Correcting some misinformation on medical care for the penniless

[Martha]

In a thread that raised certain health care issues a few posts were made regarding the ability of the down and out to get medical care if they were impoverished. For example:

Yes, I believe that once you pay all that you have for health care and become penniless, the public assistance will then step in.

I think that is also true for elderly care like nursing home costs. Just become penniless and you would be taken care of.

Poverty alone does not make you eligible for Medicaid. Federal law does not require Medicaid to cover poor people unless they fit into certain categories. Certain poor children can get coverage. Some people can get coverage if they are poor and are pregnant or have young children who are eligible. People who are poor and completely disabled are eligible. People who are poor and elderly needing nursing home care are eligible. States can choose to cover more people but the trend has been for states to cut as their budgets suffer. Most if not all states do not cover all penniless people. Overview Medicaid Program - General Information

What assets you can keep is primarily a matter of state law and states' laws are not generous.

What Medicaid will cover is also variable. For example, a state may provide coverage for hospice care or it might not. Medicaid rarely covers birth control. I worked with a young woman not long ago who was severely mentally ill and on SSI disability and Medicaid. Medicaid would not cover all the costs of sterilization and she really needed the procedure. Transplants might not be covered. Just because there is a medical need does not mean Medicaid will cover it. States may require copays as well. A couple of studies have shown that the copays have resulted in large numbers of people not filing any prescriptions because of the hardship.

Sometimes states have separate programs to try to help out people who are not eligible for Medicaid. Not all states have them and they tend to be very restrictive on who they cover, how much and what they cover. For example, I have seen states limit coverage to only a few thousand dollars a year plus the person had to pay a premium. These programs tend to come and go depending on the health of a state's budget.




__________________

 

[jebmke]

It is a widely held misconception that the poor and/or uninsured have access to health care. Nearly the entire rest of the developed world has overcome this myth.

 

[youbet]

I agree with Martha and thanks to her for making this clear.

It also brings up an interesting question. Do we really need the recently enacted health care legislation which provides subsidies for even middle class folks or rather do we need to focus our limited resources on improving Medicaid coverage for the truly indigent? What can we afford to do? I don't know. It's a perplexing situation.

 

[haha]

I agree with Martha and thanks to her for making this clear.

It also brings up an interesting question. Do we really need the recently enacted health care legislation which provides subsidies for even middle class folks or rather do we need to focus our limited resources on improving Medicaid coverage for the truly indigent? What can we afford to do? I don't know. It's a perplexing situation.

Medicaid already costs more than Medicare. There is a very good article in last week's New Yorker about a doctor who has tackled medical costs by trying to do something about the quality and consistency of care that really sick people are getting. He had database skills and he discovered that maybe 2% of the people who recieve care use up the lion's share of resources- like weekly hospitalizations. People say-it's all old people, but it isn't. It is just people with chronic and medically mismanaged conditions who really have no one coordinating their care. They might not understand their meds, they might not understand their diet, on and on.

Really, after watching that Leno video in another thread, one wonders if 99% of people understand anything beyond how to "friend" someone on Facebook, or to tweet their latest idiotic thought.

After reading this I thought there are really only 2 potentially effective and affordable paths- triage, where the system just punts completely on these people, or a more intelligent system which actually pays attention to results, and makes simple but guided interventions to get the most out of what is available.

What I believe will likely happen is neither of these. We will keep bumbling along until it completely breaks. At least people in wheel chairs do not often take to the streets.

Ha

 

[Moemg]

Another sad fact is the people who self pay pay full price do not get the discounted price available to heath care plans . So not only can't they afford it they are charged more .

 

[obgyn65]

Thank you Martha.

 

[ERD50]

Poverty alone does not make you eligible for Medicaid. Federal law does not require Medicaid to cover poor people unless they fit into certain categories. ...

Thanks Martha, this is complicated and I'm trying to understand it better.

I went to the link, but I had trouble finding much info. They mention these 'special categories' but I can't seem to find out what is/isn't included. I went to the benefits.gov and entered a profile and got a long list of potential benefits, but it was tough to make heads/tails of that. The questions seemed odd. What difference should it make what my race is? If I need assistance, I need assistance. At one point they asked about past/current occupations, and it was a really strange list:

Which of the following (if any), describe your current and/or past professional experiences? (Check all that apply.)

Agricultural producer/Farmer
Aquaculture operator
Clinical research
Coal miner
Dairy farmer
Educator (teaching, training)
Elected official
Emergency response worker
Federal employee
Firefighter
Fisherman
Health care professional
Law enforcement officer
Long shore or harbor worker
Migrant or seasonal farm worker
Military
Musician
Post-doctoral research
Practicing artist
Published writer/Poet
Railroad worker
Rancher

What is that about? Does that mean a factory worker or an Engineer won't qualify? Does a "Practicing Artist" qualify for something that another human would not? I dunno, it seems odd to me.

