need health insurance! The financial impact of being uninsured is often extreme. If you need an appendectomy, according to the book “Uninsured in America,” you’ll find that New York Methodist Hospital in Brooklyn charges health maintenance organizations $2,500 for a two-day stay for the operation, while uninsured patients pay about $14,000 for the same service. Emergency room visits typically cost about four times as much as treating the same problem in a regular doctor’s office visit. But many doctors are not allowed to see uninsured patients who owe money for previous visits, and so these individuals end up using the emergency room for all their health problems. It gets worse: many hospitals charge interest at higher than market rates on the debts patients accrue, which means that even a simple hospitalization can turn into a ten- or twenty-thousand-dollar debt.

In 2005, researchers from Harvard University published a study on bankruptcy. They used data from 2001, a year when nearly 1.5 million families declared bankruptcy. Through interviews with a significant sample of this group, the researchers found that, about 50% of the bankruptcies were caused, at least in part, by medical expenses, despite the fact that 75.7% of those who filed had health insurance.

They also found that during the two years prior to declaring bankruptcy, 61% of the study group went without needed medical care; 50% did not fill a doctor’s prescription; 30% had a utility shut off; and 22% even went without food at times.

Knowing these things, how can I possibly sigh with relief? How about you? What if we knew that the number of medical bankruptcies had increased by about 2200% over a 20-year period? (between 1981 and 2001.) (http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.63/DC1)

A more adequate response when confronted with these awful facts is interest. We who have health insurance now should want to know more.

For example, we should want to know if our health care system works for the physicians and other providers who must labor within it? If the books and websites and studies I consulted in researching this sermon are any indicator, the system is not working for these folks very well. Medical care providers are increasingly frustrated by the waste in the system, and the constraints it places on their work, constraints which force many to violate their personally-held values and moral principles.

We also should be interested in knowing who the uninsured are. We think we know: poor people, right? Indeed, two-thirds of the uninsured are individuals and families who live in poverty (incomes less than the federal poverty level or $20,614 for a family of four in 2006) or near-poverty (with incomes between one and two times the poverty level). But more than four out of five (82%) of those who are uninsured are in working families. http://www.kff.org/uninsured/index.cfm) And why are the ranks of the uninsured growing? Well, we heard a bit about this in our reading today. According to the Kaiser Family Foundation, the economic downturn in 2001 coupled with health premiums that rose 78% between 2001 and 2006, meant that fewer businesses could afford to offer health benefits. In addition, with the demise of manufacturing and other family-wage jobs, employment has shifted to jobs where health benefits are less likely to be offered, such as service industry work, temporary positions, and part-time employment.

But there’s another reason the ranks of the uninsured are growing. At the core, it’s a spiritual issue, an issue of values and morals. Though ours claims to be a society based on religious values like the Golden Rule, far too often we are seduced by our own gold, if we have any, into believing that we are not really part of an interdependent web of all life, not really part of a society in which individual good is served by the common good, but instead, that we are isolated individuals who only have to think of our own needs and desires, and those of our immediate families. As one of our members put it to me recently, “It’s as if we think, ‘Other people’s lack of health insurance is not my problem.’ As long as we have our own health insurance, universal health care becomes an optional social action ‘cause’ that we’d work on ‘if we had the time.’” The health insurance crisis in America shows how overbalanced our culture is on the side of radical individualism, and we Unitarian Universalists are embedded in that culture just like anybody else.

But the health insurance crisis does affect us, even if we’re not swayed by the moral and spiritual issues of which it is a symptom. One of the sources I read compared the provision of universal health coverage to the provision of public education – something our nation agreed long ago was a common good worth paying for, even if that support has greatly eroded in the past two decades. The author then went on to remind those of us who have insurance for our families of the public health consequences of millions of uninsured children sitting side-by-side with our little angels in school classrooms. The health insurance crisis also affects us economically, for we pay a great deal in taxes to cover the high costs of care for the uninsured now (taxes which could be better used in providing health insurance!).

Having health insurance can be the difference for so many between life and entering what the authors of the book, “Uninsured in America,” refer to as “the death spiral.”

Now, I don’t know about you, but I always thought that the “death spiral” was a figure skating term – you know, that thing skaters do when they spin and twirl and twirl…. But the book’s authors explain that in insurance parlance, the phrase “death spiral” describes what happens “when a health plan starts attracting sicker patients, which causes the price of premiums to go up, which causes more healthy people (who have other options) to leave the plan, which causes the remaining pool to be proportionately sicker, which causes the price of premiums to increase even more, eventually resulting in the company going bankrupt.” (p. 6) What they noticed in their interviews of uninsured Americans across the country was a different sort of death spiral, however. They write, “Because employment and health insurance are tightly linked, job disruptions such as layoffs or firings, starting one's own business, or taking time off to care for small children or elderly parents can lead to the loss of health coverage. That loss can easily lead to health concerns going untreated, a situation that can exacerbate employment problems by making the individual less able to work. Alternatively, the downward spiral can begin with health problems that lead to employment problems, making it less likely that one will have health insurance and thus reducing the chances of solving the original health issues.” (p. 6 – also found at http://www.ucpress.edu/books/pages/10379/10379.intro.html )

“Uninsured in America” brings us the story of Edna, among many others. Edna is a middle-aged widow who lives in Rantoul, Illinois. She’s the primary caregiver “for three generations of kin …” her 84-year-old mother who is developing Alzheimer’s disease, her rebellious unmarried adult daughter, and her developmentally challenged young granddaughter. Edna worked in a factory until the granddaughter was born prematurely – and she tried to go back once the child was deemed strong enough to be with a sitter, but her own health declined, and then her mother became ill. She has used up her retirement savings, and her household scrapes by on about $800 a month. Thankfully Edna’s mother and granddaughter have health insurance through federal and state programs. But Edna herself – with problems that include diabetes and narcolepsy -- is now uninsured. Edna told the book’s researchers about a typical encounter she had with the medical system.

