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Case
Study: The Uninsured True Stories of Unnecessary Sickness, Death and
Humiliation |
by Howard Bell Printed in The New
Physician magazine September 2000 issue The Uninsured: Myths &
Facts |
One in six Americans does not have
health insurance, and many live sicker and die younger because of it. The
ones Dr. Debra Richter thinks of are dead-like George and his sister,
Tina. Richter took care of them at an inner-city health center in Buffalo,
New York. Diabetics since childhood, their disease went untreated because
the family rarely had health insurance. When they were teenagers, Tina
waitressed and George worked in factories. None of their employers offered
them health insurance. They earned too much money to qualify for Medicaid,
and they couldn't afford to buy private insurance, so they went without
insulin, syringes and glucometer
sticks. "I'd
talk drug companies into giving us free bottles of insulin," Richter says,
"but you just don't keep free samples of insulin lying around. Syringes
were fairly easy to scrounge, but at 50 cents each, glucometer sticks were
difficult to
get." With
blood sugar levels averaging 200, George went blind at age 20. Unable to
see or work, depressed and housebound, his disability finally qualified
him for Medicaid-too late. He died at age 21 of multiple organ failure due
to uncontrolled
diabetes. Tina's
first and only baby lived for five months and never left the hospital.
Cause of death: complications from gestational diabetes. A year later,
Tina had a myocardial infarction. Despite a bypass, she died at age 25.
"It was heartbreaking," Richter says. "George and Tina had a strong work
ethic. I had to face their mother at the funerals knowing if they had
gotten good care for diabetes, we could have prevented all their end organ
disease. George would not have gone blind. The baby would have lived.
Neither would have had heart or kidney
problems." "I
see stories like these every day," Richter says, "but the public never
hears them because they're anecdotal. The cause of death says kidney
failure, but they really died from lack of
insurance." In
the wealthiest nation on earth, one of every six people delays care or
avoids care and rations their medicine because they don't have insurance
to pay for it. Richter now practices in rural, northern Vermont, but she
says the stories are the same there. "It's no different-rural or urban,
minority or white-life without health insurance devastates emotionally,
physically and
financially." The
United States spends more per capita on health care than any other nation,
yet in fairness and access for all, we rank 54th, along with the island of
Fiji, according to "The World Health Report 2000," a World Health
Organization analysis of 191 health
systems. Forty-five
million Americans have no health insurance. The number grows by 100,000
each month, according to a Health Insurance Association of America (HIAA)
study. Despite a booming economy from 1994 to 1998, the number of
uninsured rose by 4.5 million people. HIAA predicts that if nothing
changes, 55 million will be uninsured by 2008, more than one in five
Americans. Behind all the statistics and endless debate about what to do
about it, real people suffer. Who they are may surprise you.
Working Poor At Terry
Reilly Health Service in rural, southwestern Idaho, family physician Dr.
Bob LeBow offers reduced-fee care to his uninsured patients, like the
28-year-old mother of two small children who worked at a convenience store
and came to him with bacterial endocarditis. "She delayed getting care
because she didn't have any insurance to pay for it, and she earned too
much to qualify for Medicaid," LeBow says. She would have done fine if
she'd come in earlier, he says. Instead, an embolus from her heart went to
her brain and killed her. "She died because she postponed care, because
she didn't have insurance. Ironically, she had just been promoted to
assistant manager, which qualified her for
insurance." The
uninsured are not necessarily misfits who sleep in appliance boxes.
Seventy-five percent of them have full-time jobs or live in a family where
at least one person works full time, according to the May 2000 Kaiser
Commission Report, "Uninsured in America." More than half are Caucasian.
The uninsured are mothers who work at convenience stores and fathers who
work in factories. They're the working poor who earn less than $10 an hour
from employers who don't or can't afford to offer health insurance. Twenty
percent live in families where two people work full time. Most of the
uninsured work at medium to large businesses with more than 25 employees
and have incomes higher than the federal poverty
level. "What
people need to realize is that the uninsured are us," LeBow says. "They
are people who live next door to you, who work, who try to make ends
meet." LeBow
recently treated a college professor between jobs who had a bad cervical
disc that needed surgery, which he postponed for several months until he
had hand numbness and permanent nerve damage. "He eventually had surgery,"
LeBow says. "He's now filing for bankruptcy and feels
humiliated." One
in five adults say they or their family faced collection agencies because
they owed money for medical bills in 1998, according to the "Commonwealth
Fund National Survey of Workers' Health Insurance." For working-age adults
earning less than $20,000 per year, the number was one in three; one in
four for those earning $20,000 to $30,000 per
year. Sixty
percent of Americans have employer-sponsored health insurance, but Dr.
