Since access to health care and insurance are very controversial issues, over the years, a wide spread population of researchers and
writers have discussed these topics in depth. Due to the interest which so many have invested in this topic, hundreds of journal articles,
newspaper articles, web pages, etc have been created in order to contribute varying opinions on the matter. Due to this, the topic of access
for the under and uninsured has been covered fairly thoroughly.
Through my research I uncovered a great deal of information to support my opinion concerning healthcare access. The issue of citizens
having a right to receive healthcare if they are under or uninsured, as well as the ability for physicians to provide this care, are the two
main focus points for this project. It is common knowledge that many people hold the belief that healthcare is a right. Articles written by
Thomas O’Toole, Peter Simms, Bruce Dixon, and Karen Eggleston provide evidence for this by addressing these concerns in their own context.
The most common solution suggested for rectifying the unjust, money driven culture of the American health care system, is to revert
to a form of nationwide universal healthcare. Politicians have been working with this idea over the years, but no such system has yet to be
implemented. Many recognized complications have been discussed as well as the amount of time it would realistically take to completely remodel
the current form of healthcare. Also, those who have no need for universal health care, such as the rich or those with adequate health insurance
coverage, do not want to give up their rights to superior healthcare. Health care providers, like hospitals within the California area,
recognize their need for more timely reform in order to continue providing, or expand their provision of, healthcare to the under and uninsured.
Publications from the California Health Association address these concerns and help to outline solutions.
Although a great deal of information and research cover the issue of access to healthcare, I still believe it is an important topic
that I feel the need to contribute to. By compiling multiple viewpoints from various resources, I will create an easily accessed overview of
the topic. This webpage will show an array of other’s opinions, while also providing unique interviews and summaries of how physicians and
private practices can help participate in patient care of the under and uninsured.
An important aspect of this provision of care involves volunteer work. Although many private practices may believe they cannot provide
access for all patients, an abundance of volunteer opportunities exist for them to participate in. There are a multitude of opportunities for
anyone either employed by the medical field, or even mildly interested in the field, to find a way to contribute towards increasing access of
healthcare to these populations in need.
Most current physician, future physician, or anyone with an interest in the medical field, should understand the importance of providing
access to healthcare, for citizens either lacking insurance, or those who have insufficient insurance. Through this site, the ethics related to
this subject is discussed, as well as examples of how current and past physicians have approached this controversial problem. By collaborating
different ideas, more effective solutions will be uncovered, leading to an expansion of access for this essential service.
Physicians are those medical professionals who have direct contact with patients and have the power to use this relationship not only
to their advantage, but also to the patients’ advantage. It is through the relationship of patient and physician that a certain level of trust
is attained. With this trust comes the expectation of a physician to provide adequate and reasonably affordable care. Health care involves expensive
treatments which can easily cause a financial burden on a family, even if they do have health insurance. It is this issue of expense that is the
most troublesome aspect of the healthcare system.
In order to become a physician, as most people know, a great deal of dedication and drive is needed. The ability to undergo four years
of undergraduate, four years of medical school, and three plus years of residency takes enthusiasm, perseverance, and commitment. The financial
incentives to becoming a physician are normally not strong enough to pull an individual through this amount of work. A premed student must possess
compassion and a willingness to help others. Through these traits an extraordinary physician can develop.
Due to the personality traits needed for most to make it in the medical field, physicians can use this desire to help those in need, by
acting as somewhat of a bridge between health insurances and patients. Physicians control their own billing practices within a private practice,
which allows them some flexibility when providing care. This flexibility can include serving the under and uninsured in their area, which can be
completed in a variety of ways. It is through these practices that strides can be taken to help this issue of access to the underserved.
Physicians are not the only group with the ability to contribute their skills or other assets towards diminishing the boundaries standing
between lower income families and health care. Other medical professionals as well as any individuals interested in the medical field can help
provide access to these services through volunteer work and also donating money. Federal funds are somewhat limited when it comes to healthcare
services, which contributes to the existing barriers involved with healthcare.
