U.S. economic crisis having worrisome effect on health: States, individuals struggling with cuts
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* Kim Krisberg

Margaret Hulbert has a front-seat view of the nation’s ongoing economic crisis, watching as families living far from the financial tickers of Wall Street are swept up in its wake.

As vice president for the United Way of Greater Cincinnati, Hulbert’s top priorities are children’s educational success and family financial stability, but lately another issue has worked its way to the top of her list: health.

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[Figure1](http://www.thenationshealth.org/content/39/2/1.1/F1)

Dottie Neace of Wilmington, Ohio, who is being treated for breast cancer, fears she will not be able to continue her treatments if her husband, Bill, loses his job and employer-based health insurance. Bill, who recently had surgery for a ruptured colon, works for a shipping company that is cutting jobs.

Photo by John Moore, courtesy Getty Images

While the United Way chapter has not historically focused on health advocacy, the realization that access to health care — or the lack of access — is often at the root of a family’s financial problems has turned Hulbert into an outspoken advocate for health reform. And as the current U.S. economic climate and accompanying unemployment trends are likely to push more and more people onto the uninsurance rolls, Hulbert is not alone in her call for federal funding to enable publicly funded health care programs to fill the gap and keep people healthy.

“The bottom line under all of these (education and financial) issues is often that people don’t have access to health care,” Hulbert told *The Nation’s Health*. “So, it doesn’t matter what we do in other areas because one medical emergency can destabilize a family immediately.”

As Ohio looks toward double-digit unemployment numbers and a state budget shortfall upward of $1 billion, Hulbert said she hopes an infusion of federal Medicaid funds and renewed support for the State Children’s Health Insurance Program will not only fill coverage gaps but keep families healthy enough to weather the recession and sustain a health care system already struggling with uncompensated care. In fact, the Ohio organization recently began a new project to help local businesses defray the burgeoning health care costs that can lead to employee cutbacks or even a business closure by helping employers enroll workers’ children in SCHIP. Still, the Cincinnati United Way chapter is clocking a “phenomenal” growth in calls for help, many from newly unemployed residents completely unfamiliar with the assistance system and dealing with the fear and depression of job loss, Hulbert said.

“Whenever you’re dealing with low-income families or middle- and upper-income families losing their jobs, there’s a lot of different things they need,” she said. “But underlying so much of it is health care.”

According to the U.S. Department of Labor, the nationwide unemployment rate rose from 6.8 percent to 7.2 percent in December, and the number of people receiving unemployment benefits reached an all-time high in January. The unemployment numbers mean more people are at risk of joining the nation’s 45.7 million residents already living without health insurance and, in fact, researchers predict that every 1 percent rise in unemployment will lead to about 1 million more people joining the ranks of uninsured. With already-established links between income, employment and good health, the loss of coverage heightens the possibility of “grave consequences for Americans’ health,” according to “Examining the Health Consequences of the 2008–09 Recession,” released in January by George Washington University’s Rapid Public Health Policy Response Project.

The report cites a number of survey findings that people are changing their health behaviors as a result of economic stress, including a rising percentage of Americans failing to obtain needed health care and cutting back on prescribed medications. Job loss is also tied to higher levels of stress, anxiety and depression as well as greater risk of death from suicide and heart disease, the report noted. And as household budgets are stretched tighter, many families are forced to make unfortunate cutbacks. That could mean buying less expensive, often less nutritious foods and having trouble paying for household energy needs, such as heat — both of which can lead to poor health outcomes, especially among children, according to Leighton Ku, PhD, MPH, an APHA member and professor with the School of Public Health and Health Services at George Washington University.

“These (health) effects don’t necessarily occur right at once,” Ku said. “The unemployed don’t automatically stop going to the doctor or buying nutritious food, but if it goes on too long…we’ll begin to see the negative consequences.”

Many such health consequences will likely be the result of cutbacks in community health services, essential staff and funding coupled with the strain of attempting to meet increasing demands, according to Sue Abramson, MHS, director of APHA’s Public Health Policy Center. Abramson cited anecdotal reports of community health center waiting times increasing from weeks to months, growing reluctance among providers to accept Medicaid patients, an unprecedented demand for care in hospital emergency rooms, and state budget deficits that have led to Medicaid funding cuts and rollbacks in covered services. To draw attention to the health effects of the economic downturn, a new APHA policy brief examining the recession’s impact on the health safety net is expected to be released this month.

“The recession has totally destabilized the safety net and providers are no longer able to meet the explosive growth in demand for health care from the uninsured or underinsured,” Abramson said. “Patients are presenting with more complex and expensive medical conditions, and specialists who regularly opened their doors to patients in need are no longer accepting referrals. The public health infrastructure that supported community-based outreach and education programs has been cut to the bone, if not altogether eliminated. We are in the midst of a crisis — one that seems to have no end in sight.”

According to the Washington, D.C.-based Center for Budget and Policy Priorities, which examines policies affecting low- and moderate-income families, at least 26 states as of January had proposed or enacted cuts that affect low-income families’ eligibility for health coverage or curb access to services. For example, the center reported, South Carolina is limiting coverage under its state-run health programs for routine physicals and psychological care while Florida has frozen reimbursements to nursing homes and Arizona eliminated temporary health coverage for people with serious illnesses.

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Lesley Bennett, who was laid off, eats at a soup kitchen in Wilmington, Ohio, in January with her four children.

Photo by John Moore, courtesy Getty Images

To help Americans maintain their health through the recession — an issue health advocates argue is essential to a recovering economy — health advocates are urging federal legislators to increase support for state Medicaid and public health programs as well as the Consolidated Omnibus Budget Reconciliation Act, better known as COBRA, which allows certain people who’ve ended their employment to extend their health coverage. However, even if a person is eligible for COBRA, it may be out of reach financially. Findings from a January Families USA report, “Squeezed: Caught Between Unemployment Benefits and Health Care Costs,” found that the average unemployed worker would need to spend 30 percent of her or his unemployment insurance check on COBRA premiums to maintain individual coverage. That percentage rockets to more than 80 percent to maintain family coverage via COBRA.

In terms of Medicaid, a January report from the Kaiser Family Foundation, “Rising Unemployment, Medicaid and the Uninsured,” predicted that as unemployment reaches 7 percent — which it did in January — enrollment in both Medicaid and SCHIP will increase by 2.4 million and spending will increase by $8.3 billion, with $3.6 billion of that figure falling on state budgets. As of early February, additional federal funds for Medicaid and COBRA were included in the American Recovery and Reinvestment Act of 2009 stimulus bill, which passed the House of Representatives in late January.

Despite that, the outlook for public health in the current economy continues to be dire. According to a November–December 2008 survey by the National Association of County and City Health Officials, more than half of local health departments either laid off employees or lost them due to turnover and have been unable to replace them because of budget problems. The survey also found that one-third of local health departments expect further layoffs this year. In turn, even though demands on public health are likely to increase as residents lose health coverage, “local public health systems are way beyond capacity to fill any gaps,” said Robert Pestronk, NACCHO’s executive director. With 7,000 local health department jobs lost during the past year, more resources are needed just to maintain the status quo, not to mention continuing work to create a healthier nation, said Pestronk, an APHA member.

“A healthy public is the most important piece of infrastructure needed for a strong economy,” he said.

For more information on the health-related consequences of the recession, visit [www.kff.org](http://www.kff.org) or [www.cbpp.org](http://www.cbpp.org).

*   Copyright The Nation’s Health, American Public Health Association