Uninsured in America

Introduction

The Death Spiral

This book was born at a Harvard health care symposium when Rushika, a physician specializing in health policy, met Susan, an anthropologist who recently had returned to the United States after living for two decades in Israel and Japan, countries that have national health care programs. With the fresh eyes that an outsider sometimes can bring to a situation most of us take for granted, Susan asked Rushika: "Where are the bodies? If forty million Americans don't have health insurance, there must be a lot of bodies. I would think that American cities would look like Delhi or Calcutta, where trucks collect corpses from the streets each morning. Where is America hiding its uninsured sick and dying citizens?"

Rushika initially responded with standard answers: We have government programs such as Medicaid and Medicare. Many counties run clinics with sliding-scale fees. Our hospitals offer charity care to indigent patients. And, with the support of the Bush administration, churches have opened up faith-based clinics.

Yet, when the two of us began to look more closely at the statistics, we saw that these responses did not speak to the actual experiences of many people in our country. In 2003, Medicaid covered only slightly more than half of Americans whose family income was below 200 percent of the poverty line (that is, below $36,800 for a family of four). Public clinics typically are so overwhelmed that the wait for an appointment can be several months. Hospitals often fail to inform patients that charity programs exist, instead simply billing their uninsured patients and turning their accounts over to collection agencies. In fact, although the government requires not-for-profit hospitals to offer charity care, many hospitals avoid doing so by redefining the uncollectable debt as "charity care." And faith-based clinics, which were touted as a compassionate safety net to take the place of big government bureaucracies, usually seem to flounder, seeing patients only a few evenings each week and relying on volunteer physicians to squeeze in a couple of clinic hours a month on top of their already overflowing private practices.

So, we asked each other, where are the uninsured? Who are they? Why are they uninsured, and how do they scrape by? What does the absence of consistent access to medical care mean in their lives? What is its impact on their jobs, their families, their aspirations? And, equally important, what does the fact that more than forty million Americans lack reasonable access to health care mean for our country as a whole? How does the divide between the health care "haves" and "have-nots" reflect or contribute to other painful social and economic ills?

The Journey

Combining a medical perspective with the tools of anthropologyÑin-depth interviews and extensive "hanging around" with uninsured individuals and families (a technique anthropologists refer to by the more elegant name participant observation), we set out to meet Americans around the country who are scraping by without medical coverage.

During 2003 and 2004, we traveled to Texas, Mississippi, Idaho, Illinois, and Massachusetts, talking with those who determine health care policies as well as those who live (or die) by those policies. We spoke to people whose stories represent the more than twenty million middle-income families and the millions of working-poor families who are uninsured. We listened to Americans who had seen loved ones die because they did not have medical coverage. And we heard the stories of Americans who were forced to declare bankruptcy or sell their homes to pay for medical care. By the end of our journey, we had conducted wide-ranging interviews with more than 120 uninsured Americans and with approximately four dozen physicians, medical administrators, and health policy officials.

We met uninsured men and women through local churches, community organizations, friends, and colleagues; at yard sales, bars, and libraries; in lines at local pharmacies and grocery stores; and via notices tacked up in public places. One contact often led to another. Our conversations covered matters directly related to illness and medical care as well as more general personal anecdotes, family stories, political opinions, observations about neighborhoods and workplaces, and a fair amount of laughter and tears.

Not everyone we met wanted to speak to us. Some people were embarrassed that they were uninsured; some were too busy managing several part-time jobs. Other individuals, based on past experiences, had learned not to trust strangers who come asking personal questions. Still others simply were not interested in talking about private matters.

But many individuals welcomed the opportunity to speak their minds. For some of our interviewees, the $25 honorarium we offered represented their family's next few meals. Others appreciated the chance to talk to their heart's content to someone who really listenedÑit was important to them that we could witness the truth of their experiences. And some people made it clear that they agreed to talk to us because they wanted to help change the system by letting other Americans (often referred to as "the big shots in Washington") know how hard it is to get by without adequate health care.

