Published 5/1/2007
James H. Herndon, MD; Mary Ann Porucznik

What’s to be done about the uninsured?

America’s healthcare system is failing millions

According to the latest statistics from the U.S. Census Bureau, 44.8 million Americans—approximately 15 percent of the total U.S. population—have no health insurance. And the numbers are increasing. Current predictions are that one in four Americans will be uninsured by 2013—just six years from now.

For those of us who compose America’s healthcare delivery system, this statistic should be alarming. Already caring for the uninsured presents a major financial challenge—as well as an ethical dilemma—for many hospitals and physicians. With ever-increasing costs of care, and increasing reliance on government or publicly funded insurance, the highly decentralized and primarily market-driven American healthcare delivery system is being pushed to the brink of financial disaster.

System failures
Many factors contribute to the growth of the uninsured population in America. The number of people who obtain insurance through their employers is declining, as both employers and employees are faced with increasing costs and hard choices. Not all jobs offer health insurance benefits, and the number of part-time employees who are not eligible for coverage has increased. Millions of Americans work for minimum wages, mainly in service industries and often without benefits. Lay-offs, workforce reductions (eliminating jobs), and a mobile work force are all contributing factors.

Workers who have the option to obtain coverage through their employers may choose not to participate because they don’t believe they will receive benefits that will offset their costs. Younger workers often opt out because they are healthy and do not anticipate health problems. They often make lifestyle choices, such as purchasing a new car or supporting a nonworking spouse, rather than paying for health insurance. Independent contractors, self-employed small business owners, and individuals are also likely to defer coverage due to costs.

The working poor—and increasingly the working middle-class—make up a significant percentage of the uninsured. Medicaid does not cover most workers in low-paying jobs. With the Federal government sending less money to states for their Medicaid programs, the numbers of uninsured and underinsured will most likely increase.

Where can the uninsured go for care?
Uninsured patients rely on a safety net of hospitals and community clinics or physicians who will see them without payment. But many individuals without insurance will defer medical care—postponing physician visits, deferring tests, and cutting back on prescription drugs—until they really need it or their medical condition becomes an emergency. They then seek the services of specialists in hospital emergency departments, resulting in hospitalizations that could have been prevented with more timely care.

Others regularly turn to hospital emergency departments, outreach clinics, or physicians who voluntarily treat them without charge. Many hospitals, especially teaching hospitals, have a commitment to care for the uninsured, but are being hard-pressed to care for all indigent patients. Some have cut back or eliminated programs to care for the uninsured.

Access to specialty care is an even more serious problem. Surveys of hospital directors find that “access to specialty care is often or almost always a problem.” Government-owned hospitals provide half of the specialty care and major teaching hospitals provide about 25 percent of specialty care for the uninsured. Referrals of the uninsured to specialists are most successful when a primary care physician calls a colleague and asks for a favor to get the referral.

Wide variations exist among communities, physicians, and especially specialists, regarding their commitment to the care of patients without insurance. Some large physician groups agree to treat a few uninsured patients; some physicians volunteer in clinics or health centers to minimize paperwork and practice costs. National projects, such as the Robert Wood Johnson Foundation’s “Reach Out” program, have been tried, but cannot continue without local support, and surgeons are not often represented in these volunteer efforts.

Reform—like it or not—is coming
The problems surrounding health care for the uninsured reinforce the perception that the U.S. healthcare delivery system “is neither a system nor does it deliver health.” Physicians are frustrated by insurance restrictions and only one in five Americans thinks the system works well. A recent (March 14, 2007) issue of the Journal of the American Medical Association (JAMA) outlined several possible solutions, and the upcoming presidential campaign will no doubt generate several proposals for healthcare reform.

Congressional healthcare reform proposals abound. A new analysis conducted by the Commonwealth Fund focused on 10 such proposals and found that they could significantly reduce the number of uninsured and serve as a first step toward universal coverage.

Among the reform strategies currently being discussed are the following:

  • a single payer national healthcare system administered by the federal government
  • a requirement that employers provide and pay for coverage
  • a mandate that individuals purchase coverage (tax credit or income tax deduction)
  • a combination employer/employee mandate
  • some form of private/public or federal/state partnership

Earlier this year, the American Medical Association announced its partnership with the Health Coverage Coalition for the Uninsured (HCCU). The HCCU proposes to expand health coverage to the uninsured in two phases: first to children, and then to adults.

In the first phase, the proposal would expand states’ ability—and provide them with funding—to expand SCHIP (State Children’s Health Insurance Program) and Medicaid programs. It would also establish a family tax credit for the purchase of children’s health coverage and support state demonstration projects to expand health coverage.

Second phase proposals include basing eligibility for Medicaid coverage strictly on financial need, providing tax credits to low-income families for the purchase of health insurance, and providing federal grants to states to provide health coverage for high-risk populations.

The tide is turning
Americans strongly believe in individual efforts at work and personal responsibility for one’s actions and expenses. But more and more, Americans are agreeing with the Institute of Medicine that “Health care coverage should be universal…Everyone living in the United States should have health insurance.” A recent nationwide poll by The New York Times and CBS News found that 48 percent of those questioned believe that the federal government should guarantee health insurance for all Americans, and 49 percent would be willing to pay up to an additional $500 in taxes to implement such a program.

Obviously, such a radical change would be both politically and financially expensive. But rising healthcare costs and escalating new technologies—as well as fewer employer-provided programs and more predictions of potential personal and business insolvency—make it clear that we have a serious problem. From a surgeon’s perspective, metaphorically, it is time to operate, to repair and stabilize our healthcare system for the long term.

In the short term, what can orthopaedic surgeons and other physicians do? Many specialist physicians participate in volunteer efforts caring for the uninsured in communities throughout the United States. In one large orthopaedic group, for example, each physician allocates 10 percent of his or her practice for care of the uninsured. Others work in clinics or hospitals or community health centers.

A model for all of us is Sir Robert Jones, who cared for a large number of uninsured patients in his famous “Sunday Morning Clinic.” Why can’t all physicians volunteer a portion of their time for their profession and care for some of the uninsured? Why can’t we as a profession follow Sir Robert Jones’ example, but in a less onerous way and with a smaller time commitment? After all the uninsured are getting care in hospitals; the main problem is essentially the unavailability of specialty care.

As physicians, we need to become more politically active in seeking solutions to improve our dysfunctional healthcare system. Who else better understands the plight of the patient today than the patient and his or her physician? In addition to constantly addressing our own problems in the morass in which we work, we need to call on all physicians to focus their talents and to collaborate with our political and business colleagues in seeking solutions to our healthcare system’s failures—including the provision of and reimbursement for clinical care for the uninsured and underinsured.

James H. Herndon, MD, is program director of the orthopaedic surgery residency program at Partners HealthCare and a past president of the AAOS. He can be reached at jherndon@partners.org

This article is based on presentations to the Combined Orthopaedic Associations, which met in Sidney, Australia, in 2004, and to the 2005 National Orthopaedic Leadership Conference.

Mary Ann Porucznik is managing editor of AAOS Now.

Additional resources:
Uninsured Health Care by Frederick N. Meyer, MD:

Volunteer Immunity—AAOS Office of Government Relations

Care and Treatment of the Medically Underserved—AAOS Opinions on Ethics and Professionalism

Health Insurance Coverage Bills in Congress: An Analysis—The Commonwealth Fund:

Health Coverage Coalition for the Uninsured