A lot of people who care about the high rates of uninsurance in the U.S. do so because it just seems wrong that the wealthiest country in the world leaves a large swath of its population without healthcare – and, thus, facing employment difficulties, financial ruin, years of unnecessary pain or disability, and an overall impediment to pursuing the American Dream.

If you’re an unpopular president with a bizarre sense of what fiscal responsibility means, this argument might not convince you. Even if it doesn’t, you should still try to bring the rate of uninsurance toward zero out of sheer self-interest. That’s because even those of us with good health insurance plans get worse healthcare when our neighbors are uninsured.

At a presentation on Tuesday Dr. Arthur Kellermann, an emergency-room doctor and professor of emergency medicine at Emory School of Medicine, explained how high rates of uninsurance affect communities’ health in several ways.

In addition to his ER expertise, Dr. Kellermann co-chaired the Institute of Medicine Committee on the Consequences of Uninsurance from 2001 – 2004, and he’s a Robert Wood Johnson Foundation Health Policy Fellow. He spoke on Tuesday at the George Washington University School of Public Health and Health Policy, and Kaisernetwork.org has made a webcast available.

Hospitals Struggle
Anyone who’s been following the issue of U.S. healthcare probably knows that high rates of uninsurance translate into higher costs for the insured. Unpaid bills from those without insurance (or without enough of it) drain hospitals’ resources, and they respond by raising prices for their insured patients. Even so, many hospitals are struggling to stay afloat. Kellermann works at Grady Memorial Hospital in Atlanta, and reports that it’s within about two months of running out of all financial resources. Being able to afford care won’t do you much good if there’s no hospital around to provide it.

A financially stretched hospital is a tough environment for doctors as well as patients. Kellermann reported that communities with high rates of uninsurance have a harder time recruiting and retaining healthcare professionals, and specialist doctors in those areas are less likely to take ER call. (If there’s no neurosurgeon on call when you show up at the ER needing emergency brain surgery, you’ll have to be transported to another hospital, and the delay could result in lifelong disability.) Some hospitals have eliminated services with high rates of uncompensated care, such as burn units, trauma care, and neonatal intensive care.

Even if the ER has the right providers on call when you show up, that doesn’t mean you’ll get seen quickly. Ambulances are regularly diverted from full ERs, and patients who arrive by other means often spend hours in a waiting room before seeing a doctor. Kellermann emphasized that this is not the result of uninsured people using the ER inappropriately; in other words, it’s not because people without insurance are coming with ear infections and clogging the system. The problem, he said, is that there aren’t enough beds in the ER – and that’s exactly how hospitals want it.

Hospitals want to keep their beds full, preferably with a high percentage of elective patients. Elective admissions are better for hospitals than emergency admissions because they pay higher margins and keep referring doctors happy, Kellermann said. If there aren’t enough beds for patients coming in for scheduled procedures, doctors will get tired of scheduling hassles and refer their patients elsewhere. If there aren’t enough beds in the ER, the patients have to go somewhere else (and those hospitals that have free ER beds will end up with the diverted patients). Most of the patients clogging the emergency rooms, Kellermann told us, have actually been stabilized already; they’re still there because they’re waiting for inpatient beds.

Viruses Don’t Care if You’re Insured
Keeping lots of patients crowded into an ER is a great way to spread disease. Kellermann told us of a case in Toronto, a young man with pneumonia who spent the night on an emergency department stretcher while waiting for an inpatient bed. It turned out that he had SARS, and infected the two patients adjoining him in the ED and several staff members. Investigators later identified 128 SARS cases – 17 of whom died – in the outbreak associated with that hospital.

When such an outbreak occurs, having a good public health system can limit the disease’s toll. Kellermann pointed out that in addition to leaving hospitals overstretched, high rates of uninsurance can also weaken local health departments, who may be forced to divert resources from things like disease control and disaster preparedness to fund primary care clinics. Your health insurance will not protect you from the viruses (and other kinds of bugs) circulating in your community – but a strong public health system can improve your chances of avoiding food-borne illness, influenza, TB, and the many other diseases we have to worry about. Such systems can’t be purchased on the individual market.

Recommendations
Kellermann did not endorse a particular plan for extending health coverage, though he cited several that have been proposed. He did say that care should be universal, continuous, affordable, and sustainable, and that “health insurance should enhance health and wellbeing by promoting access to high-quality care.”

For more details, watch the address at Kaisernetwork.org, or check out the 2003 IOM report A Shared Destiny: Community Effects of Uninsurance. And remember these points the next time you or someone you’re listening to suggests that those with insurance don’t need to worry about the uninsured.

Liz Borkowski works for the Project on Scientific Knowledge and Public Policy (SKAPP) at George Washington University’s School of Public Health and Health Services.