Rudy Mueller, an internist in Jamestown, New York, chuckles cynically when
he describes the games employers play to avoid having to insure workers.
"One of our local employers considers working 35 hours a week to be part
time," he says. "So a patient of mine who works there and needed an X-ray
couldn't pay for it. Another of our local employers considers 30 hours a
week full time, so they hire people to work 29 hours so they don't have to
insure them. Each company makes up its own
rules." Living
without health insurance is so common in this country, doctors in all
practice settings deal with it. "I'm in private practice," Mueller says,
"so I'm insulated. Yet it's incredible what walks through my door. It's
bad out there." Mueller is collecting stories about his uninsured patients
for a book he's writing called As Sick As It
Gets. Life
without insurance whittles you down-literally in the case of a carpenter
Mueller treated. Self-employed full time, he couldn't afford insurance.
When he came into the hospital with bloody urine and uncontrolled blood
sugar, they found a tumor. He refused surgery because he couldn't pay for
it. Six
months later, he accidentally cut off his thumb. The cancer was worse now
and, because of his thumb, he couldn't work. He agreed to the cancer
surgery, which was now more extensive and expensive. Unable to pay the
bill, he received regular calls from a collection agency. His untreated
diabetes caused a foot infection, so his toes had to be amputated, which
added another bill to the
stack. Sometimes
he'd get free medicine for his diabetes. Sometimes he'd take it. Other
times he'd ration it. His vision worsened. One kidney failed and was
removed. They discovered another cancer-this one in his bladder. Then he
was forced to say "goodbye" to his
bladder. A
few months later, his family found him lying on his floor from a stroke-a
complication of uncontrolled diabetes. Nearly blind and stroke-disabled,
missing several toes, a thumb, one kidney, his bladder and his home, he
now qualified for Medicaid. His other kidney began to fail, so he was put
on dialysis. He shared a nursing-home room with four other men when he
died six months shy of being eligible for
Medicare. "These
stories have to be told," Mueller says. "The people making $8 to $10 per
hour are hurting the most, but this is a problem that touches just about
every family. Wake up, America."
I Am Woman. I
Am-Uninsured. Young to middle-aged women are losing their
health insurance, according to the Commonwealth Fund's study "Health Care
Access and Coverage for Women." Women ages 25-34 are least likely to have
insurance. Though many low-income women with children still qualify for
Medicaid, many no longer do because of recent welfare reforms. Health
coverage for women with household incomes of less than $15,000 per year
dropped from 44 percent to 37 percent between 1993 and 1998. The number of
uninsured women across all incomes rose from 14 percent to 18 percent,
while private insurance coverage for women dropped from 77 percent to 72
percent during the same time
period. Although
the Kaiser report shows that men are more likely to be uninsured than
women, it's women who seem to suffer most from lack of insurance,
according to several doctors. Mueller treated a middle-aged woman who quit
her job to stay home and take care of her ailing father. "She lost her
insurance because she quit work," he says. "Because she couldn't pay for
her care, she delayed care, presented with advanced cervical cancer and
died three days
later." "Some
of the worst cases you see," Richter says, "are working women in their 50s
with chronic diseases who can't get
insurance." According
to the Kaiser report, older middle-aged women are among the fastest
growing group of uninsured. Too young to qualify for Medicare, more than
half have full-time jobs or have someone in the family who has a full-time
job, but the employer doesn't offer
benefits. Seventeen
percent of women aged 60 to 64 live without health insurance. They also
have more trouble finding affordable coverage because of pre-existing
conditions-like the uninsured fast-food worker LeBow treated who had
diabetes and couldn't afford to manage it. "She couldn't get insurance on
her own because she had a pre-existing condition. The ones who really need
it are the ones they won't give it to. I see it all the time. The system
skims off the healthy and leaves the poor and sick to fend for
themselves," LeBow
says. Then
there was the 64-year-old woman with an ulcerated prolapsed uterus who
came to see LeBow. "Her uterus was hanging from her vagina, yet she
decided to postpone the surgery for a year until she qualified for
Medicare," he
says. Another
64-year-old woman with cancerous vaginal bleeding, no savings and who was
ineligible for Medicaid needed $10,000 for surgery. "Everyone turned her
down," LeBow says, "so she decided she'd have to wait eight months, until
she turned 65 and qualified for Medicare." After much finagling, Idaho's
Canyon County loaned her money, and she was able to have the surgery
done.
