Susan Starr Sered and Rushika Fernandopulle, Uninsured in America: Life and Death in the Land of Opportunity.

Susan Starr Sered and Rushika Fernandopulle, Uninsured in America: Life and Death in the Land of Opportunity. Berkeley, CA: University of California Press, 2005. $24.95 hardcover.

Discussion about universal health coverage has been in the prominent in the consciousness of many Americans in the last few years. With a poor economy, the rise in low-wage work, and decrease in manufacturing jobs, the proportion of Americans without health insurance is increasing. Uninsured in America provides an in-depth look at the men and women in America who do not have health insurance and provides powerful insights into the problem.

In their account, the authors focus on what they term the "death spiral." The root of the death spiral lies in the fact that insurance coverage is so strongly linked to employment in the United States. Economic forces--such as layoffs due to offshoring, starting one's own business, and family leave to care for small children or elderly parents--begin the spiral. As health problems go untreated, the more severe the problems become, and the more costly it becomes to treat, often forcing people without insurance to choose between forgoing doctor visits and prescriptions, or selling their homes or other possessions, with the possibility of homelessness ever-present. As a result of health problems and visible indicators of poverty such as obesity and missing teeth, securing anything more than the most minimal status job becomes difficult, and health coverage is unattainable. Thus, the people described in their book found work difficult to obtain and to keep, not only because of a lack of available jobs, but also because of untreated physical or mental health issues, and they found it difficult to make ends meet.

Starr Sered and Fernandopulle interviewed a wide range of uninsured Americans with many levels of education, including graduate degrees. Many were employed at the time of their interviews and some had the opportunity to purchase insurance, but for amounts that would significantly reduce their take-home pay, making it unaffordable. Others could not work because of untreated or under-treated health care issues. Still others had been laid off after plant closings, but their chances of securing employment again if the economy improves are slim due to health conditions that have been exacerbated with lack of care. They also demonstrate that adhering to the work ethic guarantees neither health insurance nor steady work and income.

The final chapter of the book outlines suggestions that have been made for universal health coverage in America, but there is no easy solution. The authors argue that the current system for the poor is not economically sound. Without access to preventative care, problems worsen until there is no choice except to visit the emergency room or receive other exorbitantly priced treatment, which may be paid for by Medicaid or may never be paid. They contend that any feasible solution must sever the link between paid employment and insurance and must provide a minimal level of health care for all Americans, much as we provide a minimal level of education via the public schools. They argue that not only is this a humane way to treat citizens, but it is much more cost-effective than the current system.

Krista Drescher Burke, University of California, Berkeley