Has Health Care Flatlined?
Good Times Weekly February 1-7, 2007 By Peter
Koht
As health care reform sparks heated debates in Washington and Sacramento, GT investigates the issue in Santa Cruz County
On any given day, more than four million Californians walk a dangerous tightrope
every day by not carrying health insurance. “Doug” fell off.
Seven years ago, this kind, slightly gruff man in his forties moved into
the studio apartment behind the house that I was renting with three other
college cohorts. While our worries rarely crept out of the academic and
interpersonal realms, his sleep was disturbed by much heavier concerns.
Doug hauled yard waste and construction refuse for a living. He was self-employed
and worked damnably hard to keep his business afloat. Even when we met
him, he was powerfully built, with his forearms and skin tone attesting
to a life spent lifting heavy objects under a blazing sun.
One day on the
job, months before moving onto our property, Doug was clearing refuse from
a roof and took a bad step through a skylight. When his coworkers on the
project found him he was lying on a concrete floor with a badly damaged
back and legs.
Lacking insurance, he was patched up at the emergency room
and told that he needed serious medical assistance to recover from his
accident—namely surgery. But that assistance came at a price far
too steep for Doug to pay. Worker’s comp was a luxury that his one-man
firm couldn’t provide.
Forced to continue to make a living, soon
every pound he lifted and hauled to the landfill became torturous. His
productivity fell, and checking the mailbox became an exercise in fear.
In order to pay his outstanding medical bills he was forced to move to
a smaller place and forgo many of the luxuries that he’d earned over
the course of his working life. By the time his truck pulled up to our
address, about the only thing he was left with was a bottle of painkillers.
For six months, my friends and I watched Doug decline into a haze of depression
and drug abuse. Early on, most mornings his truck was missing by the time
we rode our bikes up to UC Santa Cruz. But by late winter, when homeowners
were ringing to have Doug clean up the storm damage and overgrowth off
their property, he was having trouble getting out of bed.
Eventually the
insomnia brought on by the painkillers was doused with liquor, which did
nothing to improve things. Nutrition was forsaken for canned soup and Marlboros
and we cowardly four abandoned our beautiful back yard to avoid having
to talk to Doug.
Coming home from late-night revelry to our happy home,
we’d occasionally hear his anguished cries from his studio where
he suffered alone. By late spring, when we were preparing to graduate,
Doug hadn’t paid his rent in three months and was a walking ghost.
Luckily our landlords were compassionate people and while they made it
clear that Doug would soon have to find another place to live, they would
hold off on taking that action until they found him some assistance. After
myriad phone calls around the county and dozens of hours on hold, relief
was found via the Veterans’ Administration and a plan for Doug’s
future was in place.
One day in June, we watched Doug stand by on crutches
as our landlords loaded up his truck with his possessions. It was one of
the saddest things that I had seen and it was all brought on by a single
misstep.
Rewiring the System
Perhaps the most tragic part of this story
is that if Doug had fallen off a roof in Argentina, Austria or Finland,
he would have been fine. In Ireland, Israel or Japan his medical bills
would have been taken care of. In Saudi Arabia, Taiwan or France, he could
have received the surgery he so badly needed under government-run universal
health care. But this is America, capitalism’s home field, where
all too often profits and processes are valued above proper medical care.
Despite having some of the best-trained medical professionals in the world
armed with state-of-the-art medical devices and facilities, the country’s
healthcare system is broken. Now, a growing chorus of doctors, patients
and politicians are crying out that the time to radically reform it is
at hand.
In the 2007 State of the Union address delivered on Jan. 23, President
Bush focused much of his floor time on the topic, calling on Congress to
enact a number of reforms that will make health insurance more portable,
improve access to health information technology and assist vulnerable Americans. “On
the critical issue of health care, our goal is to ensure that Americans
can choose and afford private health care coverage that best fits their
individual needs,” the President said before asking the congress “to
give lower-income Americans a refundable tax credit that would allow millions
to buy their own basic health insurance.”
But the Texas Republican
stopped short of calling for universal health coverage by stating that “a
government-run health care system is the wrong prescription.”