So what happens if you are outside of one of these categories? Do they really roll you out in the street to die? I haven't heard of that happening, but maybe I'm uninformed. I am confused.

-ERD50

 

[Westernskies]

Martha, I agree with you that health care for the indigent is a real problem here in America. There are no easy answers, but the money has to come from somewhere. Just imagine what a difference it would make if we had the billions spent on health care every year for millions of illegal aliens available for programs to treat our own.

 

[M Paquette]

So what happens if you are outside of one of these categories? Do they really roll you out in the street to die? I haven't heard of that happening, but maybe I'm uninformed. I am confused.

It seems to vary among the states, but there are generally Medicaid special cases for certain illnesses associated with some jobs. That may be what that list is for.

When my mom 'retired' to a dying logging town, she volunteered as a visiting nurse to provide care to folks with no medical coverage spread around the countryside. One fellow was a former sawmill worker with squamous cell cancers in his nasal cavities, along with cancers in his lungs and soft tissues. He didn't qualify for Medicaid, and since he was stable (albeit dying), he couldn't get care through the ER dodge.

Eventually he was so bad off that she drove him to a free clinic day in a city several hours away, where he was found to be terminal. That made him eligible for hospice care, so he could get some painkillers for his last few weeks of life.

In most states, Medicaid is focused on providing care for children and their caregivers, the disabled, the elderly, and persons on temporary state assistance (with the intent of getting them healthy and back to work).

 

[ERD50]

It seems to vary among the states, but there are generally Medicaid special cases for certain illnesses associated with some jobs. That may be what that list is for.

Yes, I could see that for "coal miner", "Firefighter", maybe a few others, but...

Post-doctoral research
Practicing artist
Published writer/Poet



Elected official <insert your own joke here>

-ERD50

 

[Alan]

Martha, I agree with you that health care for the indigent is a real problem here in America. There are no easy answers, but the money has to come from somewhere. Just imagine what a difference it would make if we had the billions spent on health care every year for millions of illegal aliens available for programs to treat our own.

Is this a request for the thread for the thread to be closed?

 

[REWahoo]

YouTube - Suey!

 

[M Paquette]

Yes, I could see that for "coal miner", "Firefighter", maybe a few others, but...

Post-doctoral research
Practicing artist
Published writer/Poet



Elected official <insert your own joke here>

-ERD50

You'll probably want to check with your state's Medicaid folks and ask them what they are looking for. State programs may elect to extend Medicaid support beyond the federal mandate.

 

[NW-Bound]

As Martha quoted my post in another thread which was closed, I will respond here.

I will readily admit to not knowing a whole lot about indigent health care, and the distinction between what is provided by Medicaid which is a Federal program, and what is provided by the states. Being a layman, I should not have generalized from just a couple of cases that I knew, and with incomplete information at that.

It appears to me the system and its regulations are so byzantine that it takes an expert to know how it all works, and who can qualify for what. But I have read that the system would spend a lot on dying patients, but not enough on the health maintenance to keep them from needing such end-of-life expensive treatments. That may explain why the homeless woman whose plight I learned of got treatment for her stroke, but she might not get any health maintenance care at all. By the way, the impression I got from my mother who told me the story was that this homeless couple was in their 40s and would not be under Medicare.

Now that I have admitted to being an ignoramus on indigent health care, I would like to ponder some questions on the universal health care issue.

Because I have learned that not all the penniless people currently get coverage, it worries me a whole lot more. If we have not been able to afford what the public health care assistance is currently providing, which is actually quite limited as Martha explained, how will we be able to extend more coverage to more people with the new laws? As someone has said in other previous threads, there were really nothing in the recently passed laws that address that. How do we cap fees to the medical profession or make them work harder for less pay? I again claim ignorance as I have only glimpsed through a summary of the Patient Protection and Affordable Care Act (PPACA or Obamacare), and am not knowledgeable enough to understand any ramification or consequence, whether intended or unintended, of all its clauses.

It has been said in the past by different opinions that 1) health care providers are overcharging us, 2) insurance companies are making outrageous profits, 3) the system has terrible inefficiencies, and 4) too much money is spent on a few too sickly patients. I suspect that there is some truth in all of the above. How will we address each of those?

 

[GregLee]

It has been said in the past by different opinions that 1) health care providers are overcharging us, 2) insurance companies are making outrageous profits, 3) the system has terrible inefficiencies, and 4) too much money is spent on a few too sickly patients. I suspect that there is some truth in all of the above.

How can there be any truth in such rhetoric? How much of a charge is an overcharge? How much profit is outrageous? How much inefficiency is terrible? What is the right amount to spend on patients who are too sickly?