Reflecting the common expectation that women are responsible for the health of their families as well as for their own health issues (which often are seen as more "complicated" than men's issues), many more women than men shared their stories with us. We met with twenty Hispanic families and twenty African Americans. These numbers echo the fact that Hispanics and African Americans are more likely to be uninsured than white Americans, though white Americans constitute the absolute majority of the uninsured. Our youngest interviewee was nineteen, and the oldest sixty-four; most were in the middle of that age range. People spoke with us about the health concerns of their entire families over periods of many years.

On our journey, we gained a better understanding of the legitimate economic forces that must, in one way or another, place some limits on health care access. We learned, too, what it means to be part of the group of Americans who have been involuntarily assigned by society to carry the burden created by those forces and whose bodies bear the scars of that burden.

The "Problem" of the Uninsured

The familiar phrase "the problem of the uninsured" conjures either an image of troubled, "problematic" individuals or the notion that these unfortunate persons constitute a "problem" for the rest of society. The real problem, however, begins at a far more basic level. The inability of a large portion of the U.S. population to access health care services in a systematic and medically competent manner is a consequence of social and economic developments that predate and underpin individual life histories.

Unlike the medical systems of most other Western countries, America's health care structure centers on an increasingly for-profit system of employment-based private insurance. Employer-sponsored health coverage expanded rapidly in the United States during World War II, when the shortage of civilian workers encouraged employers to look for creative ways to attract and retain employees. In order to prevent inflation, the War Labor Board put a ceiling on all wages. It ruled, however, that unions could bargain for health care benefits without violating the wage freeze. At the same time, the Internal Revenue Service ruled that health insurance premiums would be treated as a nontaxable business expense.

During the postwar era of economic growth, employment-based health insurance became the norm in the United States, and it indeed worked reasonably well for many Americans. During this period, millions of blue-collar workers held long-term union contracts guaranteeing health care benefits, and white-collar workers expected to remain with and rise through the ranks of the companies in which they built their careers.

In recent years, however, the relationship between employment and health care has become increasingly problematic. First, as the nature of employment has changed globally, fewer people are able to stay in the same job for many years. As a result, jobs no longer serve as stable platforms for health care arrangements. Second, the fragmented nature of the American health care system, together with the political dominance of the medical, insurance, and pharmaceutical industries, has allowed health care costs to soar far above the costs for comparable products and services in Canada, Great Britain, and continental European countries. As the cost of health care rises, more employers look for ways to avoid providing insurance to their employees. The millions who find themselves uninsured are now priced out of the health care marketplace.

For growing numbers of Americans, the convergence of these two developments means that their lives have become trapped inside what we call the death spiral.

How the Death Spiral Works

In insurance lingo, a death spiral occurs when a health plan starts attracting sicker patients, which causes the price of premiums to go up, which causes more healthy people (who have other options) to leave the plan, which causes the remaining pool to be proportionately sicker, which causes the price of premiums to increase even more, eventually resulting in the company going bankruptÑin other words, dying.

The image of a death spiral is a useful metaphor for thinking about the role of access to health care within the larger context of American social and economic life. Because employment and health insurance are tightly linked, job disruptions such as layoffs or firings, starting one's own business, or taking time off to care for small children or elderly parents can lead to the loss of health coverage. That loss can easily lead to health concerns going untreated, a situation that can exacerbate employment problems by making the individual less able to work. Alternatively, the downward spiral can begin with health problems that lead to employment problems, making it less likely that one will have health insurance and thus reducing the chances of solving the original health issues.

Whatever the starting point, once a person enters the death spiral, it is difficult to escape. Because employment adversity is so thoroughly intertwined 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.

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 poorÑa traditionally fluid distinction in our societyÑhardens into a static barrier between the caste of the healthy and the caste of those who are fated to become and remain sick.

Portals into the Death Spiral

Individuals are pulled into the death spiral through many different portals. Corporate restructuring, outsourcing, divorce, family crises, chronic illness, serious accidents, and racial discrimination open some of the most recognizable doors. Indeed, given the number and diversity of entrances, all Americans, except for a small number of extremely rich individuals, are vulnerable to the death spiral's pull.

