Health Care Poverty

This paper introduces and describes health care poverty. Underinsurance and its consequences for access to health care are highlighted. Definitions of underinsurance and its prevalence are presented. Groups that experience disproportionate barriers to obtaining medical care are identified. Manifestations of underinsurance are explicated and their relationship to receipt of medical care, such as vaccinations and medications is discussed. A reframing of the health care debate is suggested with emphasis moving from uninsurance to access to health care. Key words: access to health care, underinsurance, unmet needs, social justice Introduction In the debate on health care in the United States, one might conclude that being poor and uninsured are the sole determinants of access to and utilization of health care. The effect of poverty on health insurance status, access to health care and health outcomes has long been established. But that dialogue is driven exclusively by economic status. It emphasizes both the relationship between poverty (as defined by the Federal Poverty Level, FPL) and the complete lack of health insurance (uninsurance), and, subsequently, the relationship between being uninsured and having access to health care. For instance, it is well-documented that individuals living in poverty experience higher rates of uninsurance (Holahan & Cook, 2005; Kaiser Commission on Medicaid and The Uninsured, 2004a) and consequently, a lower likelihood of having a usual source of care (Families USA, 2003; Kaiser Commission on Medicaid and the Uninsured, 2004b). While it is vital to recognize the scope of health care consequences for those living in poverty without any health insurance, this paper contends that there are additional factors critical to the examination of health care in the United States. It introduces a different application of poverty in the health care debate--health care poverty--which significantly broadens the focus. Health care poverty expands examination of issues related to health insurance and access to health care to additional, and significant, groups of individuals who are disenfranchised not solely due to poverty status and a complete lack of health insurance. It includes those who have private health insurance that is inadequate to meet their needs, regardless of their income level. In other words, the term refers to poverty of access to health care. This situation has been labeled underinsurance, and includes, but is not limited to: yearly and lifetime limits on benefits, lack of coverage for medication and other ancillary services, daunting premiums and deductibles, and levels of copayments and/or coinsurance that inhibit ability to obtain health care. Individuals in this predicament do not meet the criteria for inclusion in counts of the uninsured nor are they represented in discussions of access to health care. They are invisible because the focus of such discussions is on the presence or absence of health insurance, as if the presence of health insurance is synonymous with access to health care. However, this assumption is naive. Healthy People 2010 acknowledged multiple factors that contribute to problems with access to health care: Financial, structural, and personal barriers can limit access to health care. Financial barriers include not having health insurance, not having enough health insurance to cover needed services, or not having the financial capacity to cover services outside a health plan or insurance program. (Healthy People 2010a) This paper addresses the situation in which health insurance coverage is "not enough" to meet health care needs. It contends that the insured/uninsured discussion, while important, neglects the critical issue of underinsurance. Consequently, identification of the extent of unmet need is precluded. This paper describes the nature and degree of underinsurance and discusses implications for access to health care for individuals and families. …