The Orthopaedic Forum   |    
The Need for Increased Access to the U.S. Health-Care System
Jesse E. Bible, BS1; Richard S. Lee, MD1; Gary E. Friedlaender, MD1
1 Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071. E-mail address for J.E. Bible: jesse.bible@yale.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Feb 01;91(2):476-484. doi: 10.2106/JBJS.H.00735
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Health-care costs in the United States are rising at an alarming rate. Despite increasing national spending, health-care access remains an important issue to many Americans and is a topic of intense political debate. Over the last forty years, the health-care system in the U.S. experienced a steady increase in both the absolute and relative amounts of spending. In 2005, the U.S. health-care budget increased 6.9%, a figure close to two times the rate of general inflation1. Total expenditures amounted to $1.99 trillion or $6700 per capita and accounted for 16% of the gross domestic product (Fig. 1)1,2. Health-care spending surpasses the national defense budget by more than threefold1,2. While the U.S. spends more on health care than any other country, it remains the only industrialized country that does not offer all citizens guaranteed health-care coverage. For comparison with other nations, the U.S. represents only one-quarter of the population of the Organization for Economic Cooperation and Development (OECD, a group of thirty developed countries), yet accounts for more than half of the total health-care expenses of this multinational group3. In 2003, the OECD countries' combined average for health-care spending as a percentage of gross domestic product was 8.6% and the group's average health-care spending per capita was $23073. That same year, the U.S. spent 15% of its gross domestic product and $5635 per capita on health care3. With so much money spent on health care, some have questioned why the U.S. life expectancy stands at 77.2 years and the infant mortality rate is seven deaths per 1000 live births while the OECD averages are 77.8 years and 6.1 deaths, respectively3. Others have questioned why so many Americans are living without health coverage or have limited access to quality health care and the effect this lack of coverage might have on heath-related statistics. Most importantly, what changes in the U.S. health-care system should be considered for moving forward?
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    Jesse E. Bible, BS
    Posted on March 09, 2009
    Mr. Bible and Dr. Friedlaender respond to Dr. Novack
    Yale University School of Medicine

    We thank Dr. Novack for his interest in our review article on access to health-care in the United States, as well as his thoughtful comments. It was not our purpose to “propose and critique specific solutions” to several of the health-care problems highlighted in the article, but rather “to merely highlight key aspects of certain strategies and encourage more dialogue” (p.482). Such discussions are vital to improving orthopaedic care at the local and national level.

    One of the issues raised by Dr. Novack involved the 6.5 of the 9 million uninsured children who are eligible for public health-care coverage, but not currently enrolled. The remaining 2.5 million children are not eligible, primarily because their family incomes exceed program eligibility levels. Several possible explanations have been raised to explain the discrepancy between eligibility and enrollment. First, premiums and cost sharing required for Medicaid/SCHIP participation in many states can cause coverage to become less affordable for low-income families and, thereby, reduce participation in public services. Second, is a lack of awareness in how to apply for Medicaid/SCHIP programs. States have recently developed strategies to simplify the enrollment and renewal process to obtain coverage, as well as reduced verification requirements. A deviation from this process of streamlining enrollment was the Deficit Reduction Act of 2005, which requires individuals to provide proof of U.S. citizenship for applying or renewing Medicaid coverage. However, even with this act, an overall increase in enrollment was seen as states invested more money into community-based outreach activities. Such outreach programs will need to have additional funding in order to further increase enrollment, and such resources are unlikely with the current economic crisis.

    Another issue mentioned by Dr. Novack is that, “many adults who are currently healthy…choose to forgo paying health insurance premiums when very affordable individual polices exist”. We would agree that many healthy Americans opt out of health insurance thinking or hoping that sickness or injury will not come their way. However, we would disagree with the position that very affordable policies exist for all. National surveys have continuously found the high cost of health insurance coverage as the primary reason people are uninsured. According to a 2008 survey, premiums for employer-sponsored health insurance have been rising four times faster on average than workers’ earnings since 1999 (1). Indeed, the annual premiums for individual family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker (1).

    Thirdly, Dr. Novack correctly stated that “illegal immigrants account for many more of the uninsured”. It is likely that the current U.S. Census Bureau reports underestimate the number of noncitizens; however, as mentioned in our article, according to the 2006 Census Report 78.2% of the uninsured individuals in the U.S. are citizens (2). While U.S. citizens encompass more of the uninsured population, noncitizens have a much higher uninsured rate at 45.0% (2).

    Lastly, like Dr. Novack, we feel issues of health-care “must be part of the AAOS agenda”, and we find abundant evidence of this commitment. We hope that comments from individual orthopaedic surgeons, such as Novack and ourselves, will serve to strengthen our collective message and resolve these issues on behalf of our patients.


    1. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008.

    2. DeNavas-Walt C, Proctor BD, Smith J; US Census Bureau. Income, poverty, and health insurance coverage in the United States: 2006. Current Population Reports, P60-233. Washington, DC: U.S. Government Printing Office; 2007.

    Eric N. Novack
    Posted on February 15, 2009
    We Need AAOS Leadership

    To the Editor:

    I read the article by Bible et al. (1) with the anticipation that perhaps the AAOS and its leadership would finally be taking a stand on the goals of health care and health care reform, but I write to express my disappointment in the tenor of this article. In it,the authors lay out the talking points and proposals with one apparent goal in mind: to keep the AAOS and its leadership 'at the table' regardless of the costs.

    Never mind the abundant data showing that the vast majority of uninsured children are ALREADY eligible for health care coverage under existing government programs. Never mind that many adults who are currently healthy choose to forgo paying health insurance premiums when very affordable individual policies exist. Never mind that illegal immigrants account for many more of the uninsured. Those data were omitted from the article.

    The most galling sentence to me, however, is on page 476, "It is...presumptuous to propose specific answers to these critical questions". Is not the purpose of such an article to do exactly that-- present, propose and critique specific solutions to enormously important problems facing orthopedists and their patients?

    I believe we must stand for principles that put patients first and protect orthopedists' freedom to innovate that has resulted in so many life-saving and function improving advances. These principles must be part of the AAOS agenda. They include:

    1. Patients have the right to be in control of their own health and health care.

    2. The right of patients to keep their medical history private.

    3. The right of the fellows of the AAOS to seek to improve their knowledge and their profession, thus providing the best patient care for a mutually agreed upon fee.

    4. The right of patients to spend their own money for their health and health care.

    5. The right of doctors and patients to choose to NOT participate in a government-mandated, bureaucrat-controlled health care system.

    These simple principles, or those like it, used to be the foundation of our profession. But it seems that to our modern leadership they do not have the salving effect as seeking 'universal health care' and 'reducing health care disparities'. I fear that the Academy may become only a fabulous source of CME, rather than the deserved leader of the country's orthopedic community.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.


    1. Jesse E. Bible, Richard S. Lee, and Gary E. Friedlaender. The Need for Increased Access to the U.S. Health-Care System J Bone Joint Surg Am 2009;91:476-484.

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