Uninsurance Problem Solved by Executive Order

Satire AlertIn the next few days the Census Bureau will come out with new figures, probably showing that the number of uninsured has reached an all-time high.  This will cause gnashing of teeth, crying and wailing….possibly driving some people to drink.  It will cause apoplexy on the editorial pages of The New York Times.

So I have a solution.  And it will cost not one thin dime.  The next president of the United States should sign an Executive Order requiring the Census Bureau to cease and desist from describing any American (even illegal aliens) as "uninsured."  Instead, the Bureau should categorize people according to the likely source of payment should they need care.

So, there you have it.  Voila!  Problem solved.

Here is the idea: only people who are denied care are truly uninsured.  Everyone who gets care is effectively insured by some mechanism.  So instead of producing worthless statistics that people fling around in vacuous editorials and pointless debates, the Census Bureau should produce meaningful numbers, identifying all of the sources of funds people will draw on if they need medical care.

Also, my solution would put the United States on a par, say, with Britain and Canada. Those countries insist that all of their citizens are "insured," whether or not they get needed medical care.

Here are some categories I would use:

Self-Insured + EMTALA + Free Care.  At a minimum, everyone is self-insured up to the extent of his net worth; and it would be a useful Census activity to show the assets people have available to pay medical bills directly.  Then, the fact that the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospital emergency rooms to provide emergency care (regardless of ability to pay) counts as additional insurance.  It is supplemented by the availability of free care – variously estimated at between $1,000 and $1,500 per uninsured person per year.

Potential Medicaid.  About one in every four "uninsured" persons is eligible for Medicaid or SCHIP (for children), but is not yet enrolled.  Enrollment is a mere formality, however.  It can be done in the emergency room.  In many places it can be done several months after the care has been delivered.  Surely this must count as health insurance de facto prior to enrollment.

Self Insured + Potential Private Coverage.  There is also the possibility of buying private insurance after the onset of illness.  About one-third of the uninsured are in households earning $50,000 or more, and more than half of those earn $75,000 and up.  These people can clearly afford to buy a lot of medical care directly.  They also can afford insurance.  Six states have guaranteed issue and community rating in the individual market.  In other states, many are protected by the Health Insurance Portability and Accountability Act (HIPAA) and many have access to state subsidized risk pools – allowing access to private insurance after illness has occurred.  Sorting out how many people potentially have access to different types of private coverage would be another useful Census function.

Potential Employer Coverage.  About 80% of the uninsured are living in a household with someone in the labor market.  More than one-fifth of them were offered coverage at work but turned it down.  If the need arises, they can always enroll.  Also, anyone who already has a job can probably land one with employer-provided coverage (if needed), possibly in return for a pay cut.  Note:  HIPAA prohibits employers from denying people coverage because of their (or a family member's) health status.

In general, America has made it surprisingly easy to get someone else to pay your medical bills – even if you don't have a Blue Cross card. 

So loyal readers, feel free to weigh in.  Shall we get rid of the term "uninsured" on the grounds that it detracts from rational public policy discussion?

Comments (37)

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  1. Joe S. says:

    I vote “yea.” Let’s get rid of the term “uninsured.”

  2. Roger B says:

    I work as a Paramedic at a hospital emergency room.
    If people who have no insurance could pay as little as $10 when discharged, this would help, albeit slightly. It may give people incentive to find a personal physician and realize that healthcare is not “free”. This is a huge crisis in this country.

  3. Jerry Kerbo says:

    John: This is fantastic ! While it is right on – it is also extremely humorous as this is what most of us think but will never be !

  4. Pete Pettersen says:

    Good point, John. My stats say that the 15% plus or minus uninsured, hasn’t changed for 20 years. Since 34% of the uninsured are eligible but haven’t signed up; 32% of the uninsured make over $50k and 14% are temporarily uninsured (in between jobs, college grads, etc. it leaves on 20% or about 9.2 million truly uninsured. Interestingly the 15% considered uninsured is about the same as the number of auto drivers not insured after mandatory insurance. We need different solutions for “different uninsured”.
    Pete Pettersen

  5. Devon M. Herrick, Ph.D. says:

    A new Urban Institute study finds the full-year uninsured receive nearly $1,700 in medical care each year. The uninsured pay about $586 out-of-pocket annually towards their own care, while public and private charity care amounts to an additional $1,103 per uninsured individual.