There are a great deal of other barriers that stand between patients and access to needed healthcare. The fact that nearly if not more
than 43 million Americans do not have health insurance solidifies this point. These existing barriers include, but are not limited to, financial
resources, education level, geographic location, ethnic and social background, race, etc. The main focus of this project is infringement of access
to care due to monetary reasons. Although many factors relate to minimal financial resources, the consequences for these resources alone are analyzed.
When patients lack health care coverage, it is most often because they cannot afford it. Health insurance plans, like Medicaid, are offered
by the government to low income families; however, this does not ensure that all low income citizens will apply for and receive these benefits.
There are certain standards involving household incomes that restrict who has access to Medicaid and other governmental programs. The gap that
falls between Medicaid cuts and those able to afford private medical insurance contribute to the high percentage of Americans that are uninsured.
Within healthcare are different subsections of care, including primary care, emergency care and volunteer care. Primary care refers to the
non-emergent medical care that is provided for by physicians within the private practice realm, such a family medicine, pediatrics and OBGYN. It is
through a primary care provider that a patient gains access to the healthcare world, including referrals to specialists as well as more advanced
procedures. One of the most important kinds of care which primary care physicians offer is preventive care, including vaccinations and health education.
By receiving preventive care, a great deal of health care mishaps can be avoided in the future by these patients. If someone lacks access to a primary
care physician, they will be unable to take full advantage of what American healthcare has to offer. In order to see a majority of primary care
physicians, some form of insurance is necessary; therefore financial boundaries exist here as well.
Emergency care is somewhat abused by the American population. Since emergency departments cannot legally turn away patients, they often act
as the safety net to those patients who either lack access to a primary care physician, and/or lack health insurance. Due to this, a great deal of
time and resources, which could be used for more necessary causes (like in emergency cases) are exhausted on those cases which could easily be taken
care of by a primary care physician. Situations like this have greatly contributed to an increase in the cost of healthcare services, such as
insurance, over the years. When patients have chronic disease, such as diabetes, it is important for them to maintain a relationship with a primary
care physician whom they can refer to whenever they have any questions, rather than rely on the ED when they have any problems. It is through a PCP
that they can maintain a healthy blood sugar level as stay educated on how they should be taking care of their disease. It can be inferred from the
illegality involved with turning away patients from the ED, that physicians do have an ethical duty to serve those in need of health care. This can
be further applied to primary care physicians and their obligation to serve those in need.
Volunteer clinics and care embodies a third option of healthcare available to the public. It is through free clinics that the uninsured
populations are provided basic healthcare services that they would not normally have access to. Although these services may not be nearly what a
patient requires, they do help relieve some of the burden on physicians who work to provide access to these uninsured patients. However, these
clinics and services may not be available in all areas, especially rural towns.
Within each of these subsections of care, providers are faced with medical ethics. The biggest question involved with the under and uninsured
is: Does everyone have the right to have access to healthcare? And if so, are there limits to this right? According to Donald Light in his article
concerning Justice-based care, goals for healthcare include; “support[ing] fellow members and their families when ill…and to minimize the financial
impact of illness.” He also articulates his belief that “…any just or fair health care system must make needed and effective services available to
everyone, regardless of their health condition, risks, and ability to pay.” Other writers, such as Karen Eggleston address the moral issues involved
with insurance such as how “…heavily insured consumers tend to overuse services that appear to be “free” or are heavily subsidized.” This leaves
limited resources for the under and uninsured, helping to further support the fact that wastefulness is a rampant problem in healthcare practices.
A great push is being made within the US to establish universal healthcare; however, the reality of this type of system being established will take
quite a few years.
There are also those who oppose this ‘right to healthcare’. Leonard Peikoff, a PhD holder discusses how healthcare is not a right like those
documented in the Declaration of Independence, because it calls for the action of others, while other rights outlined are seen as a right to act
rather than a demand for others to act on behalf of another individual. By making excuses why people should not all have access to healthcare, these
arguments only help to further push the healthcare system into its downward spiral. If we continue to ignore the needs of the under and uninsured,
they will continue to take away resources from those who are able to afford insurance through emergency care, as well as increase the cost of already
expensive healthcare services. Although everyone cannot agree whether healthcare should be a right to all, they must recognize that if something is
not done about the current status of our healthcare system, only the extremely wealthy will be able to afford medical care, in the near future.