She went to a doctor in Champaign, Illinois for a diabetes-related matter, and paid $50 up front so that she could be seen. When the doctor came in, she looked at Edna from across the room and said, “Oh, you don’t have health insurance.”

“Actually, no,” Edna replied. “But you know its going to be very expensive?” the doctor asked, and then continued. “Have you tried Francis Nelson (the county clinic that has a sliding-scale fee)?” And Edna said she hadn’t, continuing to wait for the doctor to ask her something about her health or why she had come in for the visit, or to notice her terribly swollen feet. After all, she’d already paid for the visit! But the doctor continued to talk about the county clinic. When she finally did ask what Edna’s problem was, Edna said, “Well, I know I’m a diabetic. I just want you to look at my feet or something and tell me what I could do, and maybe you could give me the pills that I was taking before that had helped my feet.”

The doctor looked at Edna – again, from across the room – and she said, “Well, it’s Francis Nelson. They do free treatment and stuff like that, because this is going to be very expensive.” The doctor left without ever examining Edna. (pp. 83-4)

These days “Edna tries to manage her diabetes herself. She borrows test strips from her mother, who also has the illness, and if her blood sugar tests high, she stops eating and drinks only water … (and) After about three days, she usually finds that her blood sugar goes back to normal, although the fasting makes her tired. … Edna knows that these swings in her blood sugar … can accelerate the onset of diabetic complications, but she sees no other option. … A few months ago, she spoke to a caseworker about trying to get Medicaid. She filled out numerous forms, but she became stuck on the requirement that she send in a letter from her doctor documenting her medical problems. (Edna said) ‘They wanted medical papers, which I did not have. Remember, I don’t have a doctor. But they’re not listening to me.’” (p. 84)

Edna appears to be caught in the death spiral. She can’t get regular care because she has no insurance, and even when she pays for care, she is stigmatized for being uninsured. She cannot work because she must care for others. If she gets stuck in the death spiral, they will be, too. And the problem is that no matter how one initially gets sucked into it -- whether you’ve lost your health or your health insurance due to being laid off as your employer restructures, or because of a divorce, a family crisis, chronic illness, or an accident -- once you are in, it is terribly difficult to get out of the spiral. It’s difficult to gather either the physical resources or the financial resources needed to escape. The Institute of Medicine estimated in 2004 that 18,000 Americans died prematurely due to a lack of health insurance.

This is part of the reason the Unitarian Universalist Association has issued fifteen General Resolutions and numerous Actions of Immediate Witness on the issue of Health and Health Care since 1961. These are public statements – issued by our larger religious association. In 1992, one of those resolutions affirmed that comprehensive health care is a basic human right, and demanded the development of a system which would guarantee quality health care to every individual in the United States. Three other statements on health called for the adoption of a national, publicly funded, comprehensive system of universal health care. At least four UUA statements on economic justice declare that the establishment of a universal health care system is necessary for a just economic community. http://www.uua.org/socialjustice/issues/healthcare/41672.shtml Those resolutions and action statements are, no doubt, a good thing – and definitely a better response to the health care crisis than my initial sigh of relief.

Except that they have changed little in the American health insurance landscape.

The Chicago-based group Physicians for a National Health Program (www.pnhp.org) believes, and I agree, that we need to create a comprehensive National Health Insurance program – something like an expanded and improved version of Medicare – that would cover every one of us for all necessary medical care. It would be a system similar, perhaps, to Canada or Great Britain’s national health services, which manage to provide coverage to all citizens for about half of what our nation spends on health care.
http://www.pnhp.org/single_payer_resources/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance.php They say that four principles shape their vision of health care reform: 1. Access to comprehensive health care is a human right, and that society, through its government – not through employers or the marketplace -- needs to ensure this right. 2. That patients should have the right to choose their doctors, 3. That corporate profits and personal fortune-seeking have no place in caregiving. And 4. That in a democracy, the public should have the right to set health policies and budgets, but personal medical decisions must be made by patients and their caregivers, not by bureaucrats.

And it would seem that American voters agree as well that something must change. In a poll last year for the Kaiser Family Foundation, voters rated health care second only to the war in Iraq as the issue they most wanted presidential candidates to address. And 74 percent of voters said they'd support a reform plan that provided health insurance for everybody and involved at least some increase in spending.
http://www.pbs.org/newshour/bb/health/jan-june07/sicko_06-29.html

What do the candidates say? (You may know more about this than I do, because I can hardly stand to listen to them!) They say a variety of things. Some pundits say that any candidate in this election can only truly say what he or she thinks about health care at the risk of having his or her candidacy shot down by big-money health industry lobbyists.

But our question for today is what would Dr. King say? I suspect it might be this, “Human progress is neither automatic nor inevitable... Every step toward the goal of justice requires sacrifice, suffering, and struggle; the tireless exertions and passionate concern of dedicated individuals.”

The question for us is whether we see ourselves in his words.

Let’s continue the conversation!

Amen.

Sources:
1.“Uninsured In America: Life and Death in the Land of Opportunity,” Susan Starr Sered and Rushika Fernandopulle
2.“The Health Care Mess: How We Got into it and What it Will Take to Get Out,” Julius B. Richmond, Rashi Fein.
3.“Health Care Meltdown, “ Bob LeBow
4.www.pnhp.org
5.www.kkf.org
6.http://covertheuninsured.org/factsheets/
7.http://www.pbs.org/newshour/indepth_coverage/health/uninsured/
8.slides on health care sent by a UUCW member/physician