The Death Spiral

Uninsured.jpgAccording to a new Gallup Poll, 69 percent of Americans believe that “it is the responsibility of the federal government to make sure that all Americans have health care coverage,” 10 percentage points higher than in 2000. Law conferences at Hamline, Cumberland, and Kansas have focused on innovations in state health care this academic year. What has happened in the past 7 years to make comprehensive health care reform more of a “when” than an “if”?

I think Sered and Fernandopoulle’s book Uninsured in America provides some excellent answers. They tell the stories of ordinary Americans devastated by lack of health coverage. Consider the story of Kim, whose uncontrolled diabetes may be a prelude for critical illness:

Untreated diabetes not only makes her feel worse day to day but also hastens the onset of the serious complications the disease can cause. Because she is unable to monitor and manage her blood sugars and get recommended preventive care, she is at high risk for premature blindness, heart disease, limb amputations, and kidney failure. Standard medical treatment aims to prevent or at least significantly forestall such outcomes, but Kim does not see a way to access standard treatment.

Apropos of Dan’s post below, Kim’s story also show how the market drives dominant employers to slash benefits: Walmart, for instance, “has cut health costs per worker to $3,500 per year, fully 40 percent less than the US average . . . and 30% less than the average paid by other retailers” (34). Here’s how Kim’s employer, Walgreens, fattens up the bottom line:

Kim works part-time at a Walgreens drugstore. Though she isn’t thrilled with the work (which doesn’t utilize her college training), she would agree to work full-time, except that Walgreens isn’t hiring full-time employees either. Kim explained that she tried working more hours there after her boss told her that she would need to work full-time for twelve weeks in order to be eligible for insurance. But when she approached the twelve-week mark, her hours were cut, making her ineligible for insurance.

On a personal note–my father was an assistant manager at Walgreens, and saw that sad story played out more than a few times by managers driven to “beat last year’s numbers.” Moreover, after he was recovering from a broken leg, his boss there repeatedly forced him to do work that would be painful and exhausting for him (and easily assigned to others at the store)–almost certainly in an effort to get rid of him, since his seniority made him one of the higher paid workers there. It’s “just business” for the companies–they really can only expect to be undercut by competitors if they try to be more humane.

These market realities have led more and more Americans into (or to be aware of) a “death spiral” of lost employment, lost insurance due to that lost employment, and future inability to find work due to poor health. As Sered and Fernandopoulle explain:

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.

If we see universal health insurance after 2008, I think it will be largely because of fear of such a death spiral. Americans are, by and large, willing to accept the vagaries of a globalization that destabilizes incomes and reduces job security. But they are not willing to die for it.

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