 

[kyounge1956]

Last week I watched a DVD called "Sick Around the World". It was an overview of the health care systems in five other countries: the UK, Germany, Switzerland, Taiwan and Japan. The program, originally broadcast as an episode of Frontline, described the different types of systems, the pluses and minuses of each.

Three features were common to all the systems reviewed in the program:

1. Everyone must have health insurance
2. Nobody can be refused health insurance
3. Prices for medical care are fixed (IIRC they are set by law).

All these countries pay less (considered as a percentage of GDP) for health care than the US does. IIRC, all five countries provide health care for their whole population at a fraction of what we pay to cover only part of ours. Only one of these countries (Switzerland) has higher GDP per capita than the US, and if adjusted for relative purchasing power, we're richer per head than the Swiss too.

If they can do it without bankrupting their countries, so could we.

 

[Martha]

I summarized the main categories. The link I provided was not for detail purposes, it is a bit dated and it is next to impossible to provide details, it was just to provide some general information. You are not going to figure out easily who may be eligible for what program and where unless you have a particular community and person in mind and want to dig. There are a few things, such as full blown aids, black lung, kidney failure and other circumstances that may get you some medical care under special programs. There are also optional categories for a state, for example if a woman is screened under a screening program for breast cancer and is found to need treatment the state has the option, but not the requirement, to provide the treatment. The biggest general gap is for adults without kids and who are not old or disabled. What happens to them? They often go without care. Some die. Sometimes there are free clinics available but not all areas have them and they can end up wait listed for a long time. If you are in a rural area odds are you will get no care. Emergency rooms have to see them for medical emergencies, but only to the point of stabilization.

It is hard for people with chronic illnesses because of the difficulty in getting medications. I know one person without insurance who is about to lose their unemployment benefits and has to take epilepsy drugs. While he was on UE the pharmacy sold them to him at a reduced cost. But now he doesn't know how he is going to pay once he loses his benefits. Plus, he does not visit his doctor because he has no way to pay. And this isn't even a priority for him because he is more worried about paying rent and buying food.

The group I am most familiar with were young homeless people who had mental health problems. No eligibility for medicaid. They might decompensate and end up in the hospital. The hospital would medicate them and send them on their way as soon as they were not psychotic. They would only irregularly fill prescriptions, one state I worked in had a program to provide meds but had copays so that didn't work if you are homeless and had no cash. A number just plugged along, with depression and other issues that just never got treated. They had poor to no follow up by medical personal. And because of their own problems they were not good at helping themselves. All in all they were sicker than they needed to be. Certainly they never went to the doctor for checkups to see if they needed any particular care.

I have less experience with people who are not homeless and uninsured but I have seen data on lack of care. If you don't have a doctor because you can't pay for it you might not catch the things the rest of us catch. High blood pressure. Cancer. Etc.

Then end result is that people do not seek treatment until they are very ill and then the treatment may be inadequate.

 

[youbet]

Last week I watched a DVD called "Sick Around the World". It was an overview of the health care systems in five other countries: the UK, Germany, Switzerland, Taiwan and Japan. The program, originally broadcast as an episode of Frontline, described the different types of systems, the pluses and minuses of each.


Three features were common to all the systems reviewed in the program:

1. Everyone must have health insurance
2. Nobody can be refused health insurance
3. Prices for medical care are fixed (IIRC they are set by law).

All these countries pay less (considered as a percentage of GDP) for health care than the US does. IIRC, all five countries provide health care for their whole population at a fraction of what we pay to cover only part of ours. Only one of these countries (Switzerland) has higher GDP per capita than the US, and if adjusted for relative purchasing power, we're richer per head than the Swiss too.

If they can do it without bankrupting their countries, so could we.

In some cases, it sounds like you are confusing "health insurance" with gov't operated health care systems. Quite different things. Which are you proposing?

Did the documentary compare these five health care systems with "Obama-Care?" Was any mention made of how the health care systems in those countries are funded? Focused, specific taxes? Premiums? From the general tax generated gov't funds with no identification of funds focused on health care?

 

[Purron]

Last week I watched a DVD called "Sick Around the World". It was an overview of the health care systems in five other countries: the UK, Germany, Switzerland, Taiwan and Japan. The program, originally broadcast as an episode of Frontline, described the different types of systems, the pluses and minuses of each.


Three features were common to all the systems reviewed in the program:

1. Everyone must have health insurance
2. Nobody can be refused health insurance
3. Prices for medical care are fixed (IIRC they are set by law).

All these countries pay less (considered as a percentage of GDP) for health care than the US does. IIRC, all five countries provide health care for their whole population at a fraction of what we pay to cover only part of ours.

Martha, this is an excellent overview of the health care options (or lack thereof) for the poor. Thank you.

Kyonge1956, it is mind boggling what the US pays for health care as compared to other countries.

