The TAP-IN Blog

NPR Presents Debate on Government's Role in Providing Health Care

Through a program called Intelligence Squared, NPR produces "Oxford style" debates on public issues. On September 24 it broadcast a debate on the premise, "Universal health coverage should be the federal government's responsibility." Both edited and non-edited audio of the debate are found on the linked page. The moderator was John Donvan of ABC News and the debaters included two Canadians with differing views on the suitability of their system as a role model for an American national system.

Audience opinion on the question was polled before and after the debate.

As the web page states, by way of background:

It's a debate that has raged on and off in the United States for more than a century now, with no clear resolution in sight: whether to guarantee healthcare for every American.

During the past 100 years, medicine has advanced from a rudimentary craft to a scientific pursuit capable of near miracles. Its cost has increased accordingly: In 2006, U.S. health care spending hit $2.1 trillion, or roughly $7,026 for every man, woman and child in the nation.

As a percentage of the gross domestic product, that is substantially more than any other country. Yet a substantial portion of the American population — 47 million that same year — lacked any health insurance, according to the U.S. Census Bureau.

As the number of people without insurance increased, so did concern over the problem. But Americans have never neared consensus about what role government in general, and the federal government in particular, should play in ensuring health coverage for all, despite the fact that every other industrialized country has long since established some system of universal insurance.

The stage appears set for yet another major national health insurance debate in 2009, so the Intelligence Squared U.S. series decided to get a head start by choosing it as the topic for its first event of the season. The organization sponsors Oxford-style debates featuring six experts — three on each side — who try to sway an audience that votes before and after the session.

The Rising, Spreading Burdens of Health Care Costs

Two recently released studies provide a fresh overview of the forces in the disjointed American health care system that are driving more and more people into financial stress, insolvency and the ranks of the uninsured. Even without the market-driven economic crisis that looms over the nation's future, millions of Americans face their own financial crises in paying for health insurance and the costs of treatment.

The studies, by the Kaiser Family Foundation and the Center for Studying Health System Change, were completed earlier this year before the financial markets reached their current state of crisis. But policy analysts say the findings underscore the mounting additional strain that medical care is placing on working Americans.

“The problems people are having paying for health care and health insurance are a central dimension of the economic and pocketbook concerns right now,” said Drew E. Altman, the president of the Kaiser Family Foundation, a nonprofit health research group that conducts an annual survey of employer medical benefits.

The studies, policy analysts say, underscore the need for the government to address the growing unaffordability of care, despite the distraction — and cost to taxpayers — of a proposed $700 billion bailout of the financial sector.

The Kaiser study found that employees are paying more out-of-pocket for their health insurance coverage (more than double what they were paying in 1999) and the study by the Center for Studying Health System Change found that more than 20% of households last year had problems paying medical bills. Of these, more than half had to borrow money to pay medical bills and about one fifth considered declaring bankruptcy.

The study estimates that 57 million Americans live in families struggling with medical bills, and 43 million of those have insurance coverage. “It’s hitting both the insured and the uninsured, and it’s hitting middle-class families,” said Karen Davis, the president of the Commonwealth Fund, a nonprofit research organization that financed the study.

Because they are already in debt over their medical care, some families start forgoing treatments, even for serious or chronic conditions, Ms. Davis said. By deciding not to fill a prescription for high blood pressure medication or failing to go to the doctor for diabetes, they are at risk of incurring more serious and costly problems that can land them in the emergency room.

Some States Improving Children's Health Care Coverage

It's not all gloom and doom out there on the health care front. There's evidence that - at least at the state level - some progress is being made on behalf of children in America.

The Center for Children and Families at Georgetown University has released a report, States Moving Forward: Children's Health Coverage in 2007-08, summarized as follows:

To a surprising extent, given the weakening economy and growing fiscal strains, states have continued to move forward in their efforts to expand and improve health coverage for children. Notably, over the last year, nineteen states provided health coverage for more uninsured children and families by expanding Medicaid and the State Children’s Health Insurance Program (SCHIP) and/or cutting red tape to make it easier for eligible children to enroll, and stay enrolled, in the programs.

And in the Health Care Blog, Jocelyn Guyer brings us accounts from three of those states who presented at the National Health Policy Forum last week. Here's Guyer's description from Louisiana:

Louisiana has made significant progress in covering kids in recent years by expanding coverage through public programs (Medicaid and the State Children’s Health Insurance Program) and making it easier for families to sign up. It also has become the very best state in the country at “plugging the hole in the bucket.” While it is not uncommon for states to lose about one-third of their children when they come up for renewal, Louisiana loses fewer than one in a hundred kids - less than 1 percent.  It took leadership from the state’s political leaders and a commitment to changing the workplace culture of eligibility workers, but, otherwise, nothing too fancy.  The secrets?  Families no longer have to pull together copies of eight consecutive pay stubs when applying for coverage, they can renew by phone, and, whenever possible, the state uses information it already has on hand from other state programs to figure out when children remain eligible for coverage.