In
California, lawmakers on both sides of the aisle are already hard at work
at reforms that make Bush’s proposals seem pedestrian. Gov. Arnold
Schwarzenegger, the bane of spellcheckers everywhere, has made health care
reform one of the cornerstones of his administration. Since his State of
the State address on Jan. 9, his office has been seeking a legislative
author to make his new healthcare proposal a legal reality.
His plan seeks
to “extend health care coverage to all Californians,” through
a multi-pronged approach that places new responsibilities on individuals,
medical facilities and insurance companies. Central to his plan is the
idea of an “individual mandate” that will require people to
carry some kind of medical insurance. “Requiring people to carry
coverage is the most effective strategy for fixing the broken health care
system,” the governor wrote in his proposal. “The core problem
for California is that those with insurance pay the cost of health care
delivered to the 6.5 million uninsured.”
Citing reports by the New
America Foundation, the governor’s office believes that 17 percent
of the total cost of any insurance plan is actually assessed to cover the
losses that hospitals and doctors incur by treating and taking in indigent
patients.
Other highlights of the governor’s health care proposal
include the caveat that all children, regardless of immigration status,
will have coverage, employers with 10 or more employees would be required
to dole out 4 percent of their payroll on health care coverage and MediCal
payments will be significantly increased. Most radically, the proposal
would require all Californians to purchase plans that have minimum health
benefits and that carry at least a $5,000 deductible and a capped contribution
of $7,500.
While these are positive calls for reform, the plan is not without
its detractors at the state capital. State Sen. Sheila Kuehl, the chair
of the select committee on the Health Insurance Crisis, wrote an essay
on the governor’s proposal that was released on Jan. 16. One of the
faults that the senator found was that “every Californian could be
required to pay high premiums, high deductibles high co-pays and high out-of-pocket
expenses for very little coverage.”
When queried about the plan,
Assembly member John Laird says, “I am concerned about the individual
mandate. It seems to me that there is a chance that it could be problematic.
We need to make sure that access is available to everyone for healthcare.
The governor’s plan creates gains and losses for everyone, but it
is a good starting point for negotiations.”
Laird is currently working
to ensure passage of AB 13, which will ensure universal coverage for children
regardless of the legislative fate of the governor’s plan. He is
optimistic about its passage, which was blocked in the last legislative
session by the Republic minority during budget negotiations. “The
debate has moved much further along this year,” Laird says from Sacramento. “Insuring
all kids seems to be something that everyone can agree on now.”
Kuehl’s
plans are even more ambitious. Last year she authored SB 840, the California
Health Insurance Reliability Act, which would have radically altered the
health care landscape by setting up a single-payer system in the state.
(A single-payer system charges all health care costs to a single entity,
usually a government, and is paid for through tax revenues. Typically the
establishment of a single payer system negates the necessity of private
insurance companies.)
SB 840 passed in both houses of the state legislature
last year, but was vetoed by the governor who wrote in his veto statement
that he “cannot support a government-run health care system.”
Kuehl
plans to reintroduce the bill this month and hopes that this time, public
pressure will force its adoption. “The fact that the governor has
focused so strongly on health care is a good thing for California,” the
senator told GT on Jan. 24. “But the proposals that he made are disturbing.
They won’t lead to universal health care. The most broken thing about
the health care system now is that it is more and more difficult for individuals
to have any coverage at all. I would hope that we would being to address
the expansion of coverage that we make sure that it has to be truly affordable—not
just sham coverage.”
SB 840’s advocates, including the local
chapter of Health Care for All, are actively singing its praises. One activist,
Carol Robertson, says that the bill “is the only plan that takes
the private insurance companies out of the mix and puts all of the money
that is taken in and makes sure that it goes to actual medical care.”
“It’s
the best long-term strategy,” John Laird says about a single payer
system. “What the governor is trying to do is offer an increase in
access with the current system. I think that is a good first step, but
we will have to see if that is where we should end up.”
Two things
are certain in the legislative process. The first is that the process will
take a long time. The second is that the final product will look nothing
like what is currently on the table. What about the fierce urgency of now?
