In late 2008 many pundits predicted that the failing economy would make it impossible to commit the initial cash outlay required for the health care reforms promised by President-elect Barack Obama. Others, however, suggested that the added financial stress on consumers and providers only increased the need for urgency, and 62% of voters surveyed by the Kaiser Family Foundation (KFF) early last October said that the consequences of the economic downturn made it "more important than ever to take on health reform." The KFF surveys also revealed that one in three American families had struggled to pay medical bills in the past year.

Soaring costs, tough choices. Layoffs continue to rise in nearly every industry. Meanwhile, research by the KFF found premiums for employer-sponsored health insurance for families have doubled since 1999. In reports on the reversal of the decade-long increase in spending on prescription medications, the New York Times and Philadelphia Inquirer revealed that some patients were rationing or halting their use of expensive medications, even when those medications were crucial to their physical or psychological health. The Washington Post reported that patients were skipping screening tests such as colonoscopies and magnetic resonance imaging scans, even when the short-term savings could contribute to long-term catastrophe and higher costs to the health care system. In addition, more Americans went into medical debt, tapped into retirement funds to pay medical bills, and had to choose between needed health care and groceries or mortgage payments.

Insurance by default. The cost of buying insurance on the open market also continues to increase. And although a report from the U.S. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2007, showed that the ranks of the uninsured actually decreased from 47 million in 2006 to 45.7 million in 2007, that news isn't necessarily as good as it might seem. As more people become poorer, the number who are eligible for public health programs increases. In fact, nearly 3 million Americans were added to the rolls of public health programs such as Medicare and Medicaid from 2006 to 2007, and the percentage of Americans with employer-sponsored health insurance declined.

According to the American Public Health Association (APHA), states are already struggling to fund many public health programs, such as Medicaid and the State Children's Health Insurance Program. With growing budget deficits and ever-increasing numbers of enrollees depending on such programs, this situation may soon reach critical mass. A study published in the journal Health Affairs and cited by the APHA projected that in 2008 public health programs would be saddled with the bill for $75 billion in "uncompensated care" delivered to the un-or underinsured-a sum that could have gone a long way toward meeting the new administration's goal of providing health insurance coverage to every American.

Figure. Peggy Hicks sits in the living room of the Fort Meade, Florida, home she shared with her husband for 28 years, Eddie Hicks, who died in August 2007 from colorectal cancer. Because Hicks was uninsured he had trouble getting the chemotherapy that might have extended his life. Photo credit: Associated Press/Steve Nesius

Jacob Molyneux

Senior Editor