Road to Wellville:
Many a Bump Along the Way
Originally published in The Hook on October 24, 2004
A year ago, a Charlottesville woman between jobs contracted a bone infection. Because she was unemployed, Alice (not her real name) wasn’t eligible to be seen at the Charlottesville Free Clinic. Nor did she go to either of the local hospitals– she did not know they have programs for indigent citizens. She felt hopeless.
“But there’s nothing you can do about it,” says Alice, 46. “There’s no way to pay for medical treatment.”
So she lived with the pain– and got sicker. The infection was in her jaw, and she started to lose her teeth, one after the other. Because eating was so difficult, she began losing weight– 40 pounds since December.
Like Alice, 45 million Americans have no health insurance, according to the Census Bureau. Nearly a million live in the Commonwealth, 200,000 in Central Virginia.
A sea of red tape
It doesn’t take long for a medical problem to become a financial disaster.
“Pride can stand in the way of asking the right questions,” says Alice, who now works in a local office. Having nowhere to turn, she took Ibuprofen and rubbed over-the-counter numbing gel on her gums. But the paid was unrelenting, and her teeth continued to fall out. “It was a living nightmare,” she says.
“It’s very important for people to know that there are [professionals] out there to help them navigate the systems,” says Drew Yeannakis of the Salvation Army, who calls the local human services community “phenomenal.” And yet navigating those services can be daunting.
“If you’re totally indigent, you need to be in one system,” says Yeannakis. “If you’re middle income, you need to be in another. And you have to learn all the rules and the regs in order to find out how you can cross between them.”
A sea of red-tape on top of being sick.
“That’s where we come in and try and even things out,” says Yeannakis, who heads the Salvation Army’s Medical Assistance program. “When you’re not feeling well and are overwhelmed with what the doctors are saying, the last thing you’re going to think about is paperwork.”
When $37,700 is too much income
“Uninsured kids have many more problems,” says Jon Nafziger, vice-president for community initiatives at United Way Thomas Jefferson Area: “Asthma rates are higher, untreated ear infections are higher– and that leads to more health problems.”
The good news is that the local United Way has facilitated enrollment of 90 percent of eligible children in the state’s Family Access to Medical Insurance Security program (FAMIS), which offers comprehensive health care– including doctor and hospital visits, eye care and medicines– up to the age of 19.
But, with FAMIS, the income limit for a family of four is $37,700. “We get many calls from families with uninsured children who are above the income limits,” Nafziger laments.
The Virginia Health Care Foundation estimates that more than 25 percent of Commonwealth households without health insurance have incomes above $50, 000.
The Free Clinic: workers only
By the time Alice found part-time work and got an appointment at the Free Clinic, her condition had deteriorated to the point that oral antibiotics were ineffective. She ended up at UVA’s Emergency Room in the middle of the night where she was hooked up to antibiotics dripping through an IV tube and underwent expensive diagnostic procedures. She says she almost died.
“People without insurance are living sicker and dying sooner,” says Erika Viccellio, executive director of the Free Clinic. Because of the cost, they put off seeing a doctor until the last desperate moment. “We treated more patients last year, we had more visits last year, and we dispensed more free medication than we ever have,” Viccellio says.
The Clinic is a collaborative effort between medical volunteers and community donors including UVA Health System and Martha Jefferson Hospital. Serving working people without health insurance, the Clinic sees those whose incomes are high enough to disqualify them from subsidized care but low enough that they can’t afford doctors’ visits.
In 2003, 1,300 patients kept 3,300 appointments. Open just three evenings a week, the Clinic is so stretched that organizers are seeking more volunteers and grant funding to hire their first nurse practitioner. Until now, the 12-year-old center has relied entirely on unpaid medical providers.
“This year, we’re turning people away,” Viccellio says– sometimes as many as 10 a day– people, like Alice, who have no other option except emergency rooms. A recent query to ERs about the cost to treat a sore throat found the cheapest to be around $100, about the same as at urgent care centers, where price lists for various services are provided.
A national study found that a quarter of uninsured diabetics who went without care faced an increased likelihood of amputation, blindness, and even death.
Currently, 60 percent of the Free Clinic’s patients have chronic illnesses, but follow-up appointments for serious conditions take longer to schedule than, say, a strep test for an otherwise healthy adult with a sore throat– so fewer people can be seen.
“Eighty percent of people without insurance come from working families,” Viccellio reports. “Something is wrong with the system.”
Take your medicine
Lack of access to treatment can cost time, money, and a cascade of health problems. But drugs cost big time.
At regular drug stores, a round of cephalexin, a common treatment for strep, costs around $20. If the problem is tonsillitis, a “Z pack” of azithromycin runs about $60. If you’re earning minimum wage– $5.15 an hour– that’s a day and half of work.
In its 2001 survey, the Virginia Health Care Foundation found that over 25 percent of the Commonwealth’s uninsured households left at least one prescription unfilled because of cost.