    This “free” care undoubtedly provides a powerful incentive to remain uninsured.


  6. Betsy says:

    Well done, John.

  7. Jodie MacLean says:

    Mr. Goodman,

    I have a few comments after reading your article about health care. Even household making $100,000 dollars a year can’t afford the $40,000 it would cost to take out an appendix not to mention if something more catastrophic happened like a car accident or cancer. It would take even a well off family years to pay off such a debt and in these hard times few even have the ability to borrow this much money.

    The individuals you quote as opting out of medical care primarily do so because of cost. Yes, the priority of eating and keeping a roof over their heads is more important than paying a medial premium to cover their family’s health. It is unbelievable to me that someone could have such low regard for their fellow human beings that they would suggest they rely on tenuous government programs that are next to impossible to qualify for unless you are practically homeless.

    Most self-insurance plans are basic plans with limited benefits that do not cover all medical situations. They are cost prohibitive and although it may be the cost of a blouse for your wife for the average person it is a car or rent payment.

    Hard working Americans for example my parents, now they are retired have only Medicare to handle their massive medical expenses. My father even worked years after retirement to keep medical benefits going for him and my mom. Thanks to the donut-hole each year they get into deeper and deeper debt because their small fixed income of social security and a small pension do not cover the outrageous medical expenses they count on to survive.

    I am saddened that you Mr. Goodman do not open your eyes and see the widening financial divide that exists between people that have health insurance and those who do not. How would making sure that children, families and individuals are covered for their medical needs ruin your life?

    If you want better care than the national coverage you can pay your extra money or get better coverage through work. But why deny other human beings the basic right to health. You can juggle the numbers all you want, but when the pins fall and they will fall, make sure you step out of the way or the knock on effect of poverty such as crime and illiteracy will be the high price of medical care that no one can afford to pay.

  8. Regina Herzlinger says:


  9. David Lenihan says:

    John, as usual….you are guilty of clear thinking. I vote for you as President.

  10. D H Leavitt says:


  11. Stephen Moses says:

    This is another of your frequent superb, creative, thought-provoking pieces.

  12. Devon Herrick says:

    In a surprising defiance of conventional wisdom, the Census Bureau reports today the number of people who lack health coverage actual fell slightly in 2007 to 45.7 million – down from 47 million in 2006. The proportion of U.S. residents who lack health coverage also fell half a percentage point to 15.3 down from 15.8. In fact, during the past decade, the proportion of Americans going without coverage has fallen one percentage point – down from 16.3 percent.

    More importantly, the Census figures illustrate how many that lack health coverage are uninsured by choice.

    • Nearly 18 million of the uninsured live in households with annual incomes above $50,000 and could likely afford health insurance.

    • Up to 14 million uninsured adults and children qualified for government programs but have not enrolled.

    • For most periods without insurance will be brief – about 75 percent are over within one year.

  13. Sheba Seif says:

    Mr. Goodman,

    Your opinion on “Potential Employer Coverage” is not quite accurate. Firstly, only 5 states offer guarantee issue on all products – Maine, Massachusetts, New Jersey, New York and Vermont. Washington State only offers guarantee issue for some individuals who achieve a minimum score on a state mandated health status questionaire.

    Secondly you state that an employee can always enroll in employer-provided coverage if the need arises. An employee cannot enroll on any day he wishes. There are specific times when an employee can enroll, during open enrollment, and possibly other times according to their policies. Therefore if an employee gets sick, he cannot all of a sudden enroll and be covered that day.

    As to your assumption that anyone who has a job can land a job with health benefits, that is quite a stretch. There are many employers who do not offer health benefits at all or do not offer them to new employees without a waiting period. So many uninsured are not able to get group coverage.

    Trying to obtain individual coverage is far from easy. You seem to ignore the fact that in the states that do not offer “guarantee issue”, individual insurance is characterized by medical underwriting. This means that insurance companies can deny coverage, add riders,limit coverage, reduce benefits, etc.

    As far as HIPAA goes, each state is obligated to offer at least one option for high risk individuals. HIPAA does not limit the premiums that individual health plans can charge. So while you cannot be denied because of health reasons, the premium you will pay is substantially higher than traditional individual plans in states that do not have “guarantee issue” for individual coverage.