On the Firing Line
This year’s Community Assessment Project found
that 85 percent of Central Coast residents have a regular source of health
care. Of those 15 percent that needed health care and were unable to receive
it, the main reasons cited were that individuals either didn’t have
insurance or couldn’t afford the required treatment. So what should
indigent persons do when they find themselves in need of care? Like everything
else in the health care field, the answer is complicated.
Many simply go
to the emergency room when their health problems get out of hand. This
places a great deal of strain on the hospital that they choose to visit.
Statewide, it’s estimated that “More than 80 percent of all
Medi-Cal and uninsured patient visits to emergency facilities are for conditions
that could have been treated a non-emergency setting.”
Because they
are mandated to accept into treatment any patient who comes through the
door, emergency rooms are loss leaders for the hospitals that they are
attached to. This has led to a widespread trend of emergency room closures
throughout the state. Since 1995, 20 percent of Los Angeles County’s
emergency rooms have closed. There are 75 emergency rooms in the state
today.
“The impact is fairly significant,” says Dr. Terry
Lapid, Dominican Hospital’s Medical Director of Emergency Services. “There
are around 40,000 people in our county that are uninsured and many come
thorough our emergency room. Ideally, we would want people accessing care
at the appropriate level and not use the most acute level of care, the
emergency room, for their primary care needs.”
Dominican’s
Chief Operating Officer, Kelly Duffin, estimates that the total cost of
caring for the uninsured in the Emergency Room tops $7 million annually.
That figure includes $2.5 million in unpaid physician costs, $1.8 in emergency
call specialty coverage and another $2.7 in charity care. “We’ve
seen the level of uninsured patients that come through our doors increase
12 percent in the last year.” Health care providers have to recoup
the loss to remain fiscally viable. They do this through a process called “cost
shifting,” billing the loss to those patients and insurance companies
that have the means to pay. According to Rama Khalsa, the county’s
Administrator of Health Services, cost shifting now accounts for most of
your medical bill. “The cost-to-charge ratios for hospitals keep
going the wrong way,” she reports. “When I got here in 2000,
it was around 50-50. Now it’s around 35 percent for Sutter, 25 percent
for Dominican and 17 percent for Watsonville Community Hospital (WCH).
That means for every dollar on your bill at WCH, there are 17 cents of
actual costs for service and the rest is cost shifting.”
Many experts
interviewed for this story believe that the best idea coming out of Sacramento
right now is the focus on trying to stop cost shifting. Most believe that
health insurance premiums and costs would stabilize were the uninsured
given some way to cope with the costs associated with health care.
Where
Do We Go From Here?
Were low-income patients to heed Dr. Lapid’s
advice and seek the appropriate level of care rather than visiting the
emergency room there are multiple options open to them. But it’s
not simple.
“It’s not an easy story and it’s hard to
tell under the gun,” says Leslie Conner at the Health Improvement
Partnership, a nonprofit collaboration of health professionals, hospitals
and safety net clinics working to improve the county’s health care
system. “It’s a big complicated story and that’s why
it’s so complicated to fix. It’s really a vicious circle.”
In
Santa Cruz County, a number of “safety net” clinics exist to
try and take the load off our two main emergency rooms at Dominican Hospital
and Watsonville Community Hospital. Salud Para La Gente, County Health
Services, Planned Parenthood and SC Women’s Health Center all move
mountains on miniscule budgets to deliver quality care to low-income residents.
In addition to their heroic efforts, a number of innovative programs have
been developed to increase access to heath care. Conner, who also heads
the county’s Healthy Kids initiative that provides care to low-income
children, cites a program called Project Connect when talking about how
to reduce emergency room burdens. “It does intensive case management
for primarily homeless clients that repeatedly visit the emergency room
to get them into proper primary care,” Conner says. “By setting
that up, it saves a lot of money by curtailing inappropriate emergency
room use. The reduction is around 54 percent. We’re looking for additional
funding to grow that program so that we can case manage more clients.”
