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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  • Ray

    This elucidation of what’s wrong with United States health care is quite descriptive based on direct professional knowledge. It echoes what a growing number of experts and advocates have been saying about the problem for years. The problem remains that most of our population are still not listening, and not doing something to support the changes needed. One sticking point is obviously costs. The affordable care act is not really quite Universal Health care. What’s needed is the real thing, a single-payer plan. Most people are anxious about the impact on their taxes, but it is almost certain that the saving on health care costs would more than offset that. And if people felt they could see a healthcare professional early on, instead of waiting for dire straits, overall costs would fall steadily and steeply.

  • isarose

    Sounds like my sister. Couldn’t afford MD’s or drugs when she was working, now is on Medicare for diabetes and its related near-blindness, heart disease and kidney failure. It would have been cheaper to treat her when she was an adult.

  • Doc Smith

    One glaring problem was that employers were given a pass by the use of the 40 hour rule for coverage. If the law had insisted that ALL employers contribute to coverage based on each hour worked, there would be none of this nonsense. Since when is a 40 hour worker more entitled than a 30 hour a week barista? So what if your latte costs an extra 50 cents. Level the playing field for all. Doc Smith

  • Reasonable?

    These are really complicated matters.
    I see two distinct problems.
    The cost of health care coverage is high and the system is complex.
    People are suffering from chronic preventable diseaseses.

    A major reason why the insurance is high is because the cost of treatment via providers and medications is quite high. We are still trying to bend the cost curve by reshuffling the chairs on the deck of sinking ship.

    Instead we need to consider health care delivery at a lower cost. We need create structures to incentivize patients to reduce their own risk for chronic disease. the most effective rout is diet and exercise, which cost less than most generic drugs.

    Our current system allows people to adopt a poor lifestyle and increased risk for disease. Then we complain that its the system’s fault that the chronic drugs that the patients need fro poor lifestyle choices is unaffordable. It’s true that without treatment or lifestyle change their conditions will become more costly, but our current prevention mindset if focused on drugs, not lifestyle.

    We need a reconceptualization of preventive medicine.

  • Brian Rosman

    Thank you, Dr. Adams, for illuminating how many holes still exist in our health care system. At Health Care For All, we talk to people like Ms. X, Ms. Y and Mr. Z every day. When we talk with people around the state, the issue of high copays and deductibles, along with restrictions on choice, are raised again and again. While our care delivery system is moving towards a greater focus on health and wellness, we need to align our insurance system to be moving in the same direction.

    The problem of underinsurance is growing in Massachusetts. In just the two years from 2007 to 2009, the proportion of small group plans with very high-cost sharing – Bronze level plans – jumped from just 10% to almost 60% of all plans.

    We’re working on systemic policy proposals to begin to address these problems.We would encourage people who are unable to get the care they need because of high copays or deductibles or coinsurance to contact us.

    Brian Rosman
    Health Care For All

  • Dennis Byron

    It would be interesting to hear more details on these anecdotes because the information provided is not consistent with how the different health care insurance described works, particularly in Massachusetts, but throughout the rest of the United States as well.

    The author of these anecdotes says:

    1. Ms. Y “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.”

    What the author does not say is whether Ms. Y has Medicare Part D to pay for prescriptions; there are many Part D plans available that have no deductibles. Also — depending on the rest of the details about Ms. Y, the Part D premiums and the Medicare premium itself might even be free.

    The above is true throughout the United States. In addition, a program called Prescription Advantage in Massachusetts would provide extensive help for drug costs to someone under 65 making up to $21,000 a year. For someone over 65, the Prescription Advantage help is even more significant and available to a person making as much as $55,000.

    As for Ms. Y’s situation after becoming unemployed but before joining Medicare, the author says having a home disqualified her for Medicaid. I don’t think that’s true but I am not an expert for those under 65. But even if I am wrong, Ms. Y’s home ownership should not have disqualified her for free or very inexpensive Commonwealth Care insurance here in Massachusetts. (Perhaps the author is describing a situation from before RomneyCare was passed in 2006. If so, current readers of this blog post should understand that what the author describes above is not the case today.)

    2. In the case of Ms. X, there is clearly not enough information to figure out what the insurance issue is. Is it that the employer offers different insurance to those working less than 40 hours than it offers to those working more than 40 hours? Or is the only choice for everyone an HDHP? Or…?

    3. In the case of Mr. Z, the relation of this anecdote to health care insurance depends on whether he’s been self employed since age 18 or 33. And his family history. And his weight and diet. Apparently the author’s message is simply “get your blood pressure checked,” which of course no one will argue about. You don’t need healthcare insurance to get your blood pressure checked.

    The author branches off into other anecdotes about fee for service and FDR. From a percentage point of view according to the Massachusetts Department of Insurance, Massachusetts moved away from fee for service many years ago (before RomneyCare) so we should be seeing the results promised by the author already. As for FDR…. well let’s just say cut back on the smokes too.

  • james o’neill

    check out amazon,,,,where there are reasonable prices for diabetes testing paraphrenalia