    Therefore, I do not think that getting rid of the term “uninsured” is good public policy at all.

    Thank you.

    Sheba Seif

  14. Kenneth Heithoff says:

    John, my full support for the abolition of the term!

  15. Chris Ewin says:


    I wrote this letter to Karen Davis at the Commonwealth Fund…

    “Karen Davis,
    SIMPD would welcome dialogue with any of the leadership of the Commonwealth Fund, particularly those that are board-certified primary care physicians who run their own practices today. Communication with those that actually take care of patients on the front lines is paramount to fixing the systems problem we have in health care.

    “It doesn’t make sense to use your car insurance to buy gas & windshield wiper blades, change tires or wash your car. As PCP’s, we take care of 80-85% of the patient’s needs….well-documented by Barbara Starfield, MD, MPH from Johns Hopkins Bloomberg School of Public Health.

    “Please understand that if you cut out the middleman for primary care, then the expenses go way down for all…and in most cases, it’s affordable by all…especially the uninsured…

    “Out of all due respect, there are many smart people offering poor solutions that affect patient care and our practices. I hope you consider the following constructive comments from the PCP’s perspective.

    “A reply would be appreciated.”

  16. Peg says:

    John, I could not help but comment on the article that you recently forwarded me from the Wichita Eagle; the two democrats who were talking about universal coverage and helping with smoking, addictions and obesity. Neither one of them seem very interested in healthy decisions for themselves. One of them received a DUI last year and the other is very overweight!

    I’m just saying that that type of talk sounds better from people who are working at being an example of the success of those programs.

  17. Dan Smith says:

    Of note, the Census Bureau report was just released, and it shows the percent of uninsured has decreased slightly. Do not look on page one of the New York Times for this information.

  18. Kristin says:

    Thanks John. Do you have any stats around how many employers offer health coverage to their employees and/or the trend over the last few years?

  19. K. Roberts says:

    Please tell me this is a joke? I can’t believe you people actually think this insanity reflects reality in any way!

    Actually, it scares me and saddens me that so many people can be so blinded and thick-headed. But, of course, any comments outside of the bubble you all live in will merely be pushed to the side, so I don’t expect to be heard.

    Best of luck to you all when these people increase your medical costs so you’ll be FORCED to rely on emergency rooms for your care, and then file chapter 11 because of suffocating medical bills.

  20. JWinter says:

    Mr Goodman and all you agreeing with him, you are truly delusional. Single payer is the best solution.

    You say:
    “Also, my solution would put the United States on a par, say, with Britain and Canada. Those countries insist that all of their citizens are “insured,” whether or not they get needed medical care.”

    Last time I checked, those countries have both wisely *socialized* their health systems so that all citizens are guaranteed comprehensive health coverage from cradle to grave. Every citizen shares in the cost by simply contributing their fair share of taxes. Britain and Canada don’t waste year after year still wondering about how to “fix health care” like we stupidly do in the US. And we’ll keep on wondering year after year as long as we depend on our insane patchwork of for-profit private insurance and inadequate government programs.

    It’s quite simple and it simply works.. the single payer system!!

  21. R Bar says:

    Mr. Goodman’s basically doubts the validity of the insured/uninsured label and claims that US citizens get reasonable medical care as they would get in other industrialized countries. Fair enough.

    He therefore should be interested whether there is in fact data about the quality of the US health care as a whole, for all US Americans, and whether there are any delays or difficulty in aceess for needed medical interventions in the US. He may be excited to learn that there are in fact such studies, and the US is performing quite poorly in nearly all of them, despite the extraordinary health care costs in the US. He may be thrilled to learn, however, that according to the CIA, the US ranks, among all countries, a respectable 41st in infant mortality and 45th in overall life expectancy … quite an achievement for one of the world’s most affluent countries.

  22. Sarah says:

    After a long Saturday night with my crying two year Sophie, I realized she was in too much pain to wait another day until the walk in clinic in our town was open. Her shrieks only made me more deparate, and my attempt to help her failed. My husband and I decided to take her to the emergency room. We knew she had a UTI and all she needed was a urine test and a perscription for antibiotics.

