Another day on the front lines of health care delivery in America . . . .
I am a pediatrician in a group practice in Texas. For the record, my ideal fix for the health care abomination in this country would be single payer, but that isn't going to happen anytime soon. So I follow all the political maneuvers and sniping and backbiting that are happening both in Congress and on the blogs, but in the meantime, I go to work every day and try to take care of my patients.
Here is what it is really like on the front lines.
We have a high percentage of Medicaid patients in our practice. For our pediatric department, it is probably over 50%. If you add in CHIPS patients, it is definitely over 50%. We are in a rural/small town area. There aren't many high-paying jobs. Young people who have babies are almost never married to their partners. A single mom who doesn't work or only works part-time at a minimum wage job easily qualifies for Medicaid for her children. If the daddy has any half-way decent job (usually with no benefits) the family would make too much to qualify for Medicaid. So the parents don't get married. I have families who have four or five children--the parents have been together for years, but they don't get married. They can't risk losing their Medicaid. I wonder how the family-values crowd feels about that.
Then we have the bureaucratic nightmares people have to go through to qualify for and remain on Medicaid. It used to be a fairly simple process. You went to the Medicaid office, filled out an application, showed proof of income and were approved within a few weeks. Now, the system has been so overwhelmed with applicants that the waiting time for approval can be months and months. Add to that the inexplicable "loss" of files, applications, or supporting data that seems to occur on a daily basis. Texas used to require parents to reapply once a year for Medicaid benefits. Now it is every six months. If you don't dot your i's and cross your t's on a timely basis (and sometimes even if you do) boom--your child is off Medicaid. It can take another six months to get him back on.
In the meantime, patients who do have Medicaid get assigned to the wrong type of program and can't receive care in the town where they live. Texas Medicaid now has a combination of open-access, primary care assigned, and HMO programs. If your child is on a Medicaid HMO program, you can only see a doctor who is a member of the HMO. HMO's are assigned by geographical area. I would love to be a provider for the various HMO's that serve counties contiguous to ours, but Medicaid won't let me. So if a family lives just across the county line, and they are put into an HMO, they can't see me. Worse yet, if a Medicaid worker miscodes the county on a family's application, they can get assigned to an HMO, even though there is no provider for that HMO within 50 miles of where they live. Even when the error is the fault of Medicaid, it can take months to correct.
CHIPS is supposed to be the back-up to Medicaid. If you make a little too much to qualify for Medicaid, you just apply for CHIPS. Except that CHIPS has a mandated waiting period of 60 days after your application is approved before your coverage goes into effect. What is the point of that? What do you do with your sick child in the meantime?
So what happens to all these children who fall through the cracks of Medicaid and CHIPS? Often they end up in the emergency room for minor illnesses, tying up resources that should be available for true emergencies. Sometimes the family scrapes together $50 for the deposit my clinic requires for the patient to see me. Usually it is a caring grandma that is paying the bill. Then if the child needs a prescription, I have to search the Wal-Mart $4 prescription list, or the HEB $5 prescription list to find a medicine that might work for them. Forget about samples. The drug companies don't sample antibiotics at all anymore. We get cough and congestion medicines and a few other things, but nothing truly therapeutic.
The result is that every day I see children who are far behind on their immunizations, or who have a health condition that has been neglected. When I ask the parents why, they invariably say that they lost their Medicaid and had trouble getting it back. Now I know that often the parents have not followed through and done all their paperwork on a timely basis, but that is not surprising with this population. Often the parents have a low educational level, many do not speak English well, and they are often fairly transient in their housing, so they don't receive the letters that Medicaid sends. Oh yes--Medicaid eligibility letters are sent every month, and the patient must present the letter to receive services, but Medicaid marks all their envelopes "do not forward", so if a family moves and files a mail-forwarding order with the post office, they don't get their Medicaid eligibility letter.
You might wonder why I would be in favor of MORE government-provided health care, given these experiences. It is clear to me that most of these problems were caused by the state attempting to keep down the Medicaid rolls by increasing the hassle and red-tape that people are required to navigate. It doesn't have to be that way! There are other government-funded programs that work smoothly with none of these kinds of problems. For example, we have an excellent WIC program in Texas. It is the program that provides infant formula, milk, cheese, and other staples to low income pregnant women and children. It is very simple to qualify and people receive assistance immediately on filing their application. If there were sufficient funding for Medicaid and CHIPS, those programs could work just as well.
So here's the kicker for my long day today. I saw one of my regular patients for a cold. Her dad brought her in. Mom and Dad are divorced but I'm pretty sure the child has been on Medicaid most of her life. After I examined the child and confirmed that she had a cold, the dad said "can you believe this health care thing?" I said something non-committal like "hmm, yeah" and the dad continued "the government's taken over the banks and the auto industry and the insurance companies and now they want to take over the hospitals." I said that as far as I was concerned anything that helped more children afford the health care they needed was a good thing because I see patients every day with no insurance and they need help. Luckily, he remained pleasant and didn't get belligerent but concluded with some comment about "big brother." This from a guy whose kids are on Medicaid! I'm sure he would be screaming bloody murder if the state tried to take them off of Medicaid. Sometimes the cognitive dissonance is just too difficult to even address.
At this point, I don't even know what to think about the health care bills that are floating around Congress. I'm sure that many of the included provisions have been bought and paid for by various special interests. I can only hope that a few crumbs might filter down that could help my patients. My real hope is that once people get a little taste of having access to good health care (not just the crap they get in the ER), the floodgates of demand will be opened and people will realize what they have been missing and will insist that the government provide it. After all, anyone with an ounce of compassion should be able to see that health care is a basic human right that should not be denied because of inability to pay. Okay, maybe that statement was controversial. I'll shut up now.