No matter what the majority opinion exists as, towards this right of care, there continues to be volunteer opportunities for those interested
in contributing to the health and well being of all. Throughout the United States are thousands of volunteer clinics and hospitals which provide care
to those in need. More specifically they work to increase the standards of health care for the under and uninsured. Just by using a search tool such
as Google, almost anyone can find some type of volunteer opportunity they can participate in, within their community. Even if these opportunities are
not available, if financially able, anyone can make a donation to an organization of their choice which works with these underserved populations.
Some examples within my own home area include; Shriners Hospital for Children, Fresh Start Inc. and the Dirne Community Health Clinic. Also,
many primary care physicians in the area offer free services to those in need throughout the year. Coeurd’Alene Pediatrics holds free sports physicals
for kids a few days every year in the summer. They also work to ensure all infants in their care receive needed vaccines and well child checks
throughout their first few years of life.
People also have the opportunity to travel outside of the United States to third world countries where their problems with health care are
much more severe than ours. Although these types of volunteer projects do not directly service the American population, they are an important aspect
of helping raise awareness for the need of health care across the globe.
Although these volunteer opportunities do exist, other solutions must be explored further in order to really bring about a greater change in our nation.
Alicia Monroe wrote about physicians within the state of Rhode Island, who have helped patients unable to afford insurance or the physician’s services.
Monroe did not uncover how these physicians are being paid for this service, but referred to the national trends of adjusting charges and creating
payment plans. Those physicians that are making these adjustments to their private practice are predominantly family physicians. They feel the need
to reach out to new uninsured patients, as well as established patients who may lose their insurance during their time as a patient. Through reduced
fee services they can keep their patient population up. According to one of these family physicians; “We did not want to hinder the relationship that
was already formed because of lack of insurance.”(Monroe 2004) Not only have they been able to provide their own care but they have also worked with
laboratories who agreed to offer discounted services. Why have they worked so hard to find ways to help these under and uninsured patients? Dr. Manoj
Garg makes a point that is important to understand; “Patients can concentrate on their care, and not worry about cost.” (Monroe 2004) Stress involving
financial situations can easily aggravate a patient’s already poor health. Not only have the physicians of Rhode Island reached out to their patient
population to keep them involved with healthcare, according to Monroe they have done so without grant subsidies or a financial net loss of the private
practices.
“Although individual clinicians are not personally obligated to provide care to the uninsured and underinsured, the medical profession and
health care institutions have a moral obligation to work toward justice and equity in health care. Individual practitioners should participate in the
planning of their institutions to provide care for the uninsured.” (Jonsen pg. 181) This quote embodies the purpose of this project and helps to stress
the importance and responsibility that has been placed upon physicians and the medical field. If one were to expand off this information, they could
find a great deal of references that could help them pursue the topic further. Although the importance of this issue has been discussed, the actual
probability of providing this service nationwide cannot be determined with complete accuracy. Each community within the United States have different
characteristics which may either help or hinder this work towards equality. I urge you to look further into the opportunities open to you in your
community where you can help contribute to solving this problem.
The following information is the written interviews used in the project and the video.
In the smaller northern Idaho community of Coeurd’Alene exist many different physicians dealing with the problems of access to care for their under and uninsured patients. Coeurd’Alene Pedaitrics is a large practice within the Coeurd’Alene area, serving thousands of children from infants up to young adults in college. They have been in existence for over twenty years, serving their patients to the best of their ability.
Dr. Mary Jo Shaw MD, has been a practicing pediatrician at CDA Pediatrics for the majority of its existence. Through e-mail correspondence, she reflected on the services her practice provides and her experience with this underserved population.
Does your practice provide healthcare to the under and uninsured population? (ie Medicaid)
We provide care for medicaid patients. To my knowledge, we are the
only practice that takes new patients with Medicaid. (except newborns)
If so, do you feel this is somewhat of a financial burden to your practice?