The majority of people we met in our travels across the country lack consistent access to health care of reasonable quality despite having been employed all or most of their adult lives. Approximately one-third of the people with whom we spoke are well educated but have had the misfortune to end up in jobs that do not offer insurance: substitute teachers, adjunct professors, part-time social workers. These Americans have not chosen to be uninsured; rather, their employersÑlike Loretta'sÑhave found it cost-effective to reduce the number of permanent full-time positions while maintaining an unprotected pool of workers whose jobs by definition do not offer benefits.

Contingent workers now represent more than 25 percent of the American workforce. Some industries, such as the food industry, employ temporary, part-time, transient workers almost exclusively. Other industries retain some full-time employees but outsource certain jobs that were formerly performed in house. In the Rust Belt, manufacturing plants employ increasing numbers of temporary workers through temp companies such as Manpower. These job slots have replaced the full-time, unionized jobs of previous years, allowing employers to cut costs by not providing benefits. Those beginning their working lives are particularly hard-hit by the scarcity of jobs with good benefits: one in three young adults between the ages of eighteen and twenty-four in the United States lacks health care coverage.

Some people described in this book lack insurance because the industries in which they worked have all but closed down: mining, forestry, cotton fields, steel mills, or manufacturing plants that have relocated to other countries in order to tap into a lower-wage employee pool. Barely treading water, the workers left behind now labor in temporary jobsÑespecially in the service sectorÑthat do not offer health insurance. Unable to sell their homes in towns that have lost their economic foundation and then their population base, these workers are locked into futures that look grim indeed.

Some of the people we present are between jobs. Some are starting new jobs that require a six-month waiting period before insurance is available. Others work for such low salaries that they cannot afford insurance; still others work for employers who do not offer insurance at all. A small number of those we metÑtypically (but not always) the sickest, poorest, and oldestÑhave been able at one time or another to turn to the government for a program that provides access to health care. But far more simply fall through the cracks: they are not eligible for government assistance, and their employment situation does not make health insurance possible.

Some people in this book are uninsured because, like Greg, they struck out on their own and opened small businesses. With limited cash flow, especially during the first years of operation, health insurance is a fiscal impossibility. Others are uninsured because they work for a small business whose precarious financial situation precludes providing health benefits for employees.

Other portals into the death spiral originate in difficult, challenging, or shifting family situations. Many people have health coverage through their spouseÑwhich means that divorce can lead to a break in health care coverage. Several of the women we interviewed had fled abusive or violent marriages and thus lost their health insurance. One middle-aged woman explained to us that her health insurance disappeared when her husband of twenty years "traded me in for a new model." Other women lost their insurance when they had to quit work or reduce their working hours in order to care for aging parents, sick children, or disabled spouses.

Some people whose voices are heard in this book are unable to work because of chronic illness: back pain (perhaps caused by an earlier job-related injury), high blood pressure, mental illness. In some cases, these people would be able to work at jobs that do not demand constant physical stress, but such jobs simply are not available to them. Without employment, they cannot obtain the medication they need to manage their chronic illnesses, and so they find themselves caught ever more tightly in the death spiral. Most of the people we met work despite suffering from an assortment of chronic illnesses. In addition to the strain of working with pain or other symptoms, they live with fears about how they will manage if or when their conditions deteriorate. Indeed, we have come to see chronic illness as both a portal into the death spiral and an integral component of the descent pattern.

A small number of those with whom we spoke lack insurance because they do not understand how the health care system works. They do not quite grasp that they spend more money paying out of pocket for treatments and medicines than they would spend paying for insurance. A larger number of people understand the system only too well: they are caught between squabbling companiesÑhealth insurance, workers' compensation, and automobile insurance companies, for exampleÑwith each company claiming that the other should be covering the patient's medical costs. Often, the individual caught in the middle quietly goes bankrupt, paying out of pocket while the corporate bickering goes on.

Finally, we spoke to Americans who have health insurance but have been caught in the death spiral nonetheless. We do not address the issue of underinsurance in this book (the topic deserves its own comprehensive treatment), but we do note that even for people who have health insurance, systematic gaps in coverage (such as limited or nonexistent mental health or dental care benefits) can be disastrous. Because of preexisting condition clauses, many Americans find themselves not covered for the one condition that matters most. Moreover, many policies have high co-payments, holding the individual responsible for 20 percent or more of all bills in addition to a hefty deductible. Especially in cases of serious illness, 20 percent of a large bill can lead to the same outcome as not having insurance at all.

