...I prescribed Frank a potent steroid cream to help with the inflammation, as well as a moisturizing cream, and wrote down strict instructions as to how to care for his diseased skin. We gave him a list of free clinics in the area where he could be followed for his condition. “Frank, these medicines will cost about $30 dollars, but should last you for a couple of months….” “Thanks Doc he replied,” and walked out the door...

Although Frank may represent one extreme in the continuum of those individuals without health insurance, his story no doubt raises many salient points regarding our current system. Maybe it is too difficult to enroll individuals like Frank in the Medicaid system. Perhaps he cannot receive insurance due to his “pre-existing condition (psoriasis),” which can be a lifetime problem, and viewed as an “expense” to an insurance carrier. What if Frank was not a U.S. citizen? These are all issues which hinder our ability to be able to provide healthcare to the uninsured.

To “fix” the current healthcare system in this country, we need to realistically address 5 areas:

1) 50% of the individuals eligible for governmental programs actually enroll (1). We need to make it easier to enroll all low-income individuals who qualify into an insurance program. From an Emergency Department perspective, this idea might include using computer kiosks in Emergency Departments where people can enroll while they wait. Furthermore the standards for enrolling “low income individuals” must also be “loosened”-one must not need in addition to income, children or be disabled to qualify.

2) Of the 40 million uninsured Americans, 10-15 % have jobs but are either not offered health insurance, or cannot afford it in the private market (1). Medical Savings Accounts, or MSAs, should be an acronym that every American knows, just like IRA or 401K. These tax free savings accounts should be established by every American as a way to supplement all of their health care needs. If catastrophic illness presents, these funds may provide a much needed cushion. Whether you spend the money or not, saving for your own healthcare needs puts the individual in charge of his or her own care. In addition to insuring individuals employed by smaller companies, small businesses must receive tax and other incentives as a way to not only afford, but offer quality insurance plans to their employees.

3) Individuals with “pre-existing conditions” including a diagnosis of cancer, high blood pressure, or psoriasis, must not be excluded from being able to have health insurance-plain and simple.


4) Number of uninsured immigrants in the United States: over 10 million (2) The number of immigrants in this country without health insurance, and who are provided medical care in emergency departments, labor units, and surgical suites is astronomical, and continues to grow every year (approximately 2 billion dollars per year in California alone!). No matter where you stand on immigration reform, these individuals will still need and will use the healthcare system. The question is…who will pay?


5) Can we force people who do not want health insurance to sign up? As stated earlier, between 15 and 20 million people could afford insurance, but have decided “I am young, and healthy-when am I going to ever need insurance?” The people I know who have this attitude always, without a doubt, concede that they wish they had spent that little extra money each month (even for more catastrophic care plans) after something really happened. This can make the difference between having to pay a $35,000 versus a $5,000 hospital bill.

At this point let me reiterate the conclusion from Part I of my essay: “A large portion of the uninsured will generally go on to find health insurance (even a low estimate is 10 million), and over 15 million people just opt not to buy insurance. That leaves by conservative standards 15 million people who truly need help purchasing insurance.” Employing the methods as outlined above have the potential to help over 15 million people find insurance.

So where do we go from here? We have the ability to provide everybody in this country the best medical care in the world, and in many aspects we already do. There is little doubt people will always need help obtaining health insurance, however, the common denominator in one’s ability to obtain quality healthcare is personal responsibility….

I saw Frank leaving the Emergency Department again 2 weeks ago-new prescriptions in hand…. “lost my last ones!” he exclaimed with a toothless smile. There is no health insurance plan in the world that would actually help an individual like Frank. The reality is that there are a lot of “Franks” out there using the Emergency Department day after day, and year after year. We can throw as much money as we want at the healthcare system to help cover the uninsured, but without personal responsibility for our own healthcare, the system will sink further into disrepair.

References:
1) State Coverage Initiatives, An Initiative of the Robert Wood Johnson Foundation, “Why are People Uninsured?” July 2004.

2) DeNavas-Walt C, Proctor B, Mills R. “Income, Poverty, and Health Insurance Coverage in the United States: 2004. Current Population Reports, Series P-60. Washington: US Government Printing Office. 2004

Frank is an uninsured patient. I have seen him 4 times in the past 12 months for his chronic psoriasis-an autoimmune disorder which causes a thickening and irritation of the skin. His feet and hands are thick gloves of matted, cracked, peeling skin, which bleed and cause him a tremendous amount of pain. Even individuals with the best health insurance may have a difficult time dealing with this disease, which treatment may include UV light therapy, steroids, and creams to reduce the inflammation. Frank does not have access to therapy, except what we offer him in the Emergency Room*.

