Your Health Care System At Work-A Primary Care Conundrum

Your Health Care System At Work

Today, at 9:00AM I received a call from the school nurse indicating my sixteen year old son was in her office with a very low heart rate (in the 40’s). This in and of itself was not that distressing to me since my resting heart rate was 52 in my twenties,  and it is a family trait. However, between the time I received her call and attempted to contact my son’s primary care provider, I received another call indicating that his heart rate was so erratic they had called 911. The triage system then required that he be evaluated by the fire department paramedic and transported to the local emergency department. Once there, he was admitted and then evaluated with X-rays and other diagnostic equipment. In the meantime, I had called my primary care provider at Washington’s Community Health Plan three times, was on hold for 15 minutes, and been patched through a “call center,” all the while never having spoken with a clinician. So, the delivery of “primary care” to my son was handled by non-primary clinicians, because the primary care provider was not available.

This scenario illustrates one of the problems in our health care system, which is we have a shortage of primary care clinicians.  It is important to note this reflects a dearth of doctors who are willing to work within the basic pediatric reimbursement level, so the patients are forced to pursue other health care options, AKA the emergency department of your local hospital. This method of treatment is of course expensive and abhorred by health care policy analysts, but when you do a root-cause analysis, this pattern is informed by the lack of treatment options for basic health care in the USA.

This scenario happened in Washington State, which is fairly well off financially, and it concerned a child of a parent well versed with the health care system, so you can imagine how this plays out for ESL parents or others with less familiarity. In Washington, Virginia Mason Medical Center has excellent primary care and a  high level of patient safety, based on their Leapfrog Patient Safety evaluations, their Malcolm Baldridge Quality Award, and personal experience. However, the Virginia Mason system is not available to everyone, especially outside the Seattle area. So, where do the children of parents who are not covered under the luxurious private health care system or the realm of Medicare obtain their basic health care? More than likely they have deferred health care, which is to say very little. I can remember going through at least one Minnesota winter with untreated bronchitis, in a district with no school nurse, and with parents who were barely getting by.

  All of this relates to the lack of basic health care for children, a pattern that hasn’t changed in decades. Though the Children’s Health Insurance Plan (CHIP) which provides federal funding for children who are in the lower economic rung of our society ( which turns out to be quite a few at 7.6 million in 2010 alone) has indeed expanded health insurance coverage for acute care for children, has it increased access to primary care?

The problem with primary health care in the United States is it is so reimbursement driven that the patients experience many obstacles to obtaining timely care. In the case of my son, even with the ED intervention, the soonest the “health plan” could see him was several days away. And the Children’s Health Plan is one of the country’s most well-funded programs. Imagine how it is for adults.

Also, nationally children’s hospitals are the most well funded facilities in the country, monuments to our willingness to throw money at the most dramatic health care interventions, but lack of national motivation to provide accessible basic health care for the country. Do we need to have traumatic injuries or cancer to gain access to the best health care in American, it would seem so.

Anyway, the next time you don't approve your school bond issue, think about the lives that are at stake and this is the healthpolicymaven signing off.

This article was written by Roberta Winter, MHA, MPA, health care journalist and advocate.