    First question asked: “Are you insured?”
    Second question: “If no, how will you pay for our services?”
    Then: “If you pay your total bill today, we will give you a 10% discount.”

    Not once did they tell me that because I had no insurance, I would be charged more money as insured because Florida Hospital gave bigger discounts to groups of insured. Not once was I told that my bill might be much higher because i walked into an ER.

    No doctor ever saw me. The attending nurse took her temperature and told me how to collect the sample for the urine test. Twenty minutes later, we left with a perscription for antibiotics. For this, I was charged $260 which I paid in full from our rent money, this was after our 10% discount. Three weeks later, I got a bill from the ER doctor for $360 (we never even saw him) and a $580 bill from the hospital. One week later, we recieved a separate bill from the lab. At the end, we added up all the bills for this UTI and it added up to $1,600.

    I thought this might be a mistake and called the hospital and was iformed that the bill was correct. To add insult to injury, they took back the 10% discount because I had not paid my bill in full after all. All of this for a urinalysis and a perscription. This is how the uninsured get treated at hospitals in this country.

    Thank you, Mr. Goodman for coming out loud and clear: A true ellitist and completely out of touch with what the average American is trully experiencing. You and McCain were made for each other.

    Sarah Smith Henderson

  23. sac says:

    Thank you Mr Goodman for the perfect solution to a very politicized but a rather trivial problems. May I also suggest applying the same logic to other politically convoluted issues? For example: Iraq. Declare the occupation over, and rename the army as the ‘peacekeepers’ or even better ‘Police force ‘temporarily’ rented to Iraqi people’. Poof. There ends the war.

  24. Jackson says:

    I hope this guy is joking. This is pretty frightening that people actually agree with this guy.

  25. Debbie says:

    “Here is the idea: only people who are denied care are truly uninsured.”

    What? Clearly Mr. Goodman has never had to experience being “uninsured”. Yes, you can get care, but unless the patient is destitute and planning to stay that way, the hospital is going to make their life a living hell while they attempt to get paid. My mother in law incurred about $20k in hospital bills for a serious heart problem while “uninsured”. It took her the better part of a decade to put it behind her.

    I personally just had a minor accident at home which required a small surgery on my pinky toe, total cost over $24k! Thank goodness, we are insured.

    Honestly, this piece reads like satire. I don’t know that nationalized healthcare is the solution, but the system we have now is broken, broken, broken.

  26. Paul says:

    Dear Mr. Goodman:

    Thank you so much for the information in today's Dallas Morning News regarding my health insurance. This afternoon I am going to Vasser Brothers Hospital in Poughkeepsie, NY, to get an annual physical. Well, it's not really an annual physical since it will be the first one in twelve years. I think that while I am there I will also get a colonoscopy and consult with a nutritionist about my diabetes.

    You, sir, are literally a life saver.

  27. David Zweig says:

    I have Crohn’s Disease. Like many chronic illnesses, this is not a disease that can be treated only by emergency room visits. I only go to the emergency room when I have intestinal blockage, which – thanks to my daily prescription medication that costs $7500/month without insurance – only happens twice a year.

    I once attempted to start my own business, but I was refused insurance coverage by every institution I approached due to this illness being deemed a “pre-existing condition”, and thus, six months of health care without insurance coverage quickly put me out of business.

    I now have a family of my own and a child who is displaying symptoms of Crohn’s. She has yet to be diagnosed, but I am concerned. I have insurance through my employer at the moment, but my employer’s viability is in question.

    Mr. Goodman, what should I do if I lose my job and cannot find employment for some time? I am a widower, and thus I am the sole bread-winner. COBRA costs over $1800/month for me and my family, and medical care without insurance is not an option. Should I sell my home and all assets and move into temporary housing for homeless families so I can get covered by state insurance? And in the meantime, should I tell my three year-old that she has to just eat a liquid diet from now on so she doesn’t get intestinal blockage, which, if not handled immediately can result in rupture and quickly to death? And if a liquid diet is in order, what should I do about the possible future health problems that will cause?

    Your analysis is ridiculous and harmful. If you truly believe what you are saying, you should go without health care yourself and see how easy it is to live in need of health coverage. Or better yet, live with or observe a family that doesn’t have but requires health coverage for two months, and then report your unchanged position. Step out of the theory tower, and study real situations.