Every time I see Frank, the story usually goes something like this: “Frank your hands and feet look awful.” “I know Doc,” he usually replies. “Have you been using your steroid creams like we told you?” “No Doc, someone stole my prescriptions again.” “Where are you living now?” I usually ask. “Oh in the same hotel…” “Are you still drinking?” “You bet Doc,” he replies. I asked him why he is uninsured… “Can’t afford it Doc.” Frank divulges that his only current income is from social security and “a few odd jobs now and then.” The hospital works with him every time he visits the Emergency Department to enroll him in Medicaid, but his income is too high. Because of this problem Frank “just goes to other Emergency Rooms for prescriptions.”

We are the safety net for individuals like Frank. The Emergency Department has become the last bastion of hope, the primary care office, for many individuals lacking health insurance (approximately 30% of all Emergency Department visits are for Primary Care oriented problems-for both the insured and uninsured). I was always curious what happens to the bill Frank generates after he visits the Emergency Department, so I spoke to one of our hospital’s billing managers: “We send the bill to a viable address, and then we usually never get a response.” She told me that this particular hospital’s collection rate for individuals lacking health insurance is less than 10%. “What happens then? Do collection agencies go after these people,” I asked? “No, many do not have credit, and move around so much, it is very difficult to get them to pay.” An honest, straight to the point answer.

Aside from providing care to the uninsured in a private hospital setting, I have worked over the past 5 years in 3 major “County Hospitals,” meaning a facility which is owned and partially subsidized by the city and county in which it is located. The number of uninsured patients is usually much higher. I spent a month delivering babies at one County facility in Arizona while I was a Family Medicine Resident-90% of the 102 females I helped to deliver were either uninsured or of Immigrant status. In this situation, instead of the hospital “eating the bill, (well partially)” taxes pay the bill.

So I decided to do my research. I wanted to find out why the uninsured are uninsured. Who they are, what do they do, how can we help, and what needs to be changed:

-Number of Uninsured: approximately 40 million (1). This estimate varies widely from 25 million to 50 million and includes people who are both “chronically uninsured,” meaning for more than a year, and “transitionally uninsured,” those who will regain coverage (due to changing or gaining employment, or switching plans) within 6 months. The Congressional Budget Office estimates annually that 45-55% of the uninsured under the age of 65 (all individuals over 65 are eligible for Medicare) have health insurance within 4 months (2).

-Highest number of uninsured by race: Hispanics 32%, Blacks 19%, Asians 17% and Whites 15% make up the highest number of uninsured (3).

-Number of uninsured immigrants in the United States: over 10 million (4). There is no good estimate as to the number of immigrants who are uninsured. Census data usually includes all individuals living in the United States. The best estimate for the number of uninsured individuals who are immigrants, particularly those who are undocumented, is staggering: approximately 80-90% (4).

-Uninsured rates for low-income Americans (less than 100% Federal Poverty Level) vary greatly. Many may never qualify for Medicaid, or government assisted healthcare, if they are childless, or without disability. Most people are eligible for Medicaid, if they have children. On the opposite end of the spectrum, most states estimate that fewer than 50% of the individuals eligible for governmental programs actually enroll (5).

-Number of people who can afford health insurance and do not choose to participate in a plan: 15-20 million (6). Over 8 million people making between $50,000 and $75,000 did not buy health insurance in 2005. Likewise over 9 million people making more than $75,000 did not purchase health insurance that same year.

-Of the 40 million uninsured Americans, 10-15 % have jobs but are either not offered health insurance, or cannot afford it in the private market (6). Most are self employed, or ineligible for COBRA (Consolidated Omnibus Reconciliation Act) coverage: part-time, or working in a business with fewer than 20 people.


To me, these numbers are reassuring. A large portion of the uninsured will generally go on to find health insurance (even a low estimate is 10 million), and over 15 million people just opt not to buy insurance. That leaves by conservative standards 15 million people who truly need help purchasing insurance. We still are left wondering: “Where do we go from here?”

PART II to follow….

References:
1) The Kaiser Commission on Medicaid and the Uninsured. “Who are the Uninsured? A Consistent Profile Across National Surveys” August 2006
2) The Congressional Budget Office Economic and Budget Issue Brief. “How Many People Lack Health Insurance and For How Long?” May 2004.
3) DeNavas-Walt C, Proctor B, Mills R. “Income, Poverty, and Health Insurance Coverage in the United States: 2004. Current Population Reports, Series P-60. Washington: US Government Printing Office. 2004
4) DeNavas-Walt C, Proctor B, Lee CH. “Income, Poverty, and Health Insurance Coverage in the United States: 2005” The Census Bureau Report, Aug 2006
5) Remler, D et al. “What Other Programs Can Teach Us: Increasing Participation in Health Insurance Programs,” American Journal of Public Health, January 2003.
6) State Coverage Initiatives, An Initiative of the Robert Wood Johnson Foundation, “Why are People Uninsured?”

*(The Views expressed in this manuscript do not entirely represent those held by Stanford University Hospital and its employees. Hospitals mentioned in this manuscript are not affiliated directly with Stanford University Hospital, nor do events take place at Stanford University Hospital)