But
funding for that program, which is administered by the Homeless Person’s
Health Project, along with other vital services like MediCruz, a country-administered
program that provides limited scope coverage to low income county residents,
is constantly at the whim of capricious state leaders.
“Not only
have we not seen an increase in funding for MediCruz,” Khalsa reports, “it’s
seen numerous cuts since it started in 1983. It’s now funded at less
that $150,000 when it used to be $2 million. It’s in tatters to be
totally honest. We are hoping that the various reform measures in Sacramento
have some legs.”
Khalsa and her staff are hoping to secure state
and federal dollars to start a program called the Coverage Initiative that
would backfill both Project Connect and MediCruz by increasing cooperation
amongst hospitals, safety net clinics and medical groups to create a better
system of case management, streamline communications, medical record transfers
and referrals. The grant applications are in, only time will tell if the
project gets off the ground.
When asked what she would like to see improve
in indigent care in the county, Khalsa says, “I’ d like to
see the physician counts at the safety net clinics expand so they could
take large numbers of new clients. I’d also like to see some funds
set aside so clients can see specialists. They don’t treat cancer
or heart maladies in primary care. One of the ways we can achieve this
is through further funding for programs like the Central Coast Alliance
for Health.”
The Central Coast Alliance for Health (CCAH) is a nonprofit
medical plan that has been laboring for nearly 11 years to link 86,000
low-income clients with health care resources in both Santa Cruz and Monterey
Counties. Its executive director, Alan McKay, says that his agency “works
magic locally doing a job that the state wouldn’t be able to do successfully.”
The
CCAH links its clients (and their MediCal benefits), to community agencies,
clinics and doctors that act as their primary care providers. “This
means that they don’t have to visit the emergency room for uncomplicated
conditions,” McKay says. “Having primary care physicians means
that they are better able to navigate their way through the health care
system."
But despite the great work that all of these programs accomplish
on a daily basis. Every single person contacted for this story believes
that the entire health care system is not only broken, but heading towards
a messy implosion.
“It can’t continue the way that it is going,” Khalsa
says at the end of our interview. “It’s just insane. The system
is broken. It’s not the quality of care that’s broken, it’s
the access to it and the financing of it.”
Off The Grid
Maria Greaves
is a doctor that’s decided to remove herself from the complications
of the current health care schema by setting up an “ideal micro-practice.” Based
on Soquel Avenue, Greaves isn’t part of a medical group, she has
no insurance connections and deals in that most old fashioned of financial
instruments—cash. After surveying the costs of health care in the
county for a standard doctor’s visit last summer when she opened
her practice and found it was around $90, she decided to charge $45.
She
keeps her client load small and her costs and overhead even smaller by
working without an office manager, a medical billing and coding specialist
or six receptionists. She even answers her own phone.
When asked about
the political reforms in process, she is pessimistic. “I don’t
think these reforms will work. It’s hard to know what will actually
come out versus what they say will happen. The more you keep a middleman
in the picture—public or private—the more obstacles there are
to accessing care.”
What she values about her practice is a commodity
that has almost been stripped out of the corporate model of care—face
time. A veteran of a local medical practice, Greaves says that she used
to spend only around five or 10 minutes with each patient and now she is
able to spend around an hour with each person who comes into her office. “The
natural structure of most offices is that a doctor would have to see 20
patients a day to see any income. That seems ridiculous. You can’t
spend quality time with patients. My philosophy of care is that you can
make most diagnoses of people without even laying hands on them, you just
have to listen.”
When queried about indigent services, she says that
she does take on some people that she knows will be unable to meet her
rate schedule. “I have a couple of people who can’t afford
me and I work out those cases on a special basis. I’ve taken Ziploc
bags of change. I’ve worked out payment plans. I don’t exclude
anybody.”
While Greaves’ solution isn’t a fix for the
large-scale problems in the health care system, it is a novel solution
to the stresses that the current schema places on health care professionals.
Her small, 300-square-foot office works for both her and her patients.
“I
want to make people feel better and go home and feel like I did something
with my work day,” Greaves says. “But no matter what the scale
is, it’s a hard balance to find between having adequate access to
health care and having a high quality service.”