Uninsured in America:
Life and Death in the Land of Opportunity
Susan Starr Sered and Rushika Fernandopulle
University of California Press, 2005

Review by Margaret Foley

The statistic that over forty million Americans lack health care is constantly repeated in the media. Yet, in practical day-to-day terms, what does that mean? How does not having health insurance impact other areas of a person's life? These are some of the issues Susan Starr Sered and Rushika Fernandopulle examine in Uninsured in America: Life and Death in the Land of Opportunity.

The United States spends more per capita on health care than almost any other industrialized country, yet garners low marks when it comes to the overall health of its population. This is a direct result of the way health care has been apportioned over the last sixty years. Since World War II, health care coverage has been linked to employment. During the war, wages were frozen, and employers were searching for incentives to keep and recruit workers. Paid health care benefits became one of those incentives and, in fact, became the norm. The role of insuring health, which in many other countries is a function of the state, became tied to the private sector. As a result, the government had little incentive to develop a comprehensive healthcare system.

As the American economy has changed, so has the link between employment and benefits. Since people often no longer work for a single employer until retirement, jobs no longer provide "stable platforms for health care arrangements." Entire sectors of the economy, such as manufacturing, timber, and fishing, have disappeared, leaving many of those people with neither jobs nor benefits. Because medical, insurance, and pharmaceutical industries operate on a for-profit basis, health care costs have soared. For those who have insurance, there are no guarantees that they will continue to be covered.

As costs increase, employers look for ways to cut health benefits or to stop providing insurance altogether. When a person loses job-related insurance, most of the other options available are prohibitively expensive. As a result, people enter what Sered and Fernandopulle refer to as the death spiral, the inability to manage one's health and one's employment:

Because employment adversity is so thoroughly entwined with medical adversity, those caught in the spiral cannot amass either the bodily or the financial resources needed to break out. Descent through the death spiral, for millions of Americans, leaves irrevocable marks of illness on their bodies and souls.

There are any number of ways a person can enter the death spiral: divorce, corporate restructuring, plant closing, accident, disability, and chronic illness, to name a few. Anything that threatens employability affects health insurance. The negative aspects of job and insurance loss can multiply, particularly if others relied on the insurance and income. If one is ill or becomes ill, the lack of insurance creates its own Catch-22. If one is sick and cannot afford care, this can lead to chronic illness, which decreases the chance of finding a job, which in turn decreases the chances of being insured.

According to Sered and Fernandopulle, people who lack or lose access to health care become a separate caste. They use the word caste deliberately and in its traditional sense to describe a group of people who are characterized "by the absence of mobility" and by "recognizable external markers." When health affects employment and appearance, people lose the middle-class markers that define success in this country:

In a broader sense, the death spiral serves as a metaphor for the deep changes taking place in American society as the demarcation between rich and poor -- a traditionally fluid distinction in our society -- hardens into a static barrier between the caste of the healthy and the caste of those who are fated to become and remain sick.

Teeth are one of those caste markers. Healthy, white teeth are a sign of middle-class success. Almost everyone in the book said that if they were suddenly given health care coverage, the first thing they would is go to the dentist. For example, Sered and Fernandopulle interviewed Gina, a hair stylist, who lives in Idaho. Whenever she talks, she covers her mouth because she is embarrassed by her the condition of her teeth. Another woman, Loretta, is missing several of her teeth, lost due to the fact that she cannot afford to go to the dentist. Her solution to a toothache is to pull her teeth herself. "I've gotten toothaches so bad, so that I just literally pull my own teeth. They'll break off after a while, and they you just grab ahold of them, and they work their way out."

To collect their data, Sered and Fernandopulle interviewed 120 people living in Illinois, Idaho, Massachusetts, Texas, and Mississippi. One of the great strengths of their study is the personal stories they tell, the type of story that is often obscured in the larger debate around healthcare in this country, which revolves around cost-cutting measures and the benefits of one plan versus another, rather than what people actually need to stay healthy.

For example, Annette is a thirty-eight-year-old divorced mother of three and a victim of domestic violence. Her ex-husband beat her so badly that she still suffers from headaches and has problems with her vision. When her divorce became final, she lost the insurance she had through his employer. Her current job as an office manager does not provide benefits, and she goes to work even when she does not feel well for fear she will lose her income. She suffers from migraines, yet only receives treatment if the pain is so bad it sends her to the emergency room.

Alisha, who lives in Mississippi, has worked a series of low-paying jobs most of her life. She has been forced to come up with creative ways to take care of her health. She has asthma, but cannot afford the inhaler. If she needs one, she borrows her sister's. She also suffers from abnormal uterine bleeding and is unable to get regular treatment for it.

Other cases include a couple whose rust belt jobs have disappeared along with their insurance benefits, forcing them to decide on a monthly basis which medicines they will buy. There are people who suffer from treatable mental illnesses, yet are unable to afford the medications that would let them live normal lives. Still others must choose between buying groceries and buying diapers, must hope that kidney stones do not lead to renal failure, or must hope that a broken hand will still heal properly when protected by an Ace bandage, rather than a cast.

Some would argue that the United States does provide medical care to people without insurance through programs such as Medicare and Medicaid. However, these programs are not without their own difficulties. Medicare often does not cover all the costs of care, requiring people to use some of their own money to pay for care. In some cases, small changes in income can disqualify a person from participation in these programs. Many doctors will not accept patients on Medicare or Medicaid, leaving them without treatment they are eligible to receive.

In the United States, medical insurance occupies an odd niche. If people were told that in order to have automobile, homeowner's, and life insurance, they were required to have a job and that they had to accept whatever policies were offered, most people would cry foul. Yet, when it comes to health insurance, this, unfortunately, seems to be acceptable.

The paradox of the American healthcare system is that it does eventually provide care to the uninsured, but it does so at the moment it becomes the most expensive. While it is virtually impossible to see a doctor for preventive measures, no-one can be denied care in an emergency. It is easier to get care after one has had the heart attack than it is to visit a doctor to find out how to prevent it in the first place.

The obvious, yet politically loaded, solution to the health care situation in the U.S. is develop a system in which employment is not a prerequisite for insurance. This, in fact, is what Sered and Fernandopulle suggest:

Breaking the link between employment and health care will not fix all that is broken or right all wrongs. It will, however, help stop current inequalities from being irrevocable marked on our bodies and help prevent current injustices form hardening into a permanent caste structure.

One of the political mantras repeated over and over in the United States is the idea that citizens have rights which should be protected -- the right to privacy, the right to an education, the right to be safe -- the various modern manifestations of the right to life, liberty, and the pursuit of happiness. The irony is that good health, which makes the pursuit of all those possible, goes largely unprotected.

mmo : november 2005