Introduction to special theme issue on health insurance in the United States.

Health insurance matters. It affects the experiences, behaviors, and outcomes of patients, clinicians, family members and health care institutions. For economists, employers, and governmental policy makers, health insurance also has broad and far reaching impacts, extending into such far-flung arenas as immigration policy, bankruptcy law, and even domestic partner/gay marriage issues.1"4 Perhaps it shouldn't. That is the haunting question that weaves together the collection of articles in this special theme issue of Medical Care, sponsored by the Medical Care Section of the American Public Health Association (APHA) as a collaborative effort of the journal and the professional association that it represents. Consider this recent true story of a close personal friend, for whom insurance mattered. She is a 50-year-old physician working in a public clinic for the uninsured in Chicago, Illinois. She discovered a breast lump, and immediately went to her own physician. Her physician referred her for an ultrasound-guided biopsy. However because her health insurance was in transition, she delayed getting the biopsy for 5 foil months, a biopsy that ultimately returned as positive for adenocarcinoma. In transition? Waited 5 months? Why would a physician not have known better than to delay her biopsy nearly half a year? Although the story is complex (I will spare the reader the foil details), such complexities and delays are not unusual in the complex and frustrating world of health insurance in the United States. My friend with breast cancer was originally working part-time for a clinic where she did not receive health insurance. For many years she was covered under her husband's plan. When a new practice opportunity opened at the hospital where her husband worked, she changed jobs, joining him in working there. One of the benefits of the new job was that part-time workers (she was 55% time) received health insurance. So far so good. But this also meant she could no longer remain on her husband's plan (at that workplace, such family coverage was forbidden if both spouses work there); and because her insurance costs would be "pro-rated," requiring her to pay 45% of the premiums out of pocket, she realized that this "benefit" was actually a financial detriment. She decided she would be better off reducing her time in her new job to less than 50% so she would no longer have "benefits," and did so. It was at that moment when she discovered the lump in her breast. Untangling the disenrollement-re-enrollment paperwork dragged on for the next 5 months. Each time she thought the matter resolved, another bureaucratic hurdle had to be surmounted. Looming large over the whole process was the question of whether, in the unlikely event a cancer was found, it would be a considered a "pre-existing condition." When finally straightened out and she went for biopsy, her worse fears were realized. While each of us has a personal experience that we could also relate about ourselves, family members, or friends, the purpose of this special theme issue is to take a look at the bigger picture of how health insurance is and is not working. In my own case, written as a personal essay several years back, I concluded by confessing that while I considered myself something of an expert on health policy, I was clueless about the fact that I would