The Consequences of Scraping By

When we began mapping out this project, our initial working title was Scraping By: How the Uninsured Cope with the Health Care System. By the time we completed our trips to Texas, Mississippi, and Idaho, we had abandoned that title. First, we learned that, for most uninsured Americans, there is no health care "system." Rather, they deal with a blotchy and frayed patchwork of unreliable and inconsistent programs, providers, and facilities. Second, we learned that many, if not most, uninsured Americans are not scraping by very well at all.

Many of the people portrayed here either have had insurance or have been enrolled in Medicaid or another government program at one time or another. Others live in households in which some members (often the husband) are covered by employment-based insurance but others (often the wife) are not. Frequently, some family members (usually children) are eligible for Medicaid but others (usually parents) are not. All of our interviewees describe using a chaotic collage of health care servicesÑlocal emergency rooms, a private doctor when they can afford an office visit, a state or county clinic when their income is so low that they are defined as "indigent," a church clinic that operates one evening a week, if they are lucky enough to get sick on the day the clinic is open. No one reported having a family doctor who knows the medical histories of family members, who knows how the patient has responded in the past to particular medicines, who knows the family's risk factors, who has any inkling about the family's ability to follow through on medical instructions, or who is poised to provide any sort of health education, nutrition counseling, or continuity of care.

Such a sporadic approach to health care does not serve anyone well. Continuity of care is associated with greater use of preventive services and better control of many chronic illnesses, such as hypertension and diabetes. It also leads to fewer hospitalizations and to lower overall health care costs. Patients and physicians agree: patchwork care leads to poorer management of health problems and greater feelings of frustration all around.

Our interviewees routinely experience delays in getting care for a variety of medical problems. This means that small tumors may be left untreated until they become big and metastasize. Diabetes is not managed properly, leading to amputations, end-stage renal failure, and expensive dialysis treatments. Asthma goes untreated until the individual ends up unable to breathe, turning blue in the emergency room. Hypertension progresses until it becomes a completely disabling disease, preventing the individual from working. A small cavity in the tooth becomes a huge abscess, requiring an extraction. Sore throats become systemic infections, bladder infections become kidney infections, and earaches become the source of hearing loss. Americans without health insurance rarely go to the doctor for a checkup, rarely receive ongoing supervision of chronic problems, and rarely get treatment until pain becomes unbearable or intractable complications set in.

Without consistent access to competent medical care, uninsured Americans are left to their own devices to manage their health problems. Thus, Mexican Americans and Anglo Americans in the Rio Grande Valley cross the border into Mexico, where drugs that are prescription-only in the United States are sold over the counter. College-educated uninsured residents of Massachusetts often know someone who knows someone who knows a doctor who is willing to write a prescription or give out free drug samples without seeing or examining the patient. Across the country, many Americans take only half of a prescribed drug dose so that their medicine will last longer. They share prescriptions with friends and relatives. When their medicine runs low, they skip doses until they can afford a refill. And they play a high-stakes guessing game when they choose which of the several prescriptions ordered by the doctor they can afford to purchase in any given month.

In lieu of consistent and adequate medical care, most of the people with whom we spoke self-medicate in ways that would appall trained health care providers. Most noticeably, they take large and frequent doses of over-the-counter pain medications such as ibuprofen and Tylenol in order to get through the day or night. Many people we met live on homemade "cocktails" combining a variety of over-the-counter medicines, sometimes with alcohol or illegal drugs, in desperate hopes of feeling better.

The consequences of this hodgepodge of erratic treatment and self-medication are demonstrably negative. A recent review by the Institute of Medicine documented that the uninsured receive less preventive care and poorer treatment for both minor and serious chronic and acute illnesses. In many cases, they live shorter lives than comparable insured populations.

