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Part II: Where Do We Go from Here?

...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.

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
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.