(Circulation. 2000;101:e9048.)
© 2000 American Heart Association, Inc.
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Numbers of Uninsured Increases
Between 1988 and 1998, the rolls of the uninsured increased by 1 million persons each year, according to a recent study released by the Kaiser Commission on Medicaid and the Uninsured. By 1998, the number of uninsured Americans had reached 43.9 million.
In the early 1990s, the decreases were attributable to fewer businesses providing healthcare insurance to their employees. However, by the late 1990s, welfare reform caused many Americans to lose their Medicaid coverage, which dropped millions more from the insured rolls.
Most of the 44 million Americans who lost their healthcare coverage were younger than 65 years of age. "The uninsured are predominantly workers and their families, many of whom have low incomes," the report stated. "About one-third of the poor and near-poor lack health insurance coverage."
Children make up nearly one-fifth of the uninsured. Almost all of these children are eligible for coverage through Medicaid in the State Children’s Health Insurance Program but are not enrolled. Their parents make up almost another one-fifth of the uninsured.
Three-fourths of the uninsured are part of a family where at least one member works full time, and another 10% are in families where there is at least one part-time worker. Only 16% of the uninsured live in families where no one is employed.
The high cost of premiums is the top reason cited by these workers for being uninsured. "The employee cost for family coverage is higher in businesses that employ mainly low-wage workers than in those with mostly high-wage workers," noted the report. However, most low-income adult Americans cannot meet the stringent income eligibility guidelines to qualify for Medicaid.
Being uninsured has significant health consequences. Nearly 40% of uninsured adults said they skipped a recommended medical treatment because of the cost, and 20% said that they have needed but not received care for a serious health problem in the past year. These persons are more likely to be hospitalized for a condition that could have been avoided, such as pneumonia or diabetes. They are also more likely to be diagnosed with late-stage cancer. For example, death rates for uninsured women with breast cancer are significantly higher than those for women with insurance. Children without insurance were 70% less likely to have received medical care for common conditions, such as an ear infection, than their insured counterparts, and they are 30% less likely to receive medical care after an injury.
Cancer Rates Declining
Cancer incidence and mortality overall and for the top 10 cancer sites declined between 1990 and 1997, according to a report issued May 14, 2000, by the National Cancer Institute, the American Cancer Society, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. The report, which was published in the May issue of the journal Cancer (2000;88:2398–2424), was labeled encouraging by oncology experts in the country.
"These findings underscore the remarkable progress we’ve made against cancer," said Richard D. Klausner, MD, the director of the National Cancer Institute. The report noted that the incidence rate (the number of new cancer cases per 100 000 persons per year) for all cancers declined, on average, 0.8% per year between 1990 and 1997. The trend reversed a pattern of increasing incidence rates from 1973 through 1992.
Decreasing rates of new disease and decreasing deaths from cancer "give us great hope that in the new millennium, our dreams of conquering cancer are closer than ever to becoming a reality," said John R. Seffrin, PhD, chief executive officer of the American Cancer Society.
The greatest decrease was in men, who have higher rates of cancer than women. Cancers of the lung, prostate, breast, and colon and rectum accounted for more than half of all new cancer cases, and they were also the leading cause of cancer death for every racial and ethnic group.
The incidence of breast cancer changed little in the 1990s, but death
rates declined 
2% per year. New cases of lung cancer have been on
the decline since 1991. Mortality from lung cancer continued to
increase for women, but it started declining for men in 1990.
The incidence and mortality of cancer were higher for blacks than for other racial groups. This fact points to the need for better screening and access to care.
Insurers Rethinking Policies on Capitation
Physician organizations told American Medical News that insurers are turning away from capitation and shifting toward fee-for-service.
According to an article by Julie A. Jacob, who is part of the staff of American Medical News (May 22/29, 2000), insurers are not turning away from capitation because of physician complaints but because paying claims on a case-by-case basis is cheaper than the flat rate called for under capitation. One consultant said that insurers are abandoning capitation for primary care because they were paying more under that system and were not getting the kind of care management they needed to make a profit.
United Health Care of Colorado now pays all the doctors in its Colorado network on an episode-of-care basis rather than capitation, the report stated. Nationally, this company is also reducing capitation and claims; it will pay by fee-for-service for 90% of its physician contracts. Cigna Healthcare of Colorado has followed the same trend, as has Blue Cross Blue Shield of Florida.
However, the picture is mixed. Statistics from the Medical Group Management Association show that the percentage of medical groups with some capitated contracts is increasing, but the amount of money such groups make under capitation is actually going down.
Variations In Hospital Charges
The amount of money big-city hospitals charge for common procedures varied greatly in a study conducted by researchers from the University of Toronto and the Women’s College Health Sciences Centre in Toronto (Arch Intern Med. 2000;160:1417–1422). The results of this study demonstrated that the uninsured should price shop when they seek care.
For example, the authors noted that the charge for a mammogram ranged from $40 at one Los Angeles hospital to $346 at a hospital in Quebec City. The largest differential was for knee surgery, where the price difference was $39 825 between the most and least expensive hospitals. The second largest difference was for a normal vaginal delivery—$13 322.
To accomplish this study, the authors surveyed the 2 largest general hospitals in every city with a population >500 000 in the United States and Canada. At each hospital, they obtained the charges for patients who pay directly for 5 diagnostic, 7 therapeutic, and 3 nonclinical services. A total of 66 hospitals were surveyed.
The authors concluded that such "findings carry implications for Americans who are employed but have no health insurance. Studies suggest that such patients without insurance face barriers in access to care. The principal contribution of this research is to suggest that they also face inconsistencies in charges for care. Our main finding is that the degree of variation in charges is greater than generally appreciated and greater than that observed for patients with insurance."
Although the authors said that the uninsured need to shop around for health services, they also noted that hospitals were unwilling to disclose their charges and that obtaining the information took several telephone calls and considerable explanation.
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