The Group that Struggles the Most in American Health Care

There are more than enough needs to go around in American health care, but if I had to pick the one group that struggles the most with costs and access, it would be people with chronic illnesses who are also uninsured. These are people with cancer or heart disease or diabetes or mental health conditions, or multiple chronic health problems, who also don’t have insurance coverage.

We don’t have an exact count of the number of people with multiple medical conditions who are uninsured, but we can say it’s millions of people: about a quarter of the uninsured report that they have been treated for one or two health conditions over the past year and 1 in 10 for three or more conditions. There are about 27 million uninsured people in the U.S., and that number is projected to grow into the low 40 millions when the cuts in federal funding for Medicaid and ACA coverage fully kick in (unless they are reversed).

You could say that’s no surprise—people with multiple conditions use the most care, so they experience greater problems getting and paying for care; that result is so expected in our health system it’s almost tautological to treat it as a discovery. Fair enough, no tenure for me. You could also say that the first obligation of any health system is to take care of people who are sick; it’s a leading indicator of a health system that isn’t working as it should.

Here are a few of the numbers and a chart from a new survey of over 25,000 adults focusing on the chronically ill, which we’ll release tomorrow:

Seventy-two percent of adults with multiple health conditions who are uninsured had problems paying for their care or could not pay their medical bills in the last year.
Fifty percent had to cut back on other household needs as a result.
Sixty-eight percent skipped care because of costs over the last year.

These are about double the already very high rates experienced by people with conditions like cancer, heart disease, diabetes and mental health issues who have insurance. (The chronically ill with insurance experience cost and access problems at rates that are much higher than people who are generally healthy and use less health care).

And when they need care, the chronically ill uninsured rely on emergency rooms three times as often as their insured counterparts do.

Looking at the chronically ill uninsured as a research grouping enables us to examine what’s happening in the health care system more broadly, in this case to people with serious medical problems without insurance. There is no Association for the Multiply Chronically Ill Uninsured on K Street in Washington, D.C., and they don’t have their own powerful advocacy group working on their behalf, although the big disease groups in D.C. have combined forces to advocate for Medicaid and the ACA, which provide coverage for constituents who otherwise would be uninsured. Most of the members of these groups, however, have insurance coverage and advocacy and lobbying focuses on the problems they face paying for and getting care and the drugs they need, including the problems people with significant illnesses have navigating the health insurance system, such as their encounters with prior authorization review. People tell us in polls that prior authorization review is their top concern after costs in health care. The uninsured, of course, would feel lucky to have that problem.

There has been substantial discussion of the chronically ill in health care for years. In October, I’m delivering the keynote address at the annual meeting of the National Academy of Medicine, which is focused on chronic disease. However, most of the discussions to date have focused on prevention and disease management, including better delivery and payment models. Almost none have focused on the fact that when it comes to the “affordability crisis” driving the national discussion of health care today, the chronically ill, and most of all the chronically ill uninsured, are the tip of the spear.

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