Commentary: When Patients Fall Through The Health Coverage Gap

By Dr. Nancy Adams
Guest Contributor

Ms. X has worked hard — and fast — as a barista for years. She’s employed by a company that offers her access to health insurance, but she has never been allowed to work a 40-hour week — an increasing problem in many industries nationwide.

As a poorly controlled diabetic with high blood pressure and cholesterol, Ms. X needs a minimum of six prescription medications. She should also be monitoring blood sugars daily and have lab tests every three to four months.

But because her health insurance requires high out-of-pocket deductibles for medicines, testing strips, and lab tests as well as office visits, she cannot afford to pay for all the recommended care. So her diabetes remains poorly controlled, and that increases her risks of heart disease, peripheral vascular disease, blindness and kidney failure.

Dr. Nancy Adams

Dr. Nancy Adams

As a primary care provider for 30 years in Chelsea, Mass., I have had first-hand experience dealing with all the defects of our current health care system. And I have spent many hours trying to explain to intelligent, interested consumers why it is so flawed. A fundamental problem is that the incentives for the consumer and those for insurers and providers have been misaligned.

The insurer who pays for this year’s health costs for Ms. X, and saves hundreds of dollars by making her pay more out of her own pocket, is unlikely to be the same one who spends many thousands of dollars years from now if she is hospitalized or needs procedures.

If she does develop complications, by the time she is covered by Medicare, she may need care from multiple specialists and many more medications and tests. In a worst-case scenario, she could end up needing hundreds of thousands of dollars in additional care. The old saying “penny wise and pound foolish” certainly applies.

As health costs rise, more and more patients have to pay increasing amounts out of pocket, and this “penny-wise” problem is getting worse. Current annual deductibles for all consumers now average more than $1000 for an individual and more than $2000 for a family nationwide.

Moving toward prevention

Until recently, the predominant model of care throughout the country has been “fee-for-service” — the more visits, medicines, tests, and procedures done, the more money health care providers and institutions earned, no matter what the outcome for the patient. This encouraged waste, had little support for primary care providers, and inadequate incentives for prevention.

In Massachusetts that has finally started to change. The state, the business community and the major insurers have now embarked on a new “global payment” model which alters the incentives for all providers of health care, placing responsibility for quality and cost of care at a system level. Medicare is implementing similar changes, and the Affordable Care Act will promote similar changes throughout the country. As a result we are finally moving to emphasize prevention, a full 40 years after the concept of primary care and prevention of chronic illness was first proposed.

But prevention cannot work when even our improved insurance system is riddled with gaps.

Consider Ms. Y. She worked for years as a secretary with health insurance that paid for her prescriptions for severe hyperlipidemia – high cholesterol and triglycerides.

She was then laid off from her job and unable to afford her medications, one of which cost hundreds of dollars a month because there was no generic alternative. Without health insurance, she was charged the full price.

Because she owns a home, she did not qualify for Medicaid. So she went without her cholesterol medicine. A few months later she had a severe heart attack complicated by heart failure plus a risk of sudden death. She is now treated with many additional medicines and a defibrillator to prevent abnormal heart rhythms.

Permanently disabled and still unemployed, she is now insured by Medicare plus additional private Medi-gap insurance. She continues to have difficulty affording medications because the total of her co-pays and deductibles are so high. Like many of my patients, she has tried omitting some medicines or cutting tablets to save money, but then ended up back in the hospital. She has learned that all of her medications are required to prevent additional hospitalization and early death.

A recent Gallup survey documents a dramatic rise in postponement of medical care in the last 12 years, from an average of 19% in 2001 to 32% now. More than half of people with no health insurance (55%) state they have put off care for themselves or a family member.

Change is coming

In the rest of the country, the following will soon be a common scenario, beginning in 2014 when many provisions of the Affordable Care Act kick in:

Mr. Z was a self-employed carpenter for 30 years who never was able to afford health insurance. This changed after Massachusetts adopted its universal health care law in 2006. At his first visit with his new primary care provider, he had blood pressure in the 190/110 range and already had an abnormal EKG indicating permanent heart damage.

Blood and urine tests of kidney function also showed damage. Treatment with three blood pressure medications was started immediately. However, he already had a decreased life expectancy due to organ damage which is likely to cause both heart and kidney failure.

President Franklin D. Roosevelt died from all the complications of high blood pressure – heart failure, kidney failure and hemorrhagic stroke. In 1945 there were no effective medications, even for the President of the United States. But for decades there have been dozens of effective low cost medications which could prevent all of these illnesses.

Failure to treat blood pressure early also results in tremendously high cost due to the need for multiple medications, hospitalizations and possible dialysis (paid for by Medicare at any age) if his kidneys fail completely.

It makes no sense for our society to NOT care for people until their health is damaged and they are disabled. The cost to all of us as individuals and as taxpayers is then much higher than it would have been if good insurance with preventive care were in place for everyone.

It will take years for our deeply flawed and complex health system to gradually reform itself. But as a nation we have at last set forth on the journey. Now we need to make sure that we close the gaps in coverage to allow the prevention that keeps people from getting seriously ill.

Dr. Nancy S. Adams is a staff physician at Beth Israel Deaconess Medical Center, Chelsea Adult Medicine, and an instructor at Instructor in Medicine, Harvard Medical School

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