Covering the Uninsured Is America's Problem

May-June 2007


Dr. Tersigni is president and chief executive officer, Ascension Health, St. Louis.

The Current Health Care System Makes No Moral or Economic Sense

Almost 45 million people, about one in every seven Americans, lacked health insurance in 2005. If more current data were available, the number of uninsured surely would be significantly higher. Since 2000, the ranks of the uninsured in America have increasingly swelled, with the most significant recent coverage losses affecting poor children and working adults. Another 40 million Americans now find themselves uninsured during some part of every year. Still another 80 million people will discover, if they experience a serious illness or accident, that they have inadequate insurance.

With nearly half of our population possessing either inadequate insurance or none at all, lack of coverage has become a problem not of the poor, the misfortunate, or someone else — it has become America's problem, and it has reached a crisis state calling for an immediate and shared response.

Study after study documents the consequences of being uninsured, for both the affected individuals and for communities in which they live. According to the National Center for Health Statistics, uninsured Americans are nearly eight times more likely than those with private health insurance to skip obtaining health care services, because they are unable to afford it.1 Such people may face serious health consequences as a result of delaying or failing to get timely and effective health care. Lack of insurance has a larger negative impact on almost all aspects of health care quality and access than does race, ethnicity, income, and education, according to a recent study by the Agency for Healthcare Research and Quality.2 Most troubling of all is the Institute of Medicine's finding that 18,000 Americans die unnecessarily each year because they lack insurance.3 In the wealthiest nation in the world, these current realities are simply unacceptable.

The fact that millions of Americans are risking their health through delayed or inadequate care because they lack insurance is a terrible waste of precious human resources. Because so many people who are uninsured lack a "medical home," they are likely, once they do access medical services, to receive care that is fragmented, inefficient, and expensive. A Commonwealth Fund study found that more than one in five adults who were uninsured for any time report being given a duplicate test.4 This is twice the rate reported by continuously insured adults. As leaders in the health care field, we know all too well that many uninsured and underinsured Americans rely heavily on hospital emergency departments for the most basic primary health care services. In those cases, the care is compromised because the patient's medical records are rarely available, and the costs are high.

This is bad public policy. More important, something is morally wrong when:

  • More than twice as many women without health insurance as those with insurance have not had a mammogram for two years.
  • Seventy-six percent of uninsured men aged 40 to 64 have not had a prostate-specific antigen test to detect prostate cancer for two years.
  • One in five of all working-age adults, insured and uninsured, has medical debt he or she is paying off over time. Of these, more than half have bills totaling more than $2,000.5

The tragic truth is that today's American health care system fails to serve many who rely on it. In fact, it can lead the uninsured on terrifying, complicated journeys in search of the type of help that is immediately available to those of us with the means to pay. We all should agree: It's not right and it's not acceptable.

It also makes no economic sense for our communities or for our nation as a whole. When people who lack insurance manage to obtain treatment, someone must pay. So everyone's costs go up. This cost shift is reflected in the health insurance premiums paid by those of us able to obtain and afford health insurance. It is reflected in the costs of our health care and social safety net programs, which strain to meet the rising demands of unmet medical and associated health needs. Also, it is reflected in the price of goods and services produced within our borders.

Although the problems associated with lack of insurance persist from year to year, they cause little in the way of public outrage. Recent opinion surveys indicate growing concern, but the intensity of feeling that helps to galvanize political action is not yet apparent. Perhaps Americans have grown too accustomed to the numbing facts. Perhaps the public's expectations concerning politicians have become too modest. Whatever the cause, the nation has a critical need to identify the leaders who will drive action and develop a solution to this problem.

For 100 Percent Access
About four years ago, we at Ascension Health made a promise to those we serve to provide "Healthcare That Works, Healthcare That Is Safe, and Healthcare That Leaves No One Behind." We refer to this promise as our Call to Action, a statement of our commitment to work systematically and aggressively to advocate the sweeping health care changes we believe are desperately needed in our nation. Our planning horizon at the time we introduced our Call to Action extended five years, through 2008.

More recently, Ascension Health has reconfirmed its commitment to this Call to Action as the foundation of a comprehensive Strategic Direction that sharpens our view of the long-term future of health care and extends our planning horizon through 2020. Our Strategic Direction envisions a transformed future state for both Ascension Health and health care in the United States, one that we believe will help ensure a strong, vibrant Catholic health ministry. We believe that this transformed state will come about through a combination of inspired people, trusted partnerships, empowering knowledge, and a vital presence in the communities we serve.

The third element in our Call to Action — "Healthcare That Leaves No One Behind" — refers to the centuries-old commitment of Ascension Health's sponsors, four provinces of the Daughters of Charity of St. Vincent de Paul, the Sisters of St. Joseph of Nazareth, and the Sisters of St. Joseph of Carondelet, groups of women religious that have long given special attention to people who are poor and vulnerable.

