statistic that over forty million Americans lack health care
is constantly repeated in the media. Yet, in practical day-to-day
terms, what does that mean? How does not having health insurance
impact other areas of a person's life? These are some of the issues
Susan Starr Sered
and Rushika Fernandopulle examine
in Uninsured in America: Life and Death
in the Land of Opportunity.
The United States spends
more per capita on health care than almost any other industrialized
country, yet garners low marks when it comes to the overall health
of its population. This is a direct result of the way health care
has been apportioned over the last sixty years. Since World War
II, health care coverage has been linked to employment. During the
war, wages were frozen, and employers were searching for incentives
to keep and recruit workers. Paid health care benefits became one
of those incentives and, in fact, became the norm. The role of insuring
health, which in many other countries is a function of the state,
became tied to the private sector. As a result, the government had
little incentive to develop a comprehensive healthcare system.
As the American economy
has changed, so has the link between employment and benefits. Since
people often no longer work for a single employer until retirement,
jobs no longer provide "stable platforms for health care arrangements."
Entire sectors of the economy, such as manufacturing, timber, and
fishing, have disappeared, leaving many of those people with neither
jobs nor benefits. Because medical, insurance, and pharmaceutical
industries operate on a for-profit basis, health care costs have
soared. For those who have insurance, there are no guarantees that
they will continue to be covered.
As costs increase, employers
look for ways to cut health benefits or to stop providing insurance
altogether. When a person loses job-related insurance, most of the
other options available are prohibitively expensive. As a result,
people enter what Sered and Fernandopulle refer to as the death
spiral, the inability to manage one's health and one's employment:
adversity is so thoroughly entwined with medical adversity, those
caught in the spiral cannot amass either the bodily or the financial
resources needed to break out. Descent through the death spiral,
for millions of Americans, leaves irrevocable marks of illness
on their bodies and souls.
There are any number
of ways a person can enter the death spiral: divorce, corporate
restructuring, plant closing, accident, disability, and chronic
illness, to name a few. Anything that threatens employability affects
health insurance. The negative aspects of job and insurance loss
can multiply, particularly if others relied on the insurance and
income. If one is ill or becomes ill, the lack of insurance creates
its own Catch-22. If one is sick and cannot afford care, this can
lead to chronic illness, which decreases the chance of finding a
job, which in turn decreases the chances of being insured.
According to Sered and
Fernandopulle, people who lack or lose access to health care become
a separate caste. They use the word caste deliberately
and in its traditional sense to describe a group of people who are
characterized "by the absence of mobility" and by "recognizable
external markers." When health affects employment and appearance,
people lose the middle-class markers that define success in this
In a broader
sense, the death spiral serves as a metaphor for the deep changes
taking place in American society as the demarcation between rich
and poor -- a traditionally fluid distinction in our society --
hardens into a static barrier between the caste of the healthy
and the caste of those who are fated to become and remain sick.
Teeth are one of those
caste markers. Healthy, white teeth are a sign of middle-class success.
Almost everyone in the book said that if they were suddenly given
health care coverage, the first thing they would is go to the dentist.
For example, Sered and Fernandopulle interviewed Gina, a hair stylist,
who lives in Idaho. Whenever she talks, she covers her mouth because
she is embarrassed by her the condition of her teeth. Another woman,
Loretta, is missing several of her teeth, lost due to the fact that
she cannot afford to go to the dentist. Her solution to a toothache
is to pull her teeth herself. "I've gotten toothaches so bad,
so that I just literally pull my own teeth. They'll break off after
a while, and they you just grab ahold of them, and they work their
To collect their data,
Sered and Fernandopulle interviewed 120 people living in Illinois,
Idaho, Massachusetts, Texas, and Mississippi. One of the great strengths
of their study is the personal stories they tell, the type of story
that is often obscured in the larger debate around healthcare in
this country, which revolves around cost-cutting measures and the
benefits of one plan versus another, rather than what people actually
need to stay healthy.
For example, Annette
is a thirty-eight-year-old divorced mother of three and a victim
of domestic violence. Her ex-husband beat her so badly that she
still suffers from headaches and has problems with her vision. When
her divorce became final, she lost the insurance she had through
his employer. Her current job as an office manager does not provide
benefits, and she goes to work even when she does not feel well
for fear she will lose her income. She suffers from migraines, yet
only receives treatment if the pain is so bad it sends her to the
Alisha, who lives in
Mississippi, has worked a series of low-paying jobs most of her
life. She has been forced to come up with creative ways to take
care of her health. She has asthma, but cannot afford the inhaler.
If she needs one, she borrows her sister's. She also suffers from
abnormal uterine bleeding and is unable to get regular treatment
Other cases include a
couple whose rust belt jobs have disappeared along with their insurance
benefits, forcing them to decide on a monthly basis which medicines
they will buy. There are people who suffer from treatable mental
illnesses, yet are unable to afford the medications that would let
them live normal lives. Still others must choose between buying
groceries and buying diapers, must hope that kidney stones do not
lead to renal failure, or must hope that a broken hand will still
heal properly when protected by an Ace bandage, rather than a cast.
Some would argue that
the United States does provide medical care to people without insurance
through programs such as Medicare and Medicaid. However, these programs
are not without their own difficulties. Medicare often does not
cover all the costs of care, requiring people to use some of their
own money to pay for care. In some cases, small changes in income
can disqualify a person from participation in these programs. Many
doctors will not accept patients on Medicare or Medicaid, leaving
them without treatment they are eligible to receive.
In the United States,
medical insurance occupies an odd niche. If people were told that
in order to have automobile, homeowner's, and life insurance, they
were required to have a job and that they had to accept whatever
policies were offered, most people would cry foul. Yet, when it
comes to health insurance, this, unfortunately, seems to be acceptable.
The paradox of the American
healthcare system is that it does eventually provide care to the
uninsured, but it does so at the moment it becomes the most expensive.
While it is virtually impossible to see a doctor for preventive
measures, no-one can be denied care in an emergency. It is easier
to get care after one has had the heart attack than it is to visit
a doctor to find out how to prevent it in the first place.
The obvious, yet politically
loaded, solution to the health care situation in the U.S. is develop
a system in which employment is not a prerequisite for insurance.
This, in fact, is what Sered and Fernandopulle suggest:
the link between employment and health care will not fix all that
is broken or right all wrongs. It will, however, help stop current
inequalities from being irrevocable marked on our bodies and help
prevent current injustices form hardening into a permanent caste
One of the political
mantras repeated over and over in the United States is the idea
that citizens have rights which should be protected -- the right
to privacy, the right to an education, the right to be safe -- the
various modern manifestations of the right to life, liberty, and
the pursuit of happiness. The irony is that good health, which makes
the pursuit of all those possible, goes largely unprotected.
mmo : november