The financial impact of being uninsured is also negative and often extreme. The uninsured are commonly billed at higher rates. New York Methodist Hospital in Brooklyn, for instance, charges health maintenance organizations $2,500 for a two-day stay for an appendectomy, while uninsured patients pay approximately $14,000. Emergency room visits typically cost about four times as much as treating the same problem in a regular office visit. But many doctors will not see uninsured patients who owe money for previous visits, compelling these individuals to use the emergency room for all their health problems. Moreover, many hospitals charge interest at higher than market rates on the debts patients accrue, which means that even a simple hospitalization can turn into a ten- or twenty-thousand-dollar debt. Serious or prolonged illness can lead to debts that seem almost preposterousÑsome of the uninsured men and women we met owe as much as $200,000 or more.

Most of our interviewees owe money that they will never be able to pay to a variety of hospitals and clinics. While some hospitals have charity care programs that provide free services for the indigent and the poor, many (including not-for-profit hospitals) simply bill the patients and then sell the accounts to a collection agency thirty or sixty days later for ten to fifteen cents on the dollar, allowing the collection agencies to work as they see fit. As a consequence, just about everyone told us about receiving threatening letters and harassing phone calls from collection agencies. Their credit ratings are ruined. Most fear going back to these medical facilities, and they are cross-examined if they do return. Some people are able to shrug off the harassment; others cannot sleep at night. Some scrape together small monthly payments of $20 or $25, knowing (or not) that it will take them a century or more to pay off the debt; others become so discouraged that they abdicate responsibility for their own health, throwing their hands in the air, literally or figuratively.

Health care has become a leading cause of personal bankruptcy in the United States. Of the record 1.57 million personal bankruptcies filed in the United States in 2002, between one-third and one-half resulted from medical bills.

Claudia Lennhoff, executive director of Champaign County Health Care Consumers in Illinois, has seen local hospitals garnish patients' wages, put liens on their homes, and sue them in court. "What we see, the people who are in court, are overwhelmingly poor people, and the hospitals know this and the providers know this. Sometimes, some of the people in court, if you look at their records, you will see that they are the hospital's charity care patients. They actually already have qualified for and received some charity care, so the hospitals are suing their own charity care patients!"

Some hospitals have been known to implement even more drastic measures. Hospitals in Connecticut, Indiana, Kansas, Michigan, and Oklahoma have arrested and jailed uninsured patients who failed to appear for court hearings concerning their debt, a tactic known in the legal community as "body attachment." YaleÐNew Haven Hospital, for instance, took such action sixty-five times in a recent three-year period, from 2001 through 2003.

From Class to Caste

As more and more Americans are drawn down into the death spiral, we are witnessing a fundamental shift in the nature of American society.

In sociology courses in the 1970s and 1980s, we were taught that the vast majority of Americans identified themselves as middle class. In fact, we were told, so many Americans were middle class that the United States had essentially become a classless society. Our college professors further explained that money itself was not what led Americans to regard themselves as middle class. After all, a secretary earning $25,000 a year and a lawyer earning $250,000 clearly had very different levels of purchasing power and disposable income, yet both considered themselvesÑand were considered by othersÑto be middle class. Rather, what made most Americans middle class was a set of social and cultural understandings.

Middle-class Americans saw themselves as part of the American mainstream. They shared American values of family and work, they saw themselves as economically upwardly mobile, and they believed themselves the social equals of almost all other Americans. Perhaps most important, millions of middle-class Americans followed the same clothing fashions, chose the same hairstyles, spoke in similar accents, shared the same standards of "beauty," andÑat least superficiallyÑlooked like members of the same social grouping. In other words, the outward markings of the middle class were more or less the same for the secretary and for the attorney: one would have to look at the labels hidden inside the shirt to know whether it was an expensive designer blouse or a cheap knock-off.

The concept of caste, we were taught, differs from the idea of class in significant ways. Using India as the example of a caste society, our professors explained that caste systems are characterized by the absence of mobilityÑyou are stuck in the caste into which you are born. Caste tends to be institutionalized through recognizable external markers such as clothing or hair. Caste also is occupationally framed: the so-called untouchables in India, for instance, members of the lowest caste, were connected with the most basic human functions and performed work that put them in contact with waste, sickness, and death. Finally, the caste system is construed as a moral system: in India, lower-caste members were considered "polluted," whereas members of the highest casteÑBrahminsÑwere associated with lofty pursuits and moral virtues. In an important sense, class is about what one has, while caste is about what one is.