    You should be ashamed of your intellectual dishonesty and horrible reasoning. Go back to school and learn some humility.

  28. Derek says:

    John Goodman you sir are a joke. No, literally. I have been laughing for the past 30 minutes reading about you at the Dallas paper. I really appreciate you helping drive home the idea that McCain really is completely out of touch with the people living in this country. The story about you has been linked by quite a few sites today. It is great to see you helping win this election for Obama. I mean really – Bush has failed at the economy and healthcare and McCain’s plan is to continue his tax cuts for the rich and try to enact a health reform bill that Bush couldn’t get through? Can you not see the irony in that at all? National healthcare would cost a tiny percent of our Iraq occupation and “War on Terror”, and would actually benefit everyone in this country even elitist ***** like yourself that seem to honestly care nothing about your fellow Americans. A healthy nation is a productive nation, and America is anything but healthy currently.

  29. Alan Eshleman, MD says:

    Mr. Goodman, you have so little understanding of the realities of medical care in the USA that I don’t know whether to laugh or cry. When I first saw your comments on the uninsured I thought it was something from The Onion.

    Walk an ER shift in my shoes and leave your right wing reactionary ideology at home. You might learn something.

  30. Mary Beth says:

    Mr. Goodman, Your “opinion” regarding the abolishment of the term “uninsured” is specious on its face. I lost my job a year and a half ago, and have been uninsured ever since. You should spend a week in my shoes–you would be crying for your Mommy! It never ceases to amaze me how truly clueless and elitist people like you and Phil Gramm are. It’s true that I could go to an emergency room–is that where you would like your mother, sister or wife to go for a pap smear or mammogram? I think not. The “uninsured” masses, however, have no need or access to preventive care, do they? I sincerely look forward to the day when people like you, this administration, and Phil Gramm, who are living proof that education is not an inoculation against stupidity, are relegated to the obscurity which you so RICHLY deserve!

  31. […] I agree with him on many, many things.  Nevertheless, he recently posted a comment on his blog that I think was pretty . . . hmm, what do you get when you combine ill-considered […]

  32. Jodie MacLean says:

    Mr. Goodman, if it is so easy to get someone else to pay your medical bill, will you please tell me who they are so my parents can start eating decent meals instead of spending all their money trying to keep at least the mininum amount of medicines they need to survive! Your comments are so uninformed as to how everyday people live with non-comprehensive medical coverage it is scary.

  33. Rita says:

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  34. Brandon H. Backlund, MD says:

    You demonstrate such a lack of understanding of the problems underlying the health care system. I am an emergency physician, and see every day the ill effects of such limited thinking as you advocate in your blog. Emergency departments provide only EMERGENCY care. They are not set up to effectively provide care for the routine health care needs that people may have: managing blood pressure, cholesterol, screenings for cancer, etc. We are unable to provide those kinds of services, yet those are the kinds of services that are unavailable to those without insurance and who cannot afford to pay. The consequence is that they do not get these health care services, until their disease has progressed to the point where they do develop an emergency, such as a heart attack, stroke, or advanced stage cancer. THEN, they present to the emergency room, but far too late to for prevention, and their outcome is usually poor. This results in higher costs, and the potential productivity of these individuals is lost. Everyone loses.

    It is ignoring the problem to say that there is no problem; you are simply burying your head in the sand.

  35. Jodee K. says:

    The problem isn’t what coverage is out there. The problem is what kind of coverage is it. Affordable plans mean rediculous high deductibles. So folks are paying monthly rates and then paying for all visits because all falls to the deductible. Then we have the issue of insurance carriers dictating care instead of doctors. It’s sick. US insurance coverage is nothing more than a money making sceme. Carriers could care less about the health of their policy holders, they just want their money. That’s why so many are falling under “uninsured”

  36. Joe says:

    I rarely leave a response, but i did some searching and wound up here Uninsurance Problem Solved by Executive Order | John Goodman’s Health Policy Blog | NCPA.org.
    And I actually do have some questions for you if
    you don’t mind. Could it be only me or does it look like some of these remarks look like they are left by brain dead individuals? 😛 And, if you are posting on other places, I would like to follow everything new you have to post. Would you make a list of all of your social sites like your Facebook page, twitter feed, or linkedin profile?
    Look at my web-site insurance rate quote

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