Since Medicaid does not pay as well as private insurance for the
same service, it is definitely a financial burden. However, we have
a very efficient practice (we work our employees hard!) so we are
able to see a large portion of Medicaid patients(over 50% of our
patients are Medicaid). Also, Idaho reimburses better than a lot of
states. Family doctors do not get reimbursed as well for adult
medicaid patients, so they are hesitant to take children who have
parents on Medicaid. Dental reimbursement is very bad!! The pediatric
dentists have all restricted the number of medicaid patients they
will se due to the poor reimbursement. So even though the Medicaid
program states they provide dental care, the parents cannot find a
dentist to see their children!!
Do you have any specific reasoning behind why you provide this care?
Since so many children in our area have Medicaid, we feel
compelled to provide care for them as part of our goal to provide
pediatric care to the community.
Could you briefly explain why you feel others within your profession choose not to provide this care?
Since Medicaid does not reimburse as well as private insurance
companies, many practices will not participate. Some providers also
seem to have a bias against Medicaid recipients. Medicaid requires a
lot of paper work for referrals and certain meds-even ones they
cover, you have to complete a "prior authorization form" for several
meds. The form has to be faxed to the state office and then they
review it and fax back a response to you and the pharmacy.
Do you follow a certain protocol when dealing with patients who have no insurance?
If a patient does not have insurance, they are required to pay 1/2
of the cost of the first visit as a new patient (as are all new
patients). For future visits, they are told we request payment at the
time of the visit but we will bill them. As long as they pay toward
their balance on a regular basis, we will continue to see them.
Mary Ann Daley is part of the office managing team for Coeurd’Alene Pediatrics. She works with patients over the phone and in person concerning any scheduling, billing, and insurance problems. As an involved team member without a degree in medicine, she has a different relationship with the patients of her office. The following are her responses to the same questions over e-mail.
Does your practice provide healthcare to the under and uninsured population? (ie Medicaid)
Yes
If so, do you feel this is somewhat of a financial burden to your practice?
Yes. The front staff has to check each medicaid patient's
eligibility at each visit since this changes from month to month.
Medicaid does not reimburse as well as other insurance plans but you
still hve the same overhead. Medical offices have a huge overhead to
cover.
Do you have any specific reasoning behind why you provide this care?
The doctors decide which insurance types they will contract with.
Could you briefly explain why you feel others within your profession choose not to provide this care?
Reimbursement and billing issues. Medicaid does not cover certain
procedures such as circumcision. The billing staff has to monitor
what codes are not paid well. Medicaid requires a referral for a
patient to be seen at any office other than ours (specialist or
urgent care). There are a lot of phone calls and paper work involved
with these referrals.
Do you follow a certain protocol when dealing with patients who have no insurance?
Same as above. We do have a program called Wee Care that provides
well child checks for children during their first year for free. We
do require patients to show us that they have been denied by Medicaid
to qualify for this program. Some parents don't want to apply for
Medicaid since the mom has to list the father's name. We also
participate in a voucher program through the Health dept. If a
patient presents to the health dept for an illness and they cannot
afford a doctor's visit, the health nurse can provide the family with
a voucher to be seen for free in our office for one visit. This does
not help with chronic conditions. The Dirne clinic is also a resource
for patients with no insurance. We provide immunizations through our
office at no cost if parents cannot pay. (we are part of the state
immunization program so get the immunizations from the state but
still have the overhead of the office staff and supplies).
Dr. Robin Shaw MD has been an Emergency Physician for the past 20 years at Kootenai Medical Center in Coeurd’Alene, Idaho. As a member of the Emergency Department, he is required to see all patients who come to the hospital seeking out care. He was also requested to answer the same questions over e-mail. Although he is involved with a branch of medicine that is required by law to see all patients, he still can contribute to this discussion of lack of care.
Does your practice provide healthcare to the under and uninsured population? (ie Medicaid)
yes
If so, do you feel this is somewhat of a financial burden to your practice?
yes. However, we have an arrangement with the hospital where we
are contracted to get paid a certain percentage of our charges, so
the hospital helps share the burden.
Do you have any specific reasoning behind why you provide this care?
Required by law.
Could you briefly explain why you feel others within your profession choose not to provide this care?
Poor reimbursement.
Do you follow a certain protocol when dealing with patients who have no insurance?
All patients are treated equally. They are billed later so don't
pay at the time of service. The billing department for the hospital
handles delinquent payments.
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