The current American system in which health care is linked to employment is creating a caste of the chronically ill, infirm, and marginally employed. Because health care is so tightly linked to employment, once an individual or a family is caught in the death spiral, it is nearly impossible to find a way out. Unemployable or marginally employed because of poor health, members of this new "untouchable caste" are denied consistent access to medical care. Sick, lacking reliable health care, and locked in employment situations (especially in the service sectorÑthe same sector to which India's untouchables were consigned) that do not offer medical benefits, they find it increasingly difficult to escape.

What about the other typical traits of caste systems? Does this new American "untouchable caste" carry outward markings on their bodies? Illness itself constitutes a physical marker: rotten teeth, chronic coughs, bad skin, a limp, sores that don't heal, obesity, uncorrected hearing or vision deficits, addiction to pain medicationÑall of these signal caste in basic ways.

Echoing the classical Indian caste system, membership in the American caste of the ill, infirm, and marginally employed carries a moral taint in addition to physical markings and occupational immobility. This taint is a product of the moral value that American society has traditionally placed on productive work and good health. Work has long been construed as a moral virtue; we need only think of the generations of American women who embroidered samplers proclaiming that "idle hands are the devil's playthings."

Uninsured Americans around the country noted the stigma of lacking health insurance, citing medical providers who treat them like "losers" because they are uninsured. Similarly, the providers we spoke to emphasized the problem of "noncompliance" among the uninsured, complaining about "difficult" patients who don't follow the instructions of physicians. Sickness increasingly seems to be construed as a personal failureÑa failure of ethical virtue, a failure to take care of oneself "properly" by eating the "right" foods or getting "enough" exercise, a failure to get a Pap smear, a failure to control sexual promiscuity, genetic failure, a failure of will, or a failure of commitmentÑrather than society's failure to provide basic services to all of its citizens. The belief that illness is a marker of personal failure, together with popular images of the unemployed as unworthy "bums" or "welfare queens," functions as ideological glue that makes the link between health care and employment appear sufficiently rational to stand up to decades of efforts to change the health care status quo.

We hope that our use of a term as heavily laden as caste will stimulate meaningful public discussions regarding where our current health system is taking us as a social entity. We recognize that we are not writing about a caste system in the legislative sense that characterizes traditional Indian society. Rather, we have chosen to introduce the language of caste to describe a social arrangement that is emerging de facto from the political economy of our country at this time. As writers, we embrace the shock that readers may feel at hearing the term caste uttered in relation to American society. An intellectual jolt often is needed to recognize the cumulative impact of incremental cultural and economic changes such as those that have occurred in the United States over the past decades.

Devon, a recent college graduate we met in Massachusetts, offered a take on class and caste in America that was markedly different from the one we learned during our own college days. Speaking about what it means to scrape by without health insurance, Devon said: "I just feel that the way the system is set up is like a bizarre version of natural selection, where the people who are poorest can't afford to keep themselves healthy, and so they die."

Where Are the Bodies?

Many portals lead into the death spiral, but few lead out. The sick and dying bodies that Susan asked Rushika about are hidden inside the death spiral, in three primary locations.

Where do we hide the bodies? In emergency rooms and end-stage hospital wards across the country.

America's hospitals are legally obligated to stabilize the condition of emergency patients and to treat any life-threatening condition regardless of the patient's ability to pay. Emergency rooms are not, however, required to provide any definitive treatment or any therapy to prevent the condition from recurring. For those who are pronounced terminally ill, the Social Security disability program provides health care services through Medicare. Thus, we do not provide care to prevent emergencies or to stave off terminal illness, but we do offer a place to land at the bottom of the spiral.

We don't see corpses on the streets of Chicago or Des Moines because when people get sick enough, they are hidden in emergency rooms and end-stage treatment wards. In a bizarre economic and ethical twist, the chronically ill, if they are uninsured, are allowed to deteriorate to the point at which hospitals are legally required to take them in. They are covered if they have terminal cancer or renal failure, but not before.

