GOVERNMENT & MEDICINE

Uninsured often get second-class care

New reports show a large difference between the haves and the have-nots in the nation's health care system.

By Susan J. Landers, AMNews staff. Aug. 28, 2000.

Washington -- A great divide exists in the nation's health care system separating those who have health insurance from those who do not, says a new Consumer Reports study.

People without insurance are getting "second-class health care in a country that spends more of its gross domestic product on health care than any other in the world," said the study's author, Trudy Lieberman.

In addition, the nation's sickest 10% pay seven times what the average American spends on health care, said Gail Shearer, Consumer Union's health policy director and the author of a second report, "The Health Care Divide: Unfair Financial Burdens."

A two-tiered system of care exists for chronically ill patients, according to Lieberman. For example, an uninsured patient in the midst of a seizure may receive treatment for the seizure but no examination to determine the cause.

Doctors' frustrations

Physicians who staff the clinics and emergency departments that are often tapped to provide care to people without insurance are all too familiar with the difficulty of providing needed follow-up care to their patients.

For example, specialty care can involve a three-month wait at the Washington, D.C., Free Clinic, said Arpita Patel-Mehta, MD, a family physician at the clinic.

And, although it is possible to supply some prescription drugs free of charge, the choice is often limited and the administrative hurdles to access pharmaceutical companies' indigent drug programs are many, she said.

Dr. Patel-Mehta praised the local network that recruits the specialists who provide care to her patients, but, she noted, patients "might have to wait three or four months for a pelvic ultrasound, or two months to have a biopsy done on a suspicious breast lump. You learn to practice medicine in a very innovative way while taking care not to compromise standards of care. You practice very much as you would in a developing country."

The nation's emergency departments are also well-acquainted with the difficulties of providing ongoing care to poor and uninsured people. Thanks to the Emergency Medical Treatment and Active Labor Act, treatment in an emergency department is the only health care in the United States that is also a right, noted Arthur Kellermann, MD, chair of the emergency medicine department at Emory University School of Medicine in Atlanta.

"My colleagues and I deal with these people on an eyeball-to-eyeball, cheek-to-cheek basis, and when they look at us and ask, 'What do I do now? Where do I go after you take care of me tonight?,' I often do not have a good answer," he said.

The uninsured more often than not hold jobs, said Dr. Kellermann. "They wait on our tables, they repair our cars and they pay taxes, but they can't afford health insurance."

The hospitals that provide care to the poor and uninsured are also operating under increased financial pressures thanks to managed care's cost constraints and to pay cuts instituted under the 1997 Balanced Budget Act, said Dr. Kellermann.

"If they go down, I don't know what we are going to do," he said.

In the past, hospitals covered the cost of free care with money paid by insurance companies for covered patients and with Medicare reimbursements. Those days are over.

Lieberman also found that uninsured patients are often under increased pressure to pay for the care they receive.

This creates a situation in which patients with low incomes help subsidize the lower premiums of more affluent patients who have insurance.

Also among Lieberman's findings:

• The number of people seeking care from federally funded clinics has increased 45% over the past decade.
• The inability of uninsured people, and even some insured individuals, to pay for health care sometimes leads to bankruptcy. Last year, more than 500,000 families who filed for bankruptcy had medical problems, and more than 300,000 -- one in four filers -- identified an illness or injury as a reason for filing. Many had bills exceeding $1,000 that insurance did not cover.
• Congress provided about $1 billion in federal money last year to the nation's 3,000 free clinics. At the same time, it granted nearly $18 billion to the National Institutes of Health for research on treatments and cures for disease that may well be unavailable to uninsured people.

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