PBS to Air Documentary on the Uninsured and Nominees' Health Care Proposals

Public interest documentary producer P.O.V. will be presenting a night of programming on the condition of health care in the United States. As reported on the American Documentary web site:

Tuesday, September 30 on PBS: Critical Condition by Roger Weisberg What happens if you fall sick and are one of 47 million people in America without health insurance? Critical Condition by Roger Weisberg (Waging a Living, P.O.V. 2006) puts a human face on the nation's growing health care crisis by capturing the harrowing struggles of four critically ill Americans who discover that being uninsured can cost them their jobs, health, home, savings, even their lives. Filmed in verite style, Critical Condition offers a moving and invaluable expose at a time when the nation is debating how to extend health insurance to all Americans. A production of Public Policy Productions in association with Thirteen/WNET New York and American Documentary / P.O.V.

Immediately following the 90-minute broadcast, PBS's MacNeil/Lehrer Productions will present a half-hour special, "Rx for Change," exploring the presidential candidates' proposals for health care reform. Susan Dentzer, health correspondent for The NewsHour With Jim Lehrer, will moderate the discussion, which includes spokespersons for the candidates and distinguished health policy experts.

Down Economy Forcing People to Cut Health Care Spending

A survey last month by the National Association of Insurance Commissioners found that 22% of the 686 consumers asked were blaming economic woes for their cutting back on visits to the doctor. And 11% claimed to be reducing the number prescriptions they were filling.

The survey results - as reported in the Wall Street Journal - explain some overall market research findings for the past year:

The number of prescriptions filled in the U.S. fell 0.5% in the first quarter and a steeper 1.97% in the second, compared with the same periods in 2007 -- the first negative quarters in at least a decade, according to data from market researcher IMS Health. Despite an aging and growing U.S. population, the number of physician office visits also has been declining since the end of 2006. Between July 2007 and 2008, the most recent month for which data are available, visits fell 1.2%, according to IMS.

The article goes on to describe the plight of a car salesman, whose dropping sales have forced him to delay his sons' check up visits to the family doctor. In order to save money to pay for those visits, he is canceling his own health insurance policy.

Many others are reported to be putting off appointments for valuable health screening procedures. Thus we see how even the insured or partially insured are falling into the same health care predicament faced by the uninsured who don't make use of health screenings available through free clinics.

Even the Insured May Struggle to Find Doctors

While the uninsured are challenged to find any medical care at all that they can afford. those with insurance do not necessarily face smooth sailing. Not only are many physicians opting out of treating those dependent on Medicare or MediCal, but fewer new physicians are choosing to fill the role that we've come to depend on for most health services.

The primary care physician - the internal medicine specialist who serves as the first line of health defense and referral for all - may become a rare resource if trends continue for incoming medical students. A survey published in the September 10 issue of the Journal of the American Medical Association found that internal medicine is the last option chosen by the sample of 1,177 students at 11 U.S. medical schools. Only 2% of the respondents chose that path for their careers. A similar survey from 1990 found 9% choosing internal medicine.

“It’s getting increasingly difficult to find a (family medicine) doctor especially in rural areas. It’s a tenuous situation as students look to careers that are financially rewarding because they have a lot of debt and they’re looking away from primary care,” Dr. Mark H. Ebell, the study’s author and a primary care doctor at the University of Georgia, said.

For example, medical students owe a median of $140,000 in student loan when they graduate.

There are many reasons for which medical students look away from primary care, starting with the long hours they have to work and the low pay they get for what they work. Many medical students are simply turned off by the amount of paperwork general internists have to deal with, a situation that doesn’t offer them a chance to a personal life. Many students today seek careers that offer them the chance to balance their work life with their personal life. And the thought of dealing with elderly patients with complicated diseases is another thing these medical students consider when choosing internal medicine.

NeedyMeds Provides National Database of Free and Low-cost Clinics

The non-profit organization NeedyMeds, which provides information and resources to those requiring assistance for medication and medical care costs, now provides a database that includes over 2,100 free or low-cost clinics and is, according to its press release, the most extensive list available in the country.

According to a report released by the Urban Institute, at least 22,000 adults in this country died in 2006 because they did not have health insurance. “ As bad as this statistic is, it does not include all the people who will die or have medical problems in the future because they do not have their medicine today,” said Rich Sagall, MD, President of NeedyMeds.