From Welfare to Work-and No
Insurance When it comes to getting health insurance, many
low-income men and women are better off not working. According to a study
conducted by Families USA, nearly 1 million low-income parents have lost
Medicaid coverage, and most have become uninsured, since Congress and many
states overhauled the nation's welfare programs in 1996. The number of
low-income parents enrolled in Medicaid in 15 of the most populous states
dropped 27 percent between January 1996 and December
2000. "Our
study shows that hundreds of thousands of low-wage working parents were
cast adrift without health insurance when they did the right thing and
found jobs," says Ronald Pollack, Families USA's executive
director. At
the same time Medicaid enrollment decreased, the number of workers getting
insurance through their employer did increase, according to the Kaiser
report. But, those gains were not enough to offset the declines in
Medicaid
enrollment. By
law, anyone leaving welfare is entitled to Medicaid for six months to a
year thereafter, but states have not always complied. And most states
place strict limits on how much a parent can earn and still qualify for
Medicaid. In 32 states, parents who work full time at the minimum wage of
$5.15 an hour earn too much to qualify for
Medicaid. The
main cause behind this crisis for these individuals is simple to
understand-most people moving from welfare to work take low-paying jobs
that do not offer health benefits. They are far more likely to have
problems getting health care than those who have continuous Medicaid
coverage. And even if they are offered benefits, they often can't afford
the premiums, let alone the cost of an individually purchased policy. A
typical monthly premium of $80 ($2,160 per year) for family coverage means
a $25,000-income earning family would spend more than 8 percent of their
income on health
insurance. One
hundred dollars in salary was the difference between having insurance and
not having it for a woman in her 50s that Mueller treated for diabetes and
hypertension. "She worked part time in a nursing home and didn't have
insurance," Mueller says. "But she earned $100 too much to qualify for
Medicaid. She'd borrow her sister's insulin and [had] lost so much vision
[that] she'd watch TV through a plastic pair of children's
binoculars."
Remember the
Children When parents lose insurance, so do their children.
Hundreds of thousands of children lost Medicaid when their parents lost
welfare benefits during the last half of the 1990s, the Families USA study
reports. Despite the decline in Medicaid coverage for low-income children,
conditions for them have improved somewhat during the 1990s, according to
the Kid Count Survey, sponsored by the Annie E. Casey Foundation. Infant
mortality, child death rates and pre-term birth rates are all
down. The
Kaiser report says that problems with access to care are less common for
children than for adults. The number of children covered by
employee-sponsored insurance grew somewhat during the last half of the
1990s, thanks to a strong economy. However, as with adults, this increase
was not great enough to offset declines in Medicaid enrollment, resulting
in a net increase in the number and percent of uninsured children. And
according to the Kaiser report, an uninsured injured child is 30 percent
less likely to receive
treatment. Richter
recalls a young boy who had a heart defect that made him vulnerable to
infections. His mother, a janitor, couldn't afford to take him to the
dentist when he developed a tooth infection. By the time his pain grew
intolerable, his heart was infected with bacteria from the mouth
infection. Spiking fevers, fatigue and chest pain developed a few weeks
later. He arrived at the ER with subacute bacterial endocarditis, which
required six weeks of preventable hospitalization. Damage to the boy's
heart was
irreversible. Medicaid
still covers one in five children-but only half of all poor children and a
quarter of all "near-poor." The 1997 Children's Health Insurance Program
(CHIP) covers uninsured children in families above Medicaid eligibility
levels but cuts off for those in families earning more than 200 percent of
the federal poverty level. Unfortunately, not all who are eligible for
CHIP know of this benefit. By 2002, Medicaid will expand coverage to
include all children under age 19 with incomes below the federal poverty
level. The bottom line for this insurance shell-game is this: From 1994 to
1998, the number and percent of uninsured children increased. Sixteen
percent of children were without insurance in 1998. Two-thirds of them are
in low-income families.
