Clinics must plan for increased numbers of uninsured patients.
by April Allison, MA, MPH. Reprinted from Michigan Primary Care Association, Spring/Summer 1997.)
People are being urged off welfare and into low-paying service sector jobs that don't provide insurance coverage. Fee-for-service health care is giving way to managed care plans that sometimes select new members based on their demographic profiles. When privately financed insurance is available, it is often of variable quality. Deductibles of $2,500 on commercial health insurance policies can effectively exclude enrollees from essential health care access.
These concerns are not new, and they are not going away, as Community/Migrant Health Centers (C/MHC) committed to providing health care access to all regardless of financial resources, are acutely aware.
Even though the Michigan Department of Community Health's Division of Planning and Evaluation reports that Michigan's rate of uninsured compares favorably with the national average,  there is still abundant cause for concern. The U. S. Bureau of the Census indicates that in 1995, 11 percent of Michigan's population age 0-64 was uninsured, and young adults in the 21-24 year old group had the highest uninsured rate (25 percent) of any age group.
It might be surprising to the general public that so many young adults are uninsured, since public attention and political debate often focus upon access to health care by young children. However, it makes sense that as young adults leave their families of origin - where they may have had coverage through Medicaid or through their parent's commercial coverage - and move into entry-level employment, that they might not be in a financial position to obtain coverage on their own. Compared with an overall 71 percent of Michigan residents of all ages covered by employer health insurance, only 54.7 percent of this age group enjoys employer coverage.
Since statistics on insurance coverage include Medicaid coverage along with commercial insurance coverage and Medicare, it is not surprising that these statistics indicate that those whose family income is slightly above the poverty level (125-149 percent of poverty) have the greatest percent of uninsured (31 percent), compared to those who have higher or lower family incomes.
Growth in Medicaid enrollment in Michigan increased by 23 percent from 1990-94, and in rural counties up to 30 percent of all residents may be on Medicaid.  If state government succeeds in moving a substantial number of welfare recipients from government rolls to private sector employment, they and their families may increase their income just enough to make them eligible for Medicaid benefits.
Yet employer coverage for health insurance in 1995 included 28.8 percent of those whose family income was from 100-124 percent of the federal poverty level, while 92.5 percent of those whose family income was at least 400 percent of the poverty level received this fringe benefit. As former Medicaid recipients move into low-paying jobs, we must note that the working uninsured are "always one serious illness away from poverty and job loss." 
C/MHCs both must be prepared for this probable increase in uninsured patients in their own clinics and be organized to advocate policy initiatives that would extend coverage to low income people who are no longer eligible for publicly funded coverage.
A number of recent policy initiatives in Michigan have targeted the working uninsured. According to the Michigan Public Health Institute, a combination of sometimes unrelated factors contributed to the poor outcomes in these programs. Among the problematic factors were high and/or rapidly changing premiums, projects billed as demonstration projects with ending dates, poor choice of providers, limited benefit packages, unfavorable risk ratings for small firms, and exclusion of owners from coverage plans.
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This page posted November 2.
Last revised January 31, 1998