SCHIP veto, Rossi Response

Last month our illustrious president, George Bush voted not to provide health care for 900,00 low income children by vetoing the expansion of the Supplemental Childrens Health Insurance Plan, known as SCHIP. According to the nonpartisan nonprofit Kaiser Family Foundation, in 2005 there were 46.1 million people under the age of 65, without insurance in the United States. Of that group, only 25% are eligible for state Medicaid programs, including the SCHIP. Fifty six percent of the uninsured are not eligible for public health care programs but need financial assistance to purchase health insurance or health care. This means that if you are a family of four and earn more than $20,650, you are over the Federal Poverty Level. The SCHIP guidelines allows families earning no more than 200% of the FPL rate or $41,299, to apply for Medicaid coverage for their children. The proposed federal expansion for SCHIP would have allowed families with incomes up to 300% of the federal poverty level (about $61,950) to apply for Medicaid coverage for their children. The presidential veto of this legislation caused a schism among Republican legislators and considerable ire with Democratic representatives as well. The fallout of this decision was felt throughout the country, including Washington State where Dino Rossi, the loser in the last gubernatorial election and who is running for governor again commented on the President’s decision.
According to CounterIntelligence journalist, John Feit, gubernatorial candidate Rossi had this to say, "The majority of the children that are going to be coming on (to SCHIP expansion) are either illegal or currently have health insurance from the private sector." This article addresses the inaccuracies of Mr. Rossi’s statement, though one has to wonder about Rossi’s Catholicism and whether or not he is adhering to Catholic principles when he views children of immigrants who are living in this country as less valued than children who were born in America.
Here are the facts Mr. Rossi:
Your assertion that uninsured children have access to insurance coverage through private employers is wrong. The Kaiser Commission on Medicaid and the Uninsured reviewed this very question in 2007 and here is what they found:
Fact-The majority of the uninsured (56% according to the 2007 findings) are not eligible for public programs for health care and have incomes below 300% of the Federal Poverty Level. Of the six million children who live in poverty (200% of FPL), seventy percent live with families with parents who work, largely for small employers. Small employers do not offer health insurance to their employees at the same frequency as larger employers and fewer employers are offering coverage to their employees. The Kaiser Survey of Employer Sponsored Health Benefits for 2007 shows a precipitous decline in the proportion of small employers offering health insurance to their employees. For firms with fewer than ten employees, only 45% offer health insurance now, down from 56% in 1999. For all firms with less than two hundred employees, only 59% report offering health insurance today, versus 65% in 1999.
Your assertion that the expansion of SCHIP for families with incomes up to 300% of the FPL would disproportionately cover "illegals".
Fact- According to the Kaiser Commission, 85% of the pool of children who would be eligible for the SCHIP expansion are native United States citizens. Additionally, most new immigrants are excluded from Medicaid coverage during their first five years of residency, except for emergency treatment. Finally, the Deficit Reduction Act of 2005 requires residents to show proof of citizenship when applying for Medicaid, which also applies to SCHIP.
Rossi’s assumption that private employers are indeed making health insurance available and affordable for families living at 300% or less of the federal poverty level.
Fact-Most of the families who earn 300% or less of the federal poverty level are employed by small employers, many of whom do not offer insurance. According to the 2007 Survey of Employer Sponsored Health Benefits, the average cost for an individual enrolled in an employer sponsored health plan in the United States is $4,479 and $12,106 for a family of four. Since employees are usually expected to pay a significant portion of their health care premiums under private employer benefit plans, how can a family of four earning less than $ 41,300 per year afford medical insurance? The budget in this chart assumes the employee is expected to pay all of the cost for his dependents enrolled on insurance.

Family of Four Budget
Income Ceiling for SCHIP Expansion
$ 61,949
FICA & Medicare
4,740
Taxes at minimum rate after credits
7,981
Net available for living expenses
$ 49,228
Expenses
Housing
12,000
Utilities
3,000
Phone, cable television
591
Food
10,950
Transportation-inc. repairs, insurance, parking, maintenance, payment or lease
10,000
Savings/retirement-3% minimum
1,858
School expenses
500
Clothing
500
Personal care-hair cuts, etc,
1,000
Miscellaneous-repairs, etc,.
1,200
Subtotal for living expenses
$ 41,599
Net available for Health care
$ 7,629
Health Care Costs
Healthcare copayments
250
Health insurance premiums (employee, spouse & 2 children)
12,106
Subtotal health care expenses
$ 12,356
Net After Purchasing Health care
$ (4,727)

Since you are wrong on so many levels about your health care assumptions, is this what we can expect from your gubernatorial ambition? Next time get your facts right.

This article was written by Roberta E. Winter, MHA, MPA, who is a graduate of the University of Washington School of Public Health and the Evans School of Public Affairs.