The House Is On
Fire More than half of the uninsured are Caucasian, but
racial and ethnic minorities are much more likely to be uninsured.
Twenty-five percent of African Americans in the United States don't have
health insurance, compared to 14 percent of Caucasians. Hispanics are the
least likely to have insurance among all ethnic and racial groups.
Thirty-five percent of them are uninsured, according to the "1999 American
College of Physicians-American Society of Internal Medicine (ACP-ASIM)
White Paper on Uninsured
Hispanics." Beneath
her professional composure, Dr. Helen Burstin's outrage simmers at what
comes through her door every day at La Clinica Del Pueblo free clinic in
Washington, D.C. Take, for example, a 37-year-old Latino woman-dead from
cervical cancer. "It's a completely preventable disease," Burstin says.
"No one should have cervical cancer in this day and
age." And
then there's Burstin's patient who has a brain tumor who's waited two
months for a CT scan. And another with a stroke who should be on blood
thinners, but he can't get in to see a specialist. "I'm putting him at
risk for another stroke," she says, "while I beat the bushes looking for a
specialist who'll see him. We spend most of the day on the phone calling
friends of friends-the informal network that is already overburdened. You
don't have to hunt for stories here. All my patients are uninsured, and
all have trouble getting
access." Burstin
says Hispanics have it extra rough in Washington, D.C., where the safety
net has bigger holes in it compared with other states. "I've got a guy
with an ugly stress test and a bad heart who needs to see someone now,"
Burstin says. But even if she finds a doctor who'll treat him, hospitals
don't want to give free tests, financially beleaguered as they are by the
1997 Balanced Budget Act. "The people who get hit the hardest in our
somewhat tattered health-care system are the ones who can't get timely
care. They usually don't have insurance. They're the ones who get real
morbidity, which costs all of us. As a society, we're really shooting
ourselves in the foot by not giving these people access to care," Burstin
says. Hispanics
are more than twice as likely to work for an employer who does not offer a
health plan than are African Americans or Caucasians. Thirty percent of
Hispanic children are uninsured, compared to 20 percent of
African-American children and 13 percent of Caucasian children.
"Hispanics," the ACP-ASIM report says, "bear a heavier burden of illness
and death because they don't have insurance." Hispanics are six times more
likely than Caucasians to suffer end-stage renal disease caused by
diabetes. Mexican-American women are up to 3.5 times less likely than the
general population to seek care to control hypertension. Uninsured
Hispanic women with breast cancer are 2.3 times more likely to be
diagnosed at a later stage. And uninsured Hispanic men with prostate
cancer are 3.75 times more likely to be diagnosed with late-stage
disease. It's
tempting to chalk these differences up to genetics, but you would be wrong
to do so, Richter says. "Social class, not race or ethnicity, predisposes
someone to higher mortality," she
says. Canadian
studies compared cancer survival across socioeconomic lines and found less
class difference in survival in Canada compared to the United States. "One
could conclude," Richter says, "this is because Canada's system provides
equal benefits to all Canadians, whereas we don't. U.S. studies show that
when the insured and uninsured are hospitalized with the same illness, the
uninsured are more likely to die, mostly because they delayed care, not
because they are Hispanic or
black." The
uninsured life for African Americans isn't much easier, especially for
men. Between 1980 and 1990, African-American men lost 1.8 years of life
expectancy, making them the only demographic group actually dying younger
than they used to. As a group, poor African-American men are
disenfranchised not only from the health-care system but from society as a
whole, with the highest rates of incarceration and violent death. "Men are
dying-the house is on fire," says Chicago internist Dr. Eric Whitaker.
