The TAP-IN Blog

A trillion here, a trillion there. Money to cover universal health care.

The amount of money being loaned, lost, borrowed and blown is beyond comprehension. Bailouts and deficits are now counted in the trillions of dollars. This after we'd had our minds exploded by the hundreds of billions spent on the war in Iraq. Not that sum pales in comparison.

So the shock of an estimate of $1.5 trillion over the next decade to pay for universal health care is buffered just a little bit. This number was arrived at by health care experts who advocate such a plan, but the Obama administration is not putting out such figures, obviously concerned that they would upset too many people.

On the other hand, has anyone come up with an estimate for the cost to all of us of having over 50 million people uninsured for those same 10 years?

Institute of Medicine sees "state of crisis" in health care

Reporting on the site of its sponsor, the Robert Wood Johnson Foundation, the Institute of Medicine (IOM) released America’s Uninsured Crisis: Consequences for Health and Health Care on February 24. (pdf)

The IOM issued 6 separate reports on the urgency of America's need to provide health care coverage to all. The most recent of these reports was released in 2004, but over the past 5 years, "there has been no comprehensive national effort to expand coverage to everyone."

The purpose of the current report "is to inform the health reform policy debate—in 2009—with an up-to-date assessment of the research evidence. This report addresses three key questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?"

The report confirms what would seem obvious - that people without health insurance are at much greater risk of getting serious illnesses - but it takes this kind of approach to bolster up Washington politicians to support bold action. And so the IOM recommends the following:

The committee recommends that the President work with Congress and other public and private sector leaders on an urgent basis to achieve health insurance coverage for everyone and, in order to make that coverage sustainable, to reduce the costs of health care and the rate of increase in per capita health care spending.

Hospitals Closing. Even the Insured Face Health Care Crisis.

A report out of New Jersey makes plain the fact that our health care system is crumbling, not only for those without insurance, but for all of us.

Eight hospitals in the state (New Jersey) have closed in the last two years, but the survey indicates the industry's economic pain is far from over.

 The most common trend is a growing demand for treatment by people without insurance, according to the survey, which included top officials from half of New Jersey 74 hospitals. Eighty percent of hospitals reported a spike in charity care patients, and 76 percent reported their emergency rooms were busier.

Over that same period, 72 percent of hospital executives also reported charitable contributions declined. The amount of cash available to run their institutions dropped by an average of 27 percent.

Last year, almost one out of every two hospitals in the state coped with the economic crisis by laying off workers and eliminating jobs. Already in 2009, 21 percent of those surveyed said they expected to trim jobs later this year.

"Contrary to business myths, hospitals are not immune to an economic downturn," said John Gribbon, president and CEO of CentraState Healthcare System in Freehold who also heads up the association's board. "Quite the contrary: hospitals struggle with the same financial difficulties that the other employers face -- plus they hold the added responsibility of providing an essential public service at a time when a growing number of individuals are in need."

The survey also found 60 percent of hospitals said patients are scheduling fewer elective surgeries and other procedures, and 17 percent reported closing clinics and discontinuing psychiatric services to save money.

Tracking Financial Pain in Atlanta's Health Care

We  are all members of this American society - a society facing many tough choices, but one that we at Tap-In believe is basically good and compassionate. What happens in a place like Atlanta has an impact on the rest of us and is certainly happening in other regions of the nation. When Tap-In began, we knew the health care system was in trouble. Today, that trouble is a fast-expanding crisis, driven by the combination of job layoffs, rising costs, reduced numbers of practicing health care professionals and financial distress across most health care facilities.

The faltering economy and payment crunch have hurt the state’s 170-plus hospitals, industry officials said.

“Elective procedures are decreasing rapidly,” said Kevin Bloye of the Georgia Hospital Association. “For a lot of hospitals, it’s their bread and butter —- hernia repairs, knee replacements, bariatric procedures.”

Hospitals are delaying equipment purchases and renovations, Bloye said. The credit crunch has raised their costs of borrowing money.

