HEALTH CARE/Joan Retsinas

America's Dwindling Middle Class

Behold America's dwindling middle class. On paper the middle class is robust. Median household income is up -- though more members of a family are working to bolster that income. And people are working longer hours. Western European workers often take month-long vacations in the summer; American workers are more likely to take weekends off. A few might squeeze day trips into hectic work schedules.

But the middle class scourge is expenses. The costs of daily living are soaring. Fuel to heat homes, electricity to cool those homes, gas to run cars, which you need to take you to work -- all cost more this year than last year. Next year, forecasters predict no reversal: The direction points "up" for outlays.

And each year a new outlay creeps upward: health expenditures.

In the grand old days of everybody's parents, being "middle class" meant you had health insurance through work. That insurance cost you little (sometimes nothing), was comprehensive and left you with no after-the-fact bills. There was an era of $10 newborns: Insurers would pay for prenatal care, delivery and postnatal care. Maybe the family would get a bill for a telephone in the hospital. Maybe not. Ditto for major surgeries: The itemized bill might run to five figures, but the discharged patient would chuckle at the $0 owed under "patient balance," relieved at his good fortune to work for a beneficent employer who provided a beneficent policy.

Those days are gone.

Today workers pay a portion of premiums. For some workers, the premiums are so high that they decline coverage, opting to be uninsured rather than pay the premiums. Those workers' decision is not irrational. On a $35,000 annual income, $4000 for a family policy won't leave much for housing, food, utilities, gas.

Insured workers pay deductibles -- $500 is common, but deductibles can go into the thousands. Workers also have co-payments for office visits, hospitalizations and medications. Policies deny coverage for some conditions and treatments. Cardiac rehabilitation, facial reconstructive surgery, dental surgery, newer medications, colonoscopies -- these are not standard in all policies. Most enrollees don't know what their policy excludes until they need a treatment. Only then do they discover the coverage gaps.

Insured workers can end up paying for treatments of "preexisting conditions." Insurers routinely deny coverage for "preexisting conditions"; that is, if an enrollee has no insurance and signs up for a policy, the good news is that s/he at last has coverage. The bad news is that the policy won't cover any major illness that the enrollee had at the time of enrollment. Preexisting conditions can range from diabetes to asthma to cancer. If you have one, your policy will not cover treatments. Another gap.

So the "health expenditure" outlays are not surprising. The Commonwealth Fund recently reported that a substantial swathe of insured Americans is struggling to pay medical bills. Consider families earning $50,000 &endash; $74,999 a year: They think of themselves as middle-class. Yet one-third reported trouble paying medical bills. For families earning more than $75,000, 21% reported trouble. The lower the income, the harder the burden. For families earning between $35,000 and $49,999, half the adults struggled to pay their insurance premiums. (46 million Americans have no insurance. Some of them think of themselves -- or used to think of themselves -- as middle class.)

A few more years of this escalation in expenses, and the middle-class worker will be middle class in name only. Each month s/he will be struggling to make ends meet, a few paychecks from bankruptcy. (Bankruptcies are also up.)

Uncle Sam, though, can help the middle class. The government cannot summarily force down the price of fuel, institute month-long vacations for everybody or slash rents. But it can ease the expenditures for medical care. The answer -- obvious to everybody but our elected officials -- is universal health insurance.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, October 1, 2006

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