Older but still relevant article: Nation, uninsured find fewer doctors in the house

this article, written by Peter Killborn for the NY Times, is dated 1998, but is sadly still relevant. It deals with uninsured Americans, and the difficulties getting them care. Doctors' revenues are getting squeezed by reduced payments, meaning that they can't do as much charity care because they need to focus on profitable patients (not that charity care is any sort of permanent solution). Emergency rooms are required to treat all presenting patients, but the ER cannot deliver meaningful primary care.


DESPITE a decade of steadily rising prosperity, a million more Americans a year are losing the protective umbrella of health insurance. As a result, more than 41 million people, or 15 percent of the population, don't have coverage.

They lack insured care because they can't get it at work or can't afford it. Most are adults under 65, the age when they become eligible for Medicare. Most are men. Most have no children at home, so they are ineligible for Medicaid, the insurance program for the poor. Most have jobs, or live with someone who works, but their incomes, typically below $25,000 a year, make them ineligible for Medicaid.

Yet even as their numbers grow, the uninsured are finding that their last resort -- charity care -- is being threatened by the rapid expansion of managed care, which is putting tremendous financial pressure on doctors and hospitals to focus their resources on insured patients.

It's true that in crises the uninsured can take their diabetes, their rotted teeth, their tuberculosis, their hypertension, their addictions, their obesity, their asthma attacks -- all scourges of the poor -- to emergency rooms, where by law they must be seen and treated free.

For less urgent care, they can go to doctors' offices, public hospitals and clinics subsidized by the government and philanthropic groups. Often, that care is free as well, or the patient agrees to pay a few dollars a month for it, albeit for years.

Recently, however, anything beyond emergency treatment has become harder to get in much of the country. As managed care has expanded to cover 85 percent of the working population, it has succeeded in stabilizing costs for employers and their managed care subscribers. And the Government is reaping similar rewards for taxpayers by steering Medicaid recipients and the elderly into managed care plans, and by cutting Medicare reimbursements to doctors, hospitals and health maintenance organizations.

But as part of the process of containing costs, the Government and the managed care industry have also pressured doctors to take cuts in their incomes or to take on more paying or insured patients to maintain their current incomes, which has left them with less time for charity.

Free Care, but Not Much

One fraying thread of the safety net is the Most Holy Trinity Catholic Church's medical clinic in the Corktown neighborhood of Detroit. Sister Mary Ellen Howard, the registered nurse who manages the clinic, uses volunteer physicians and nurses to treat 3,000 patients a year, all uninsured, on an annual budget of $50,000 collected from small foundations.

The care is free, but there's less of it.

''I had somebody come in here who had blood in his urine,'' Sister Mary Ellen said. ''He needed further diagnostic study, and we couldn't do it. He couldn't go to an emergency room because that's not an emergency. There was a urologist I could call and say, 'Joe, will you take this one client?' He would take him.''

''Now when I call, he says, 'Sorry,' '' she added, noting that he has cut back on charity care because he has to see more and more patients to maintain his income. ''My clients are able to get primary care here,'' Sister Mary Ellen said. ''But I cannot get any kind of a specialist to see a poor person in the city of Detroit.''

Dr. Richard Corlin, a senior officer of the American Medical Association and a gastroenterologist in Santa Monica, Calif., says he won't turn away poor patients sent by a similar clinic in nearby Venice who need gall bladder removals and colonoscopies. But he says the Government, like managed care, is draining his reserves for charity.

Once, Dr. Corlin said, he could ''balance bill'' by charging wealthy Medicare patients the difference between Medicare's reimbursement for a procedure, which might be $180, and his usual fee of $300, and then use the difference for charity. Balance billing is now prohibited by the Government, and because of falling reimbursements from both Medicare and H.M.O.'s, Dr. Corlin says he now collects 50 percent of his standard fees, compared with 75 or 80 percent 10 years ago.

Such complaints by health care providers help explain the findings of a survey in June sponsored by the Henry J. Kaiser Family Foundation, which specializes in health-care philanthropy. ''Contrary to a common belief that the uninsured are able to get the medical care they need from doctors and hospitals, in 1997 uninsured adults were four times more likely than those with private health insurance to say they did not receive the medical care they believed to be necessary,'' the survey found. ''Over half said they had postponed getting care, and a quarter had not filled a medical prescription -- both because they could not afford it.''

The Kaiser foundation and many providers of charity care say shortchanging the uninsured by treating them only in emergencies is often more costly than preventive care -- for the patient, for the health care provider and for the overall economy.

An uninsured diabetic is cheap to treat when he is delivered comatose to an emergency room and dies. But a more typical emergency-room visit brings charges of $200 to $500, which the hospital often swallows as charity care.

Dr. Joy Everson, director of patient financial services at Good Samaritan Hospital in Phoenix, says an ''emergency treat and release'' costs $50. An EKG costs $125, and the doctor who reads it charges $50 to $100. Holding a patient for observation costs $26 an hour. Admitting him to the hospital costs $725 a day.

'Train Wrecks'

In the argot of emergency rooms, many uninsured patients are ''train wrecks.'' They show up every month or so, with asthma attacks or chest pains, and incur similar charges each time. But a patient in a managed care plan, receiving the regular preventive care that prolongs lives and spares the emergency room, is cheaper to care for.

''One reason people dismiss the problem of the uninsured is that they don't believe people are turned away,'' said Drew Altman, president of the Kaiser Family Foundation. ''They're right. What happens is people delay getting care. And when they get it, they are more expensive to treat.''

Dr. Jonathan Weisbruch, director of the Maricopa County Health Department in Phoenix and a former medical director for the county of Los Angeles, estimates that universal care and prevention could curb the nation's $1 trillion spending on health care by one-third. ''If we intervene with people when they're 45 years old, get them to do things like stop smoking and reducing their weight,'' he said, ''imagine what that would do to the cost of Medicare after they're 65.''

Correction: September 13, 1998, Sunday An article on Aug. 30 about health care for the uninsured misspelled the surname of the director of the Maricopa, Ariz., County Health Department. He is Jonathan Weisbuch, not Weisbruch.