A recent American Hospital Association survey of 736 hospitals found about half have experienced an uptick in the proportion of patients unable to pay for care, which is putting pressure on hospitals’ financial health. Many hospitals, including some in Georgia, have cut administrative costs, staff and services.

Across the state, rural hospitals’ percentage of patients who have no insurance has climbed to 20 percent from 12 percent to 14 percent, said Jimmy Lewis of HomeTown Health, an organization of rural hospitals in Georgia.

As so many of the posts on this blog have described, the escalating problem is simple to describe.

1. If people don't have health insurance or cannot afford it, they will tend to not seek treatment.
2. They put off preventative treatment or diagnosis until they absolutely have to get taken care of.
3. If they have a free clinic nearby, they will arrange for an appointment.
4. If they can't wait for that appointment, they will go to the nearest hospital emergency room that will accept them.
5. The same lack of money that caused them to delay treatment will prevent them from paying their hospital bills.
6. The accumulation of thousands of unpaid bills burdens the hospital, often forcing the closure of ERs to the uninsured.

Free clinics are the last resort for a rising tide of our fellow Americans. We can hope for some kind of universal health care solution, but we dare not reduce our efforts to care for those who have not other options. One way or another, we all pay the costs for those of us who can't afford to maintain their health.

Among other medical trends amid the poor economy:

> The number of prescriptions filled in the United States fell 0.5 percent in the first quarter and 1.97 percent in the second, compared with the same periods in 2007 —- the first negative quarters in at least 10 years, research firm IMS Health said.

> A drug industry program called Partnership for Prescription Assistance —- offering free or reduced-cost drugs to low-income people —- has seen a major increase in applicants nationally, with the number of Georgians seeking this aid jumping from 4,000 in September to 7,000 in October.

> A flood of uninsured patients have recently sought services at Georgia’s network of “free” medical clinics. “A lot of them are new patients,” said Donna Looper of the Georgia Free Clinic Network. “I talked to people who have lost their jobs and have no health insurance.”

A Clinic Fights to Keep Providing Services

There are heroes out there, across the country, who simply won't stand for people not having options for health care. They sacrifice their own time and their own savings and financial security so that people more unfortunate than them can at least get some medical attention for themselves and their children.

Many regions in the U.S. have growing populations of families and individuals barely able to cover the essentials of housing and feeding themselves, much less paying for health care. In such areas, medical and health care services see little potential of profit, so they don't build facilities and don't provide services. Into the gap come free clinics or - in the case of West Valley, Utah - self-supporting clinics that serve both the completely uninsured and those who can pay through an insurance plan or Medicaid.

The WestView Community Health Center is "always near collapse due to short funds, and in the current slow economy, the clinic is seeing more patients while earning less money," as reported in the Salt Lake Tribune. LaRohnda Dennison and her mother, Goldie, founded the clinic after recognizing the lack of coverage in the West Valley area. They converted their medical billing service into a clinic that provides insurance counselling to its patients. But as the number of uninsured patients rises, the income from the barely insured is proving to be less than operating costs.

The clinic averages between 125 and 150 patients per day, many of whom lack insurance.

"We don't turn anyone away," LaRohnda said.

That means the $250,000 it costs to run the clinic each month comes from those few patients who do have insurance or Medicaid. The clinic has a financial counselor on hand to see if patients qualify for public assistance, but many are put on a sliding-fee scale and just pay what they can.

Maribel Huanco recently visited the clinic when her 18-month-old son, Mark, had a cold and fever.

Huanco lacks insurance, and said through an interpreter she could not afford health care for her three children without the clinic. She feels very comfortable with the Spanish-speaking staff, and believes even though the care she receives is inexpensive, the quality is second-to-none.

Huanco also received prenatal care at the clinic, which is one of the greatest areas of expense. The clinic employs two obstetricians, who each deliverabout 35 babies each month.