"Most government health programs and social services focus on poor women
and children." So Whitaker decided to do something for this overlooked
group of
Americans. Last
year, he opened Project Brotherhood, a free clinic for African-American
men in his own Woodlawn neighborhood on Chicago's South Side. The
community boasts one of the worst rates in the city for HIV, sexually
transmitted diseases, heart disease and
homicide. "I
talked to guys," Whitaker says, "and learned that not having insurance is
only one barrier to health care for black men. They told me they felt
disrespected when they went to traditional clinics. The doctors weren't
like them. Most of the patients were women and children, and [the men]
felt uncomfortable. I learned I had to create another reason besides
health care to get them to come to the clinic, so we offer free hair cuts
and pizza and a relaxed atmosphere where they'll feel comfortable."
Frayed Safety
Net Though well-intentioned, the nation's safety net is
catching fewer of the nation's most vulnerable, according to an Institute
of Medicine report. How the nation's safety net currently works to help
the millions of uninsured can be compared to the futility of an
administrator trying to sell cookies to save a financially troubled
hospital-it just doesn't
work. "If
the economy slumps and the number of uninsured climbs to 50 million, we'll
have something approaching a domestic crisis on our hands," says Dr.
Quentin Young, a Chicago internist and national coordinator of Physicians
for a National Health
Program. Richter
thinks of the nation's safety net as a false-bottomed prop in a black
comedy when she remembers the young electrician in florid diabetic renal
failure who died at age 37. She saw him for seven years. "When he went
blind and was unable to work, he qualified for Medicaid," she
says. Officially
disabled, the electrician qualified for Social Security Disability. But
then he no longer qualified for Medicaid, which meant he could no longer
pay for his medicines, which Social Security does not cover. To pay for
his medicine, the blind electrician went back to work. He'd feel his way
along the wires. "The hoops of desperation people go through-it's
disgraceful. It makes me sick," Richter
says. Surveys
show most Americans believe the uninsured can get health care if they
really need it-if not at a free clinic, then at an emergency room or
through some government program. And most Americans think Medicaid takes
care of the
poor. But
Medicaid covers only 41 percent of the poor, even less than it used to
since welfare-to-work reforms. Single adults and childless couples don't
qualify for the program. LeBow believes a lot more who aren't on Medicaid
could be if states made it easier to apply. "States make it hard by
requiring 16-page applications," he says. "It's the official policy in
most states to try to minimize how much they have to spend on
Medicaid." There's
always the emergency room, the primary source of care for many uninsured
and also the most expensive. But by the time most uninsured go to the ER,
their problem is much more serious. One of Richter's patients showed up at
the ER with a massive hand infection that was streaking up his arm from
cellulitis. "It would have been so much cheaper if he'd come in earlier
and got treated as an outpatient instead of needing inpatient IV
antibiotics and debridement," Richter
says. Many
uninsured are afraid to go to the ER, according to Mueller. "They're
afraid of the cost," he says. "They're afraid they'll end up with a
collection agency after
them." Even
when the uninsured go to the ER for nonemergencies, they can't afford to
pay for follow-up care. "They go untreated and sometimes undiagnosed,"
Mueller says. "Clinics won't even offer them an
appointment." And
emergency rooms can't do much for people with chronic diseases anyway,
Richter says. "You can't get dialysis in an ER. You can't get chemotherapy
or blood pressure
pills." In
the end, defaulting the uninsured to emergency rooms costs more than
insuring them and is one reason, according to Mueller, U.S. health-care
costs are so high compared to those of other countries. The United States,
for example, spends $4,000 per capita, twice as much as Canada and almost
twice as much as Germany, both of which insure all its citizens. "We know
it's cheaper to provide universal coverage," Richter says. "Instead of
paying for insurance, we should pay for care and stop filtering the money
through expensive insurance overhead. Instead, we have competing entities
vying for the healthy and ignoring the 10 percent who generate 70 percent
of health-care
costs." Free
clinics and community health centers provide care for many uninsured (see
"An Even Exchange," p. 37), but most have limited resources. They see
patients on a walk-in basis and do not always operate on a preventive
primary care model, preferring instead to mainstream patients into the
system for follow-up care. "These clinics are simply altruistic responses
to an intolerable problem," Young
says. Doctors
and hospitals do not provide as much charity care as they used to, because
of managed care's focus on revenue and productivity, according to a study
published in the Journal of the American Medical Association. "The
charitable impulse in American medicine has been attenuated," Young
says.
