• Rosalind Kaplan, M.D.


The rate of uninsured patients in our country is up, the highest it has been since the beginning of 2014, when the Affordable Care Act first mandated individual insurance coverage. Like many of you, I am very worried about this. I'm not surprised, as every time I see patients, I encounter a few, even in the generally affluent area where I practice, who have no insurance. Many of these patients are young adults, in their late 20s and early 30s. While those patients are less likely to have chronic medical problems than older people, they also rarely have resources that could cover the cost of care for anything more than a minor illness or injury. And even some of the patients who do have insurance have such high co-pays for some services, such as advanced radiology or physical therapy, or have such poor prescription coverage, that they end up going without recommended tests or treatment.

Examples of this, off the top of my head: a young woman with a suspected ruptured ovarian cyst tells me she's not going to get the ultrasound I ordered; she'll just have to go with the odds that it's a ruptured cyst and not ovarian torsion or a malignancy. A man with intractable headaches cannot afford to see a neurologist. A patient with poor healing of a fracture, in need of physical therapy, has such a high copay that, if he goes to P.T., he will not have enough money for food each week.

In the news today, I read about a school superintendent who took a febrile, sick 15-year-old student to a clinic herself, because there was nobody else to do it, and he was refused care due to lack of insurance. She then checked him in to another clinic under her own son's name. He was diagnosed with strep, and she also filled his amoxicillin prescription under her son's name. The superintendent was later arrested for insurance fraud, which is a felony.

No, I don't think insurance fraud is okay. But I have to admit that I had nothing but sympathy for her and for the student-left with few choices, she made one that was illegal, but got care for a kid. Was it a moral decision? You decide.

What choices are there for the uninsured people out there? If they aren't eligible for Medicaid or Medicare, and can't afford insurance premiums, what should they do? One option is free clinics- there are municipal clinics, but they won't necessarily treat someone with no insurance and no way to pay. There are some volunteer clinics, often manned by medical students and residents overseen by a volunteer attending doctor, but these are few and far between, and the exact type of care needed by a patient may not be available. Emergency rooms are an option because they are required to provide care, but the patient will still get a bill, and will be sent to collections if they don't pay. Besides, the hospital is forced to eat the cost of this care, and uninsured patients most often go to the hospitals that can least afford this. And the cycle goes on, as insurance premiums rise if hospital costs rise... Besides, ER's will address emergent and urgent needs, but there is no continuity.

Think about this. The United States is the only industrialized nation in the world without universal coverage. Health parameters in many of these countries (health maintenance, life expectancy, infant mortality rates, etc.) are better than in the U.S. In other countries, health problems you already have are called your Past Medical History. But in the U.S., they are also called 'Pre-existing Conditions', and we live with the threat that these pre-existing conditions might not be covered, or that those with serious pre-existing conditions won't be able to get insurance if we lose the ACA. So where is the logic in maintaining the status quo (which is not really status quo, since life expectancy in the U.S. has dropped in the last year, and, as I said, the percentage of uninsured Americans is rising.)??

Meanwhile, the government has been shut down for 34 days, and some of the government workers who are on furlough or are working without pay have lost their health benefits because their insurance premiums have not been paid. Yes, it's temporary, but if someone happens to get sick or injured during a temporary lapse of insurance, they will either go untreated or incur costs that they are unlikely to recover.

When I talk about these issues with people, I often hear things like 'I hear that care in countries with socialized medicine is bad.' Or 'People have to wait for months or years for care in those countries.' Or 'People have no choices in those countries. I want to choose my care.' There's no perfect solution to anything. But if the health of the population in these countries is better than the health of our population, we have to really question these preconceived notions.

There will always be 'extra options' for the wealthy. I don't think there's any way to avoid two-tiered systems. Right now, I'd be okay with that- let's just start taking baseline decent care of the general population.

So what should we do? I think we should be pushing for universal coverage. Think about joining Physicians for a National Health Plan. In the meantime, for those with the time and the opportunity, consider volunteering (for some people, malpractice coverage prevents it- another really messed-up part of our system). Make sure you don't let your own health insurance lapse.

And pray that the government reopens....

#patientoutcomes #patientcare #patientsafety #emergencymedicine #medicalpracticemodels #urgentcare #doctor #medicaladministration #primarycare #physician

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