Where do we hide the bodies? In homeless shelters across the country.

People we met spoke with terror about losing their homes. Medical debt can lead to liens on one's house or to bankruptcy, and illness disrupts household income and interferes with rent or mortgage payments. In what we see as a classic death spiral dance, once you are homeless, your health deteriorates further (shelters are hardly healthy places to sleep), and your outward appearance makes you unemployable (homelessness limits opportunities for personal grooming and care of clothing), thus making it less likely that you will find a job with health care benefits.

Only a small number of our interviewees had experienced periods of true homelessness, but many spoke about tough times during which they had to move in with relatives or forego necessities in order to pay their rent or mortgage. Even more, including those who looked and sounded "middle class" and whose incomes over the years had been in the range of $35,000 a year, spoke in hushed tones of the fear of losing their homes. These people understand that a middle-class income does not provide adequate protection in case of illness or job loss. Those who have more resourcesÑfinancial, educational, family, and communityÑavailable to them are less vulnerable, but for most Americans (all but the very richest), enough disasters clustered together can spell an inexorable downward descent.

According to a recent study of homeless shelters in New York City, the death rate among homeless men and women was four times greater than the death rate among the general U.S. population.

Where do we hide the bodies? In prisons across the country.

Studies show that morbidity rates among America's prisoners are extremely high. This is especially true of those with mental illness. Indeed, the Washington Post in 1999 reported that more than 280,000 mentally ill people were locked up in our nation's jails and prisons and that the Los Angeles County Jail and New York's Riker's Island were the country's two largest "treatment facilities" for the mentally ill.

In a pattern typical of the death spiral, we fill our prisons largely with people who have committed petty (mostly drug-related) crimes. We reclassify many of these crimes as felonies, which means that, once released, the former prisoners cannot find reasonable employment. Thus, they lack access to health care, which means that they get sick(er), which means that they need to find waysÑlegal or notÑto obtain life's necessities, including medication. And they end up back in jail, sicker than before.

The likelihood that prison will serve as a repository for sick bodies is not distributed evenly across the American population. Men more than women, African Americans more than whites, and the mentally ill more than the physically ill are in danger of finding that their death spiral slide ends behind bars.

Severing the Link between Employment and Health Care

Seeing the death spiral in action in the lives of men and women across the country has convinced us that, as a society, we must cut the link between employment and health care in order to prevent millions of Americans from being sucked into a lethal vortex of ill health, medical debt, and marginal employability. The link between employment and health care might have made sense when it was fashioned in the 1940s. But in the new millennium, new conditions make the link counterproductive at best, and deadly at worst. Employment patterns are changing, resulting in less job stability, weakened labor unions, and the movement of jobs into the low-wage service sector. Family dynamics are different: fewer people now live in conventional nuclear-family households, for example. And even the nature of illness has changed, as ever greater numbers of people suffer with chronic illness. In today's world, potential portals into the death spiral are too numerous, too diverse, and too unpredictable for patchwork safety nets to be sufficiently protective.

We learned an additional lesson on our journeyÑone that crystallized as we monitored our own reactions to the people we met and the stories we heard. We discovered that the death spiral intensifies as more people fall through its portals and that its growing strength reaches throughout our society, to affect both the insured and the uninsured.

If millions of American children do not have reliable, basic health care, all children who attend American schools are at risk through daily exposure to untreated disease. If millions of restaurant and food industry workers do not have health insurance, people preparing food and waiting tables are sharing their health problems with everyone they serve. If uninsured residents of Texas routinely take unregulated courses of antibiotics from Mexico, antibiotic-resistant bacteria will develop and threaten us all. If tens of millions of Americans go without basic and preventive care, we all pay the bill when their health problems turn into complex medical emergencies necessitating expensive and specialized treatment. And if we condone a health care system that contributes to the formation of an untouchable caste of the ill, infirm, and marginally employed, all of us, as a society, will lose the right to feel pride in the democratic values that we claim to cherish.

For these reasons, we have come to believe that the most efficient and effective way to break the power that the death spiral holds for so many Americans is to make the provision of basic, comprehensive health care a public rather than a private responsibility.