LaRohnda Dennison said the clinic could save thousands by stopping prenatal care because medical malpractice insurance is so high for the specialty, but she knows continuity of care leads to healthier pregnancies and healthier babies.

Many of those infants keep coming to the clinic after birth. Matthew Agresta, a family practice physician at the clinic, estimates 70 percent of his patients are children.

He sees between 20 and 30 patients each day, and treats a wide range of ailments. Much of his time is spent on well-baby care and other pediatric checkups, but he also removes moles, places IUDs and performs circumcisions and vasectomies.

To save patients money, the clinic's doctors perform many procedures that would normally be done by specialists.

Another challenge for Agresta and the other doctors is uninsured patients tend to wait longer before coming in for treatment. The doctors often see more advanced disease progression, which is usually harder to treat.

Follow-up visits are also difficult, because many patients are hard to track, not knowing their birth date and lacking a home address or phone number.

Hard Times

Washington Post reporter Travis Fox took a month-long trip around the United States to see how Americans were coping with the economic downturn and how it was influencing their votes in the election. He chronicled his journey in a weblog called "Hard Times" and accompanied his writing with video clips.

In this article titled "Uninsured Consequences", Fox visits Vicki Zeoli in Altoona, PA, and talks to her and her volunteer doctor at the local free clinic about her circumstances and those of the other uninsured people dependent on the clinic's services.

Zeoli’s doctor, Zane Gates, has recently seen a “dramatic increase” of people like Zeoli seeking free medicine in the clinic.

“When I first started, it was mostly people who had been suddenly unemployed,” he said. “Now it’s mostly the employed. With the economy getting worse and worse and worse that number is going to skyrocket.”

Uninsured Get "Wallet Biopsies" in Hospitals

In an article published in the Washington Post, a doctor practicing in Memphis, Tennessee describes the treatment that uninsured patients often get when admitted to hospitals where they have no insurance with which to pay.

Although the uninsured look like any other patients, it's easy to spot them: Their charts have places for their address, emergency contact and insurance information; an empty insurance box is a telltale sign. Some doctors examine this sheet before examining the patient -- a practice we refer to as a wallet biopsy.

Dr. Manoj Jain not only works in a hospital where he has witnessed this practice, but he also volunteers with his wife at the local Hindu temple clinic where they provide counseling for patients on vaccines and infections. As Dr. Jain explains, medicine is one of the only vocations where a professional provides uncompensated service to one fifth of the customers. Yet, that is the unavoidable situation facing hospitals today.

I do not discriminate at an individual level, but many doctors, including myself, discriminate more broadly by moving our clinics to wealthier parts of the city, for example. To compensate for the cost of treating uninsured patients (about 10 percent of my practice), I inflate my charges for all patients, thus increasing my income from commercial insurance. According to a Kaiser Commission report, uncompensated care for the uninsured cost $41 billion in 2004 , the majority of which was paid by the government.

Even a Clinic's Long Legacy Can't Pay the Bills

Not even 37 years of history can guarantee that a neighborhood health clinic can meet its expenses. Such is the case with the Whitmore Lakes Health Clinic in Michigan. The combination of past-due patient payments, a growing patient load and rising costs have added up to a debt of over $400,000. The community is sponsoring fundraising events to try and cut into the shortfall, but it's hard to see how used book sales and motorcycle poker runs will pay down the debt.

Doctors and students from the nearby University of Michigan medical school have long been a source of volunteers for the clinic, but with more than 1,600 patients relying on its services, the expenses still mount relentlessly.

"We believe the clinic serves an important need in the community by providing health care for everyone regardless of their income," says U-M second-year medical student Jessica Sedley.

"The doctors at the clinic are fantastic to work with and spend as long as needed helping to educate patients. I shudder to think what would happen to these patients if the clinic would close, and they'd lose their primary care physicians. They'd probably end up in an emergency room."

More than half of the patients who go to the Whitmore Lake Health Clinic are uninsured or underinsured, a number that Ely says continues to increase. The Clinic's annual budget is close to $500,000.

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.