“Sometimes young mothers come for their babies’ antibiotics,” says a pharmacist, who asked not to be named. Then they’re told the price. “They just stand there and look at me,” she says. “I know they can’t afford it. Some of them say they’ll be right back and walk out and never come back.”
Some patients are able to afford generics or get free samples from their doctors. Others who qualify can pay as little as $3 a prescription at the Free Clinic or the UVA pharmacy, where the Salvation Army covers up to 1,500 co-pays a month. But chronic conditions mean chronic expense.
“I’ve seen older people– and you know every dollar they have is in their wallet– and the [medicine] is hundreds of dollars,” says the pharmacist. “And [they’re] deciding they won’t be able to eat, trying to decide how much medicine to buy, how much they can afford.
“Some of them buy five tablets at a time,” she says, “which makes the cost higher. It’s cheaper per tablet to buy in the quantity that it’s packaged from the manufacturer. [But] they’ll say, ‘I want two tablets of this and three tablets of that.’ Or five dollars of this and two dollars of that. It’s horrible.”
Doctors are businesses
Many doctors provide free or reduced fees for needy patients. But they are businesses, with overhead that includes staff, buildings, equipment– and rising malpractice insurance premiums.
Dr. Claudette Dalton, a local physician, says she knows of three Virginia practices that closed in the past year because they weren’t adequately compensated. “You can only offer so much free care and keep the lights on,” she says.
Dr. Bill Maloney, who works at Downtown Family Health Care, offers a sliding scale of fees for his uninsured patients.
“Our bottom line is we really want to help people in our community,” says Maloney, whose practice includes a volunteer dentist, counselor, and optometrist. Many of his patients pay just $20 a visit. He believes the system needs fixing.
“Canada’s is a really good system,” says Maloney. “It’s worked better than ours in providing care for the most people.”
Physicians for a National Health Program endorse the Canadian single-payer system. To those who fear that the program means medical rationing, they say, “18,000 Americans die every year because they don’t have health insurance. That’s rationing.”
Hospitals charge differently
Alice eventually learned she was eligible for UVA’s indigent care program. But she didn’t learn about it during the ER’s intake procedure.
“They knew I didn’t have an upscale address and that I had no health insurance,” she says. “You’d think that would have sparked a little something in them to say, ‘You may qualify– here’s our financial screening form.’ But no.”
Still, she’s very grateful for the program. (Someone else told her about it.) Based on her income, Alice is now responsible for just 45 percent of the cost of her medications, doctors’ fees, and hospital visits.
Indigent policies for UVA Health System, a government agency, are set by the state. Someone qualifies if their income is less than 200 percent of the federal poverty guidelines, currently $37,700 for a family of four. Personal wealth is also taken into account.
While UVA Health System’s chief financial officer Larry Fitzgerald can’t say how many people are denied income-based assistance for medical services, he knows that UVA is the state’s second biggest provider of charity care.
The most recent annual figures show 29,431 indigent patients treated at UVA, at a cost of almost $70 million. Resources to cover indigent care come from Medicaid, Medicare, and UVA’s operating margin.
“All healthcare providers,” Fitzgerald says, “have the mission to treat patients regardless of their ability to pay.” And that includes Martha Jefferson, a private non-profit.
Over the past year, 2,600 patients received help through the Martha Jefferson Health Trust which covers hospital expenses and fees at its primary care sites.
“The number of uninsured individuals has increased in our community, related to job losses in the area,” says Ann Nickels, the hospital’s director of public relations. “Some jobs have been added, but these are lower paying and offer few if any benefits.”
When indigents pay more
A September 24 article in the Washington Post reported some 50 lawsuits against nonprofit health care systems nationally, including Inova of Virginia. Allegations include price gouging of uninsured patients.
One was charged $29,492 for a day of heart care at Inova of Fairfax. Medicare would have paid $15,000 for identical services. According to the Wall Street Journal, Medicaid would have reimbursed only $6,000.
Some might argue that a person without insurance– someone least able to afford to pay full price for services– should not be charged more than insurance companies or the government.
“There’s a good deal of variation in billing practices, as I understand it,” Lt. Gov. Tim Kaine tells the Hook. “Hospitals negotiate prices with those who pay. [Sometimes] they’ll negotiate different deals even with different insurance companies. So they’ll have one deal for one insurance company and one deal for another– one deal for somebody who’s uninsured, and one deal for the state.”
Or everyone may be charged the same– but not everyone pays the same. It’s like standing in line to settle the bill for a meal at a restaurant, only to see the guy in front of you– and the woman behind you– hand over less for an identical dinner.
“There are no discounts, but government payers pay us what is permitted by law and regulation,” says Fitzgerald. “There’s nothing we can do about the amount they pay us.”
Do insurance companies do that at UVA? “They don’t limit reimbursement rates, but we may negotiate an agreed set of rates with them for specific services,” says Health System spokesman Peter Jump.
For patients ineligible for indigent funds and without wealth or insurance, Jump adds, “We’ll try to work out a reasonable payment plan. We don’t want to impose financial hardship on anyone.”