Check out this information provided by the OECD:

http://www.oecd.org/dataoecd/46/33/38979719.pdf

The US pays much more for health care per capita and as a share of GDP.

 

[BigNick]

In some cases, it sounds like you are confusing "health insurance" with gov't operated health care systems. Quite different things. Which are you proposing?

I think that the point is that whether you have a mostly gov't operated system (UK) or a mostly insurance based system (Switzerland), there are ways to do it which are more efficient than how the US does it.

One of the great canards of the debate in the US has been that it's a choice between American Free Enterprise Yessiree Bob versus some kind of Soviet system based on cold showers and gruel. Maybe this is because it's easier for Americans to interview (unhappy) people in the UK because of the language. Few countries have anything like the degree of "socialisation" of the British system; there are as many alternative ways of organising a health system as there are countries.

 

[samclem]

Only one of these countries (Switzerland) has higher GDP per capita than the US, and if adjusted for relative purchasing power, we're richer per head than the Swiss too.

I wonder how that happened.

There are certainly better systems than the non-system we have now. As I likely mentioned before, we're "lucky" in that there's so much waste and inefficiency in our present way of doing things that we'll likely be able to provide better care for everyone without increasing the overall % of GDP spent on healthcare. One of the goals of the better system will be better care for poor Americans and more equitable costs and cost sharing. But we shouldn't think that just because our present system is not great that anything would be an improvement.

 

[kyounge1956]

In some cases, it sounds like you are confusing "health insurance" with gov't operated health care systems. Quite different things. Which are you proposing?

I'm not proposing anything specific at this time, just putting forward the idea that there is some way it could be done. It seems to me whenever the topic of health care comes up someone says or implies "we can't cover everyone, it would cost too much". This program described how other countries do cover everyone without it costing too much, and the three features shared by all the systems covered in the report seem to be the common denominator. With those three features it can be done in a variety of ways. It may also be possible to have a viable health care system cover everyone even without all three, but none of the countries in the report did that.

Did the documentary compare these five health care systems with "Obama-Care?" Was any mention made of how the health care systems in those countries are funded? Focused, specific taxes? Premiums? From the general tax generated gov't funds with no identification of funds focused on health care?

There was no comparison to the recent health act. I believe the program was originally broadcast before the act was passed. The funding mechanisms varied from country to country. One (UK) has tax-funded government health care, the others were insurance-based with government involvement of one kind or other.

 

[kyounge1956]

Only one of these countries (Switzerland) has higher GDP per capita than the US, and if adjusted for relative purchasing power, we're richer per head than the Swiss too.

I wonder how that happened.

There are certainly better systems than the non-system we have now. As I likely mentioned before, we're "lucky" in that there's so much waste and inefficiency in our present way of doing things that we'll likely be able to provide better care for everyone without increasing the overall % of GDP spent on healthcare. One of the goals of the better system will be better care for poor Americans and more equitable costs and cost sharing. But we shouldn't think that just because our present system is not great that anything would be an improvement.

The point I was trying to make is that these countries are not able to afford health care for their whole population at a lower fraction of GDP because they are richer than we are. They aren't richer than we are. I don't say or think that absolutely anything would be an improvement on the status quo, but the report shows that there are several different routes we could take, any one of which would be an improvement over what we have now. It would cover more and cost less. Maybe we agree—I don't think I fully caught your point.

 

[ERD50]

... It seems to me whenever the topic of health care comes up someone says or implies "we can't cover everyone, it would cost too much". ...

Really? It doesn't seem that way to me at all. I think this is a (perhaps unintentional) straw-man.

Here is what I'm 'hearing':

HC costs are going up, due to many factors.

Almost everyone is 'covered' one way or thee other - often very inefficiently (emergency room - or escalated because of poor preventive care), so there ought to be a better way.

Good HC reform should cost less than the way we do it now.

I think that much of the angst over the current bill is that it did almost nothing to control costs.

Also, those same OECD countries almost all spend less per capita (I think the Swiss spend slightly more) on education and get better results. So HC isn't unique in this regard. Our education system is publically funded, everyone is covered, but that hasn't led to lower costs and better results. I don't think the answer is that simple.

-ERD50

 

[donheff]

But we shouldn't think that just because our present system is not great that anything would be an improvement.

True but I think many of us view it sort of like some in the GOP viewed tax cuts - the "starve the beast" view that without money programs would have to be cut. The health care version is "with no pre-existing conditions the system will have to enforce mandatory coverage or single payer," and "as costs go up efficiency changes (e.g. rationing of some sort) will eventually be forced on the overall system al la "starve the beast."

I don't know if this view will work -- maybe costs will go up forever and we will just continue dickering around. But I fall on the side of continuing with the experiment we have embarked on (and which may indeed fail) rather than returning to the experiment we were embarked on and that has already demonstrably failed.