Some people argue that there are not 47 million uninsured in this country because they are not uninsured the entire year. I came across a NACHC report that suggests that more than 56 million are disenfranchised. I suspect even more are poorly insured and vulnerable.
The denial of the existence of the uninsured is puzzling. Presumably and by implication, the uninsured are just good old upper middle class Americans who can afford to COBRA their insurance between jobs and just elect not to. They live in nice suburban neighborhoods and commute past the golf courses and malls, all the way to shiny office towers where they put in an honest day's work and make a value decision on their way home.
Well, maybe this is just a fantasy, but I'm not sure where people come off denying the existence of things they cannot possibly see on their own commutes or social circles. You do not see uninsured Americans if you hang out in Georgetown and don't travel to Southeast, the capital's crime-ridden center of ghetto violence. The uninsured are invisible on the beaches of Florida or on adventure tours of Bryce Canyon or the San Juan Islands.
The fact is many of my insured patients are the same ones that were uninsured two months ago and will be uninsured in a few more months because they got this plan temporarily as they worked their way through school. Or they just couldn't afford their premiums once they got to their new job that was supposed to be a great step up for them. The uninsured, as well as Medicaid patients, tend to bounce on and off the rolls every few months or years. I would argue that financial stability is not usually to be had for 2 to 3 years, so would count anyone who has been uninsured for any period of time over the past several years. Anyone who has ever tried to get off the ground after a fall, knows you are the most off-balance as you're trying to get back on your feet.
Yes, I know SCHIP is being extended to individuals over 300% of poverty, but has anyone noticed that the official federal term is "Federal Poverty Guideline", a term chosen specifically because nothing can strictly define poverty. The US does not have a poverty level, in part because of regional variation in what would be a basic subsistence income.
Living in the Washington metro area, I can assure everyone that 300% of poverty is less than subsistence in these parts.
What does this mean for the uninsured? It means 47 million is an underestimate of the vulnerable population. Yes they deserve access. I'm not sure they deserve everything that medicine possibly has to offer. The practicalities of life is that there are financial limitations to everything and as several commenters have observed on this blog, health care does not necessarily contribute all that much to overall health status as measured by crude population vital statistics. I think this is the law of diminishing returns at work, but is insufficient reason to offer nothing.
Community Health Centers [disclosure: I am the medical director of one] can provide quality health care, usually better than "private" practices for lower cost. A follow-up study, conducted with the Graham Center, a policy think-tank that supports the interests of primary care, points to the economic benefits to be had by assuring access to health care through low-cost, high-quality centers.
The rest of the health consumers out there can make their own decisions where to go and how to spend their dollars. Community Health Centers generally don't turn away patients with insurance.
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3 comments:
Thank you, Dr. Ammon, for trying to shed a realistic view on the uninsured, or underinsured, issue as related to health policy. I fear that those persons who argue the details of programs (such as S-CHIP) on philosophical grounds have absolutely NO COMPREHENSION of the economic realities of many lower-middle class families who face health issues.
My opinion comes from person experience. Two years ago I was diagnosed with Multiple Sclerosis. As a self-employed musician living in the DC area, I have an individual health insurance policy with Carefirst. But my prescription coverage is capped at $1500 annually which I discovered after attempting to fill a prescription for an MS drug costing $21,000 annually.
I was referred to the drug assistance program. Based on an AGI of $32,000 in 2004 (the most recent tax report at the time and in which I did not deduct any retirement contributions), I was awarded 50% assistance for 1 year, leaving me with a guaranteed expense of $10,000 for this single medication. After filing 2005 taxes, AGI of $27,000 and medical expenses of $9,000, I appealed for additional assitance but was DENIED.
This spring, I applied again, AGI of $19,000 and medical expenses of $15,000, and was finally awarded 100% assistance for 12 months.
During 2006, I had applied to several other programs but was always denied based on earning about 270% FPL (and not being pregnant or having children), while my doctors made great efforts to get me samples and 'left-over' study medications when possible. Without that additional help from the doctors, I would have need to spend an additional $8000 on meds in 2006.
So for a single person, living in the DC metro area where the median income is about 700-800% FPL, I am forced to limit my income to 200% FPL in order to afford one single medication which should help to delay disability. I would have to earn a gross income of $66,000 to be able to pay for my medication, taxes, contribution to retirement, and still be able to live on a take home pay of $1250 a month.
Dr. Ammon, how many people in the DC area do you know who can afford to live independently on $1250 a month?
Lisa, I know you are a musician and a blogger. Sixty-six thousand may be in your range, but you'd probably have to bust your butt, something you cannot do given your health status.
It is truly unfortunate that you have to stop being a productive member of society in order to get the help you need, to get better.
There is irony here for all the economic types who don't understand that they're measuring the wrong thing when it comes to health care ROI. The real impact of expanding health care coverage is quality of life and some economic benefit. It only needs to break even to make sense.
Given the emotional stresses of being ill, it is easy to understand why some people are so desperate to also get health care they don't need. Telling some people "no" is the central problem of extended health care coverage.
How do we offer some help, but not bone marrow transplants for cancer patients for whom there is no proof of efficacy? At some point, it no longer benefits society to have unlimited financial assistance to people with serioud illness.
I agree that establishing limits is absolutely necessary. Parents who set limits for their children are able to teach valuable lessons of discipline, patience, responsibility, fairness, respect, and moderation. I am thankful that my parents taught me to distinguish between true needs and selfish wants.
When it comes to healthcare economics, my WANTS are simple: fairness amongst the stakeholders, efficiency in delivery and access, simplification of the process to receive sufficient financial assistance when appropriate, elimination of the need to sacrifice current and future economic stability in order to potentially preserve physical abilities and quality of life, and finally less manipulation of statistics (numbers can always say whatever you want them to say).
My NEEDS are less simple: a belief that daily self-injections of a $21,000 drug will significantly delay permanent disability, faith that a 38% efficacy rate in reducing MS relapses is worth the personal financial sacrifice, the limitation of potential economic contributions to society simply to gain access to aforementioned drug, and a firm belief that patients should not have to make the financial choices I have made.
Before discovering the prescription coverage limit of my insurance policy, I was satisfied with the $25 office visit copays, 10% coinsurance requirement, and $50 ER copay. Outside of my health insurance plan, I spent money to see an acupuncturist regularly, to receive therapeutic thai massage when those muscles just don't want to loosen, and to attend yoga classes at the local county reccenter.
Although I am a believer in taking individual responsibility for your own physicial and financial wellness, I strongly object to the notion that one of these must be sacrificed for the other. No one should have to be shackled by the realization that earning $5000 too much in one year will result in an extra $10,000 expense the following year, or earning $10,000 will result in a $21,000 expense. The alternative would be to forfeit access to the medication, which may or may not protect quality of life for awhile, in order to maximize financial gains now which may or may not ensure future economic security.
My mother was very clever in teaching my brother and I an important lesson in fairness and negotiation. For example, if he and I both wanted the last piece of cake, she gave us a choice. We could choose which of us would cut the cake and the other person would have first choice of pieces. My brother quickly learned that I was a more skilled cake-cutter and that he would have a better choice of equal pieces. We both benefited from this arrangement. Most importantly, though, neither of us were allowed to take any portion of the cake (or profit) before it was to be divided equally.
Sometimes I wish that I could be the one to ensure that all stakeholders of the healthcare industry (including patients) get what they truly NEED, but not necessarily everything they greedily WANT.
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