Ascension Health has made a commitment to 100 percent access. What do we mean by that? We intend to create a logical, direct journey — the best journey — to improved health outcomes for individuals and communities. We will exercise our leadership power as agents of change to create that journey. And we will define and administer our role in building a sense of belonging. When a person is sick, that person wants to feel safe, welcome, and that he or she belongs. He or she does not want to feel like a Ping-Pong ball batted back and forth among health care facilities that are unable to communicate with one another.

To guide our Strategic Direction commitment to achieving 100 percent access, Ascension Health has developed six principles for transforming health care:

  • We are committed to access for all.
  • We believe that health care is a right required for human dignity.
  • We reject a "two-tiered" health system that separates those who can pay for services from those who cannot pay.
  • A comprehensive solution to finance the care of the uninsured and underinsured is the shared responsibility of public and private partners at the local, state, and national levels.
  • Health care systems must redesign care delivery to achieve safe, accessible care for the uninsured.
  • To achieve access to health care for all, a new model of access leadership involving inclusive, "ego-less" collaboration is required.

Although principles help guide an organization's agenda, they mark only a beginning. Ascension Health has developed a five-step approach to 100 percent access. We have engaged our local Health Ministries* in acting on this model, and we have begun to demonstrate results from its implementation.

*Ascension Health refers to each of its local integrated delivery networks as a "Health Ministry."

Building a Formal Infrastructure Step one of our approach is building a formal infrastructure that can support safety-net services for the uninsured and underinsured in the communities we serve. Doing so involves gathering together committed leaders, sharing information systems so that uninsured patients are tracked wherever they receive care through life-long electronic health records, and raising the money necessary to get the 100 percent access model started locally.

Filling Service Gaps Step two is filling important gaps in existing safety-net services, especially dental, pharmaceutical, and mental health services.

Developing and Implementing a Care Model The third step is developing and implementing a care model for the community's uninsured population that stresses effective coordination of services throughout the continuum of care.

Recruiting Physicians The fourth step is recruiting private physicians in the community to volunteer to provide "medical homes" and specialty care for uninsured patients.

Generating Sustainable Funding The fifth step is generating funding from all involved — state and local governments, the business community, and individuals — to sustain the 100 percent access initiative for the long term.

More than $31 million in federal grant funds have been invested in Ascension Health access models in cities across the nation, and we have matched the federal money with approximately $10 million of our own. Close attention is paid to each of the dozen sites. Our Health Ministry CEOs' at-risk compensation is tied to increasing their commitment to provide care for people who are poor in the communities they serve. The lessons learned from these collaborations are being shared across our national health ministry.

In addition to the efforts noted, each Health Ministry leadership team is committed to completing our Access Leadership Planning Program. This means that each of our Health Ministry leaders has committed him- or herself to creating, in collaboration with other community leaders, a blueprint for achieving 100 percent access. Our leaders are from regional health centers, large urban hospitals, and small rural health ministries in various parts of the country — women and men with varying experiences and expertise, all working to build a common basis of understanding and to develop a common terminology and set of tools to use in improving access to health care. We anticipate that within three years all Ascension Health CEOs will have developed access leadership plans for their communities.

Because we believe that transforming our leaders is so important to achieving 100 percent access, I shared the Ascension Health model of access leadership with the 91st Catholic Health Assembly in June 2006. Through this model, our leaders come to integrate the competencies necessary to catalyze 100 percent access into their day-to-day work. This transformation of our leaders is foundational to what we are and where we want to go as a national health ministry.

Where is Health Reform Going?
In my discussions with business leaders, I hear growing frustration. They believe they are doing their part by providing their employees with health insurance. They also recognize that they are paying for all the uninsured through cost-shifting. Many are cutting back on their benefit plans and shifting costs to their employees; others have stopped offering benefits altogether. The steady erosion of employer-based coverage can only lead to heightened health care insecurity for the 160 million Americans who rely on their jobs for health insurance. The escalating burden of financing our major health care entitlement programs — Medicare and Medicaid — brings the sustainability of those programs into question.

The problems we Americans face in our health care system stem from the health care financing structure that we have today. A hodgepodge of public and private sector policies has evolved into a way to finance health care for those Americans fortunate enough to have privately, or publicly-sponsored health insurance, and for those who access our health care safety net. This financing system distinguishes us from countries, primarily those in the developing world, in which the poor, the sick, and the disabled are left to fend for themselves, often with tragic consequences. With a few exceptions, however, we remain unique among industrialized nations in failing to provide for universal coverage.

Until the United States has a true health care policy — not just a health care financing policy — those of us who provide care for the uninsured will continue to shoulder the growing cost of unfunded care. At some point, the status quo will become unsustainable. I believe that we have reached this point.