What a Difference Insurance
Makes Life without health insurance can mean the difference
between getting care and not getting it and in some cases between living a
long, healthy life and a short, unhealthy
one. What
life without insurance does to people's pride and dignity bothers LeBow
almost as much as the unnecessary sickness and death. LeBow saw an older
man with congestive heart failure who didn't come in to be treated until
it was so bad his legs looked like water balloons. "Why didn't you come
in?" LeBow asked him. "Because I still owed you $12 from the last visit,"
the patient replied. "People have pride," LeBow says. "If they don't have
insurance, they won't come in no matter how sick they
are." "I
don't want to be a beggar," a 64-year-old librarian told Mueller. "I just
pray I can make it seven more months when Medicare will pay for what I
need." Then
there's Mueller's patient who maxed out her credit cards to get the
medicine she needed because she didn't want to burden her son. "I have my
pride," she said
simply. Whether
you have it or don't have it, health insurance controls your life, Mueller
says. "I've got patients who won't get married because they'll lose their
coverage. I've got patients who got married just so they could get
insurance. People refuse to quit jobs they hate because they'll lose their
insurance." And
then there's the Hispanic mother who came to LeBow's clinic with her
17-year-old son, who needed antibiotics for his septal defect and an
inhaler for his asthma. The clinic's pharmacy only charged her $8, yet the
mother started sobbing and left without the medicine. "We went after her,"
LeBow says. "She didn't have any money and felt ashamed. The system skims
off the healthy and leaves the poor and sick to fend for themselves. It
humiliates people and makes them beg. It's shameful. I see it every day
and it makes me very angry."
The Toll It Takes on
Doctors Patients without insurance force physicians to
compromise their best medical judgment. Richter recalls a 60-something
uninsured driver's education instructor who called in complaining of chest
pain. "She begged me not to send her to the ER, because she wouldn't be
able to pay the bill," Richter says. She tried to explain that she can't
diagnose chest pain over the phone, but the woman refused, so Richter did
her best differential diagnosis by phone. "It turned out to be a
respiratory problem," she says, "but it was still the wrong way to handle
it. You feed into what patients want and end up not giving the best
medical
advice." Another
of Richter's patients was an obese diabetic with atrial fibrillation and
chest pain. She refused to be worked up at the hospital because she'd have
too many bills to pay. "I treated her like an outpatient at her home with
beta blockers," Richter says. "I called her four times that night. It was
so inappropriate. The system forces you to practice inferior medicine on
the uninsured. You change medication every time a patient comes in and
switch them to whatever free samples you happen to have that day. That's
wrong. It goes against everything we were
taught." The
only thing keeping a suicidal schizophrenic stable is the free samples
Mueller finds on his shelf. Meanwhile, the woman's husband is on 10
different medications. "He wants me to give him free samples of 10
different medicines until he can find work," Mueller says. "It's
crazy." Richter
recalls putting a fast-food worker who needed amoxicillin on the much
stronger Augmentin instead because she had free samples and the woman
couldn't afford the amoxicillin. "Every day, I practice survival medicine
in an industrialized country," Richter
says. When
Burstin offers medicine, patients ration it. "I ask them," she says, "'Are
you actually taking the medicine?' They smile sheepishly, embarrassed, and
tell me they take it every other day so it'll last longer. Those with
hypertension are at increased risk for stroke. The diabetics are at
increased risk for eye and kidney
disease." It's
the lies that gnaw at Mueller. "The doctors lie, and the patients lie," he
says. "I even had a minister who lied so he'd get the care he needed. It's
ridiculous." Richter
routinely neglects to bill patients whom she knows can't pay. She
exaggerates symptoms so hospitals will admit her uninsured patients. "You
have to lie," she says. "It's degrading to have to do it, but it's the
right thing to do. I took an oath to help patients."
New Physician contributing editor Howard Bell is a
medical writer living in Onalaska,
Wisconsin. |