All The Pieces Are There, But How Do We Put Them Together?

In 2006, approximately 609,600 Alabamians Ð'- including 63,570 Alabama children Ð'- were uninsured. As alarming as those numbers are, they pale in comparison to the national figures: 44,153,999 uninsured Americans and 8,587,948 uninsured children. These figures from the United States Census Bureau begin to shed light on the health care crisis that has been building for years.

In 1993, then First Lady Hillary Clinton spearheaded the first major effort towards universal health care in the country. Despite grand intentions and widespread initial support, the Clinton health care plan became a victim of other priorities, secret deliberations, party-line attacks, and ultimately, in the face of Whitewater hearings, the plan ended up becoming too complex and convoluted, leading it to a very subdued end in 1994 (http://www.upenn.edu/pnc/ptbok.html).

Since then, there have been small steps towards providing better health care options for select groups of Americans; in 1998, Alabama became the first state in the nation to have its' Children's Health Insurance Program (CHIP) expansion approved, providing coverage for thousands of otherwise uninsured children. From 1997 through 2005, the availability of this program and Medicaid combined to influence a 33% drop in the number of low-income, uninsured children from 23.3% to 14.9% (Lambrew 2007). In Alabama alone, this program Ð'- called AllKids Ð'- has provided coverage to nearly 186,000 children, and as of April 2007, the number of uninsured Alabama children had fallen to 7.2%, far below the national average of 11.5%. However, at the end of this fiscal year, this program will expire, and it has been a heated issue between Congress and the President. Twice the House of Representatives has passed legislation to maintain and increase funding for the program, and twice President Bush has vetoed the bill, insisting that there should instead be cuts to the funding. The House has been unable to override the veto either time.

On the other end of the spectrum are the nation's elderly, who are in theory covered and protected by Medicare. However, according to the American Association of Retired Persons (AARP), Medicare premiums have more than doubled in the last eight years, costing seniors more money out of pocket. The cost of prescription medicines has increased significantly, a fact that hit many seniors extremely hard in January 2006 with the rollout of the Medicare Part D prescription drug plan. In addition to increased deductibles and co-pays Ð'- particularly for those who had been covered by both Medicare and Medicaid Ð'- there was a lot of confusion and misunderstanding among not only recipients but also those who were "expected" to understand, such as pharmacists. Coupled with computer glitches and poorly communicated glitches, the change was anything but smooth and saw many seniors facing the reality of not having the medications that they required (Rovner 2006).

As bad as those two situations sound, the fact is that the two extremes are far better off than those in the middle. In 2005, the number of non-elderly uninsured in the United States reached a new high at 17.2%. Amazingly, even with the numbers soaring there is still a misconception about "who" is without health coverage. The uninsured American does not fit what most people would expect: 80% of uninsured Americans are in working families, and more than 32 million had household incomes of at least $25,000 per year; only 14.6 million uninsured earned less than that per year. Half of all uninsured Americans are non-hispanic whites, and 23.1% worked in companies with more than 500 employees. But the most frightening reality is that nearly 18,000 Americans die each year as a result of not having health insurance (http://covertheinsured.org).

In the healthcare industry, the department most critically impacted by the health care crisis is the Emergency Department. Because the emergency room cannot refuse treatment to anyone requesting treatment for a medical condition, it becomes a refuge for uninsured people who otherwise cannot afford to see a physician. The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent "dumping" of patients and to insure that anyone in an emergent situation receives care regardless of their ability to pay; however, this legislation that protects those who are truly in need of medical care also comes full circle to play a part in actually harming the uninsured. Just like the elderly, these "middle of the road" Americans are faced with rising healthcare costs at the same time that the Centers for Medicare and Medicaid Services (CMS) has continually decreased the amount that they are paying providers in reimbursement for services provided to Medicare patients. Far from affecting only Medicare and Medicaid recipients, this has much farther-reaching effects because more often than not, many private insurance companies follow suit and adjust their payment guidelines to fall closer in line with CMS payments, which in turn decreases the amount paid to