Our nation's lack of a health care policy contributes to billions of dollars wasted on duplicative, inappropriate, or poor quality services; excess paperwork; and high administrative overhead. Although estimates of the costs vary widely, we know that, whatever the precise amount, much could be saved from systemic reforms. Those savings could be reinvested in covering the uninsured and improving the overall performance of the health care system.

We Americans have developed intricate ways to pay for health care, but we have not stepped back to ask how we can transform the current system into our vision of what health care should become.

We need to achieve access for all, but we need to do so in a way that is sustainable for our economy. Getting there will require partnerships between public and private leaders, providers and consumers, and employers and employees.

I am encouraged to believe that we can get there because I see the beginnings of change. Indeed, I think we may have reached that "tipping point" because businesses, health care providers, labor unions, political leaders, consumers, and others are beginning to unite behind action to cover the uninsured. A most important sign is that states all over the country are stepping up to develop solutions. Maine, Vermont, and now Massachusetts have enacted comprehensive reforms with the objective of insuring all of their citizens. Illinois has begun implementing changes designed to achieve 100 percent coverage for all of its children. Most recently, comprehensive reform proposals have been announced by the governors of California and Pennsylvania. According to a recent survey by the Blue Cross Blue Shield Association, most states are working to expand coverage of uninsured children, and a dozen states will debate bills in their legislatures this year to provide subsidies to employers that offer health insurance to their employees for the first time.6

Some may argue that these state efforts are destined to fail; at best, they provide for short-term fixes that will unravel once state economies, now in their best fiscal shape since 2000, take a turn for the worse. I am more optimistic. I applaud these state efforts for the innovation and leadership they bring to the national debate. They show the good that can result when leadership brings all of us to the table and we become willing to give up something in order to collectively achieve a greater good for our communities and our nation as a whole.

Other signs also give me hope. Stakeholder groups that often are at odds with one another are coalescing to present Congress with a unified front in urging federal action on health reform.

One such initiative, in which Ascension Health is a participant, is the Health Coverage Coalition for the Uninsured. Sixteen influential national organizations that often have been on opposing sides in previous national health reform debates have come together to press Congress to act on a two-phased consensus proposal. Its first phase, aimed at shaping reauthorization of the State Children's Health Insurance Program (SCHIP) is a "Kids First Initiative." This initiative would both make it easier for parents to enroll their children in public programs like SCHIP and Medicaid and also provide for a new tax credit that helps families cover some of the cost of providing children with private health insurance. A later phase of the proposal seeks to expand coverage for low-income adults.

Another sign of progress is the recommendations sent to Congress and the president last fall by the Citizens' Health Care Working Group. Mandated by Congress, the Working Group, which was chaired by Patricia Maryland, DrPH, an Ascension Health leader and president of St. Vincent's Hospital and Health Services, Indianapolis, met with citizens from around the country to learn their views on the state of our health care system and options for reform. Congressional hearings on the Working Group's recommendations, the first of which is that all Americans have affordable health care, could serve as a springboard for a more focused national debate on more concrete proposals.

Yet another indicator that the tide has turned is an initiative called "Divided We Fail." Sponsored by AARP, the Service Employees International Union, and the Business Roundtable, it will stage coordinated activities to spur federal action on health care, including town hall meetings in the major presidential primary states. The initiative also will promote joint personal appearances and the submission of opinion pieces to newspapers by representatives of the three organizations.

Perhaps the most important sign of progress is the opportunity for serious national debate on covering the uninsured and health reform offered by the 2008 presidential campaign. Ascension Health, and the health care community in general, should work to see that every presidential candidate addresses how he or she plans to provide for 100 percent access to coverage.

I personally am committed, as a citizen and leader of one of the nation's largest health delivery systems, to work collaboratively with any serious effort to move toward 100 percent access. It is not the time to be partisan, nor is it the time to push a personal agenda. It is, instead, the time to come together — to collaborate in finding the solution to one of our nation's most serious challenges.


  1. Citizens' Health Care Working Group, The Health Report to the American People, March 31, 2006, p. 2 (www.citizenshealthcare.gov/healthreport/healthreport.pdf).
  2. Agency for Healthcare Research and Quality, Key Themes and Highlights from the National Healthcare Disparities Report, updated January 2007 (www.ahrq.gov/qual/nhdr06/highlights/nhdr06high.htm#intro).
  3. Institute of Medicine, Fact Sheet 5: Uninsurance Facts and Figures, updated January 13, 2004 (www.iom.edu/cms/17645.aspx).
  4. S. R. Collins, et al., "Gaps in Health Insurance: An All-American Problem: Findings from the Commonwealth Fund Biennial Health Insurance Survey," Commonwealth Fund, April 2006, p. 14 (www.cmwf.org/usr_doc/collins_gapshltins_920.pdf).
  5. Collins.
  6. Blue Cross Blue Shield Association, State Legislative Health Care and Insurance Issues, February 2007.


Copyright © 2007 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Covering the Uninsured Is America's Problem

Copyright © 2007 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.