Medically uninsured up in the 1990's

But the economic vitality, coupled with an expansion in state-federal health programs, may have finally stanched the increase, researchers say.

Their predictions will be tested Friday when the Census Bureau releases the official tally for 1999.

At last count, in 1998, nearly 44.3 million people, or 16.3 percent of the U.S. population, lacked health insurance. That compares with 34.7 million, or 13.9 percent, in 1990.

Far from declaring victory, though, researchers say a stable or declining number would represent only a tiny step forward.

"The fact that we've experienced a year without a slide doesn't eliminate the fact that we've deteriorated tremendously over the past decade," said Judy Feder, dean of policy studies at Georgetown University in Washington, D.C. "We are still in a very deep hole."

If the number of uninsured goes up again, Ms. Feder and others say, it will further draw attention to the magnitude of the problem and raise public attention weeks before the presidential election.

Democrat Al Gore and Republican George W. Bush have outlined proposals on this issue. But the uninsured have been overshadowed this year by passionate calls for prescription drug coverage for senior citizens and a patient's bill of rights.

As researchers await this week's census release, they attribute their optimism to several factors:

The Children's Health Insurance Program, created by Congress in 1997, insures more than 2 million youngsters.

The number of small businesses (those with fewer than 200 workers) who offered workers health insurance jumped to 67 percent this year, from 60 percent in 1999.

The Medicaid rolls have stopped their recent slide, and they are increasing as children and former welfare recipients enroll.

A non-Census government study found that the number of people who lacked health insurance fell to 42.8 million for the first half of 1999, from 44.8 million in 1996. The finding was not statistically significant.

Making a tough choice

Regardless of what the latest numbers show, events of the 1990s have demonstrated that the problem of the uninsured will not go away by itself, experts say. More than half of Dallas County's uninsured have jobs, but a job does not always mean insurance.

"The economy improved, employment improved, but the level of people insured did not improve," said Dr. Sam Ross, who heads the community clinics for Parkland Health and Hospital System. Even when the unemployed went back to work, "people could still not afford the cost of premiums," he said.

On a salary of $8.39 an hour, even $50 a month for individual insurance coverage is often out of reach, said Tonya Davidson, who supervises cafeteria workers at Fred F. Florence Middle School in Dallas. Plus, her employees do not get paid during the summer or holidays, she said.

That's why only a few of her nine employees accept the health insurance offered.

Although as a supervisor she's able to pay for insurance for her and her 10-year-old daughter, "I couldn't afford it as a regular employee," she said.

Tiny Anderson, who has worked for the school district for 14 years, said she joined Parkland's sliding-scale health plan instead. Her young daughter has asthma. "I need benefits," she said.

Some who turn down their employer's insurance take a gamble that their families either won't get sick or will be taken care of in an emergency.

"The kids, they figure, are basically healthy, and they can take the risk," Dr. Ross said. "They also know that between our clinics and Children's Medical Center, they will be able to get emergency care. No one is going to turn away a sick child."

Strain of high premiums

Officials at the Dallas Independent School District say they have heard widespread complaints, even from teachers, that insurance premiums are too expensive. Coverage for a family ranges from $269 to $379 per month, said Marita Hawkins, executive director of DISD's compensation and benefits.

"Everybody in this organization agrees that our copay is extremely high," Ms. Hawkins said. "In order for us to be competitive, we need to look at different strategies on how we contribute to the cost of the premium. It doesn't come easy, unfortunately."

Many families hovering just above poverty have to choose what they will pay for, said Sister Mary Anne Owens, executive director of Catholic Charities of Dallas. "This is what gets cut out," she said.

Sister Owens is starting to have even deeper sympathy for the people straining to pay for their insurance. The premiums for her 175 employees will go up 27 percent next year, she said.

"The people we work with tend to be hourly wage workers," she said. "Even with the hourly wages and both parents working, insurance is the last thing they're going to take."

While the number of people earning less than the poverty level has decreased in recent years, the number of uninsured has increased, experts say. That's mostly due to a drop in the number enrolled in the Medicaid program for poor women and young children.

After states adopted welfare reform in the mid-1990s, many former welfare recipients assumed incorrectly that they were no longer eligible for Medicaid. Others found low-paying jobs that did not offer health insurance. As a result, Medicaid rolls declined by more than 4 million between 1995 and 1998, to 27.9 million.

On the bright side, the number of people with employer-paid health insurance has increased during the same period. And there's no sign that employers are dropping coverage or shifting costs to workers, even though health insurance premiums are growing at more than 10 percent this year.

"We are now in an economic situation where fringe benefits have become a very big part of competing for workers," said Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured.

Overshadowed issue

Most researchers doubt that any improvement would be sustained if the economy turns around.

"I've been saying for a long time that if we have a recession, all bets are off," said Paul Fronstin, a senior research associate at the Employee Benefit Research Institute. "You are probably instantly at 20 percent uninsured, maybe more. Small employers are going to start dropping coverage, and large employers are going to start shifting costs onto the workers again."

For now, attention seems to have shifted from the uninsured to other health-care issues. Patients want insurance protections for managed-care enrollees, including the right to sue health maintenance organizations for medical malpractice damages. They want tougher medical privacy protections. They want programs to reduce medical errors.

"Just having insurance isn't enough," said Dr. John M. Eisenberg, director of the federal Agency for Healthcare Research and Quality in Washington. "You have to be sure that once you have insurance, you get high-quality care."

Researchers offer two more explanations for the fleeting attention to the uninsured: their low voting rate and the public's ambivalence toward a government-run, universal health-care system.

"People still remember the Clinton health-care reform debate, and neither side is particularly interested in reliving those days," said Leighton Ku, a senior fellow at the Center for Budget and Policy Priorities in Washington.

Parkland's Dr. Ross said that he does not know how the problem of the uninsured will be solved, but that more people in positions of power will have to start talking about it first. "I think with all the other competing issues, it has not risen to the surface," he said.

But he predicted that eventually it would.

"Everybody has faith in this country," Dr. Ross said. "Ultimately, when it's time to do the right thing, people will figure out a way to do it."

Charles Ornstein reported from Washington, D.C., and Laura Beil from Dallas.