But if someone is paying more than an insurance company or the government pays, they might wonder if a “payment plan” misses the point.
The business angle
Half of all uninsured Virginians are employed by small businesses.
Kaine says the issue has grave human and economic consequences, so he has appointed a commission to study ways to make insurance more accessible to small firms. Possibilities include tax credits for companies that offer benefits, and an insurance-buying pool made up of entities like trade associations, the state, and Chambers of Commerce. The bigger the group, the better the negotiated fees.
Timothy Hulbert, president of the 1,200-member Charlottesville Regional Chamber of Commerce, says even though the cost of insurance is outside their control, most members provide some coverage to full-time employees. He believes they will continue to do so to compete for workers. But the cost of coverage exceeds the ability of many small businesses, with the average employer-sponsored premium for a family of four around $10,000.
Bob Colley, president of CK Courier, a local delivery business, is uncomfortable about not providing health insurance to his 20 employees– but he says he’s competing with similar companies that don’t provide insurance.
“Insurance right now is just ridiculous,” says Colley of the overhead his company is already paying. Still, he hopes to offer something– perhaps a health insurance allowance– next year.
“I hear from many companies,” Kaine reports, “who say, ‘By doing the right thing, I put myself out of the market’.”
The recent loss of local manufacturing jobs not only cost paychecks but also health insurance. The Chamber’s Hulbert speculates about the 2,300 people who lost these positions, wondering if they’re now part-timers.
Like Alice, nine out of 10 part-time workers in Virginia are uninsured. And scrambling.
Alice now faces paying off the $3,500 she owes UVA for her medical treatment. At her part-time clerical job paying $9/hour, she finds the prospect daunting.
But not everyone is struggling.
According to Forbes, the president of Richmond-based Anthem Insurance Southeast, Thomas Snead Jr., earned $33 million last year in salary, incentives, and stock options. And Larry Glasscock, Anthem CEO, enjoyed a pay package of $46 million.
“The company has performed in an extraordinary way,” William J. Ryan, a Maine banker who chairs Anthem’s compensation committee, told the Indianapolis Star, “and it would be unfair for the executives not to be paid in an extraordinary way.”
On the other hand, if these two gentlemen made just a million each, the leftover funds would be enough to insure some 7,700 families– approximately 30,000 people.
The big picture
But having insurance doesn’t mean financial security. High deductibles, high co-pays, and high premiums eat into family budgets. Twenty percent of a $100,000 hospital tab is still a lot of money.
As one local businessman says, “We’re all just a big medical bill away from bankruptcy.”
The two people running for Congress in the 5th District have distinct views about healthcare policies.
Republican incumbent Virgil Goode touts two measures he has supported to help the uninsured: one is a check-off on the federal tax forms for refunds.
“You can designate it for the uninsured who aren’t covered by Medicaid or Medicare. That will help some persons,” says Goode. “It won’t cure the situation, but it could provide probably a couple billion dollars a year.”
(Goode acknowledges that a wildlife group is also requesting a tax refund check-off status.)
The congressman supports a fully refundable tax-credit of up to $3,000 for qualified families to purchase insurance. The plan he supports would provide an additional 50 percent of the premium costs.
Does Goode consider healthcare a right? “I believe the government should assist persons with healthcare treatment,” he says, “and we do. Medicaid is a joint effort of federal and state. [Depending] on the amount of income you have and your [eligibility] status, you get free healthcare in this country.”
But not all poor people qualify for Medicaid. And because of low reimbursement amounts, not all doctors accept it.
Goode is wary of “socialized medicine” and mentions the Canadian and the British programs. “You have a lot of folks in Britain and Canada and every other country coming to America for healthcare treatment,” he says. “I’ve not heard of many persons going to Mexico or Canada for their healthcare.”
Al Weed, Goode’s Democratic opponent, says Americans aren’t going north for healthcare because they’re not Canadian citizens and therefore not entitled to that country’s medical care. Weed calls the U.S. system fractured.
“When you get sick, you should be able to see a doctor,” says Weed. “It’s that simple.”
He disagrees that a single-payer system, which he supports, constitutes “socialized medicine.” A single payer system, he says, would serve as an expanded Medicare, providing choice of doctors and hospitals– and prescription drug coverage.
The plan calls for small co-pays depending on the service provided.
“We already pay more than enough to have single-payer universal coverage,” Weed maintains. “A national health insurance program could save approximately $150 billion on paperwork alone.”
The candidates agree on one thing: The compensation package for the CEO of Anthem Insurance. Goode called it “absurd.” Weed thinks it’s par for the course.
“It’s why private insurance companies have overheads of up to 20 percent,” he says. “It does nothing for patient care.”
Alice is feeling better and is thankful for all the care she’s gotten. She’s looking forward to eating real food again. After waiting her turn and finally seeing a dentist at the Charlottesville Free Clinic, she says her dentures should be ready by December.