“We are adding new clinics everyday and this database is important to the work of NeedyMeds because low-cost medicine programs can’t help who people who cannot afford to see a physician,” continued Dr. Sagall.

The NeedyMeds free clinic database is the only one of its kind currently available and the need for this information is growing and critical. Minnesota, for example, has 36 free clinics in the database. A new report from Families USA says that more than three people die each week in Minnesota due to lack of health insurance. Like many of the other programs found on NeedyMeds, the free clinics are for uninsured and underinsured people with low to modest incomes.

NeedyMeds invites anyone to submit clinic listings to the Free Clinics page of its Web site if they are not already included in the existing database.

Free Clinics: a Finger in the Dike

Even as more free community clinics come into being the rising tide of unemployed and uninsured is creating demands that clinic resources cannot meet. This article from the Charlotte (North Carolina) Observer includes several stories of people who have worked hard, but nevertheless found themselves depending on the Charlotte Community Health Clinic for vital care. And yet, even those who show up early to stand in line often fail to gain entry because the clinic lacks the funding and volunteers to accomodate them.

At 9 a.m., when the doors to the free clinic finally opened, the first 50 people crowded into the waiting room and started filling out paperwork. Outside, 67 were turned away.

“I'm very sorry,” said clinic staffer Amy Gemereth, who passed out flyers with names of other free health services.

That was little consolation for Adrienne Waller.

“I've been trying to do this for two months,” said Waller, who moved from Las Vegas in December and hadn't yet found a job.

“I keep getting here earlier and earlier, and I keep getting turned away. This is ridiculous.”

The demand for services by free clinics is rising as the economy sours and more people lose there jobs, with fewer employers providing full health care benefits. "We can't serve them all," one clinic board member was quoted.

Free clinics are part of a fragile patchwork that fills some gaps in the U.S. health system.

Those who qualify can get primary care, free prescription drugs and education about how to prevent illness or control a chronic disease.

In Mecklenburg, the largest free clinic is Charlotte Community Health Clinic on Eastway Drive at Central Avenue, which has nearly 280 volunteers, including 40 doctors.

Many of the uninsured, out of desperation, go to hospital emergency rooms when they can't get treatment at a clinic. They usually experience long waits and are then sent huge bills; the cost differential for getting the same health care service from a clinic vs an ER is dramatic.

“The average cost to go to the emergency room for a nonemergency is about $1,600,” said Amanda Berrier, executive director of the S.C. Free Clinic Association.

It would have cost a free clinic about $65 to provide that same service, she said.

Free clinics save hospitals from incurring medical bills for patients who can't pay. “It really does make sense to have a strong free clinic system,” Berrier said, “regardless of what we do about universal health care.”

Not having health insurance increases the likelihood that people will forgo or delay care. And that means they'll be sicker when they're diagnosed.

Survey Finds 37% of Retired North Carolina Physicians Interested in Volunteering

A survey performed by the Cecil G. Sheps Center for Health Services Research, Department of Family Medicine, and School of Social Work, The University of North Carolina at Chapel Hill, and reported in the Annals of Internal Medicine, aimed at determining the interest of baby boom generation doctors in health care–related volunteering during retirement. The 910 physicians surveyed were 55 years of age or older and practiced in North Carolina and were trained to provide general medical care to adults.

Results, as published in the report abstract in the Annals included the following:

Of the respondents, 89.8% were male and 87.4% were white; 57.4% worked full-time, 21.7% worked part-time, and 21.0% were retired. Of current retirees, 37.1% expressed interest in volunteering. Areas of greatest interest were medical teaching, working in free medical clinics, and international care. Strong incentives included staying mentally active (67.3%) or involved in medicine (61.2%) and contributing to society (60.5%). Substantial barriers included concerns about malpractice (61.5%) and paperwork or bureaucracy (46.0%). The majority of respondents (66.7%) felt that lack of payment would not influence volunteering.

A Retired Nurse Finds Her Volunteer Niche

The Charleston, South Carolina Post and Courier published this story of a 68-year-old native Columbian - Louisa Barnett - who, after a career of nursing, now "serves as a vital link between caregivers and their patients and families"

Four years ago, she volunteered to assist in the newborn nursery at Bon Secours St. Francis Hospital. When the nurses learned of her bilingual skills, she was asked to help teach baby care to new, Spanish-speaking mothers.

Speaking by phone from Bogota, Barnett said of her volunteer work, "It really gives me good satisfaction and warmth in my heart because the people are in need."

During the past year, Barnett was forced to take a temporary leave from her volunteer work to be treated for liver cancer and then undergo a quadruple heart bypass operation. After seven months of chemotherapy, her cancer is in remission. When her health got better, she returned to rocking babies at the hospital.