- Rose Shaffer's heart attack taught her a lot of things
that, as a nurse, she should have known. She learnt it pays to eat carefully
and exercise regularly. And she learnt the hard way that if you cannot
afford medical insurance in America, you better hope you don't get sick.
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- A Chicago hospital saved Mrs Shaffer's life but she feels
it is now trying to take it back. Since that frantic October night three
years ago, the hospital owners, a Christian, non-profit foundation, have
hounded her for crushing bills she could not afford, partly because as
an uninsured patient she had been charged double.
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- The hospital sent debt collectors after her who called
her all hours of the night, at home and work, until she gave in and was
forced into bankruptcy. Now, at the age most people are thinking of retiring,
she has to work long hours seven days a week at a nursing agency for the
next three years to have any hope of holding on to her last asset, a suburban
bungalow.
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- "When I was young I thought that, when you reach
60, if you don't have anything, then you're nothing. Well, I'm 63 and I
don't have nothing, and I'm not going to get anything," Mrs Shaffer
said, sitting at her kitchen table sifting through some of her latest bills.
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- "The whole system is messed up. In this country
the rich get richer and the poor get poorer, and no matter how much you
work, you're going to get poorer."
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- In the US today, there are nearly 44 million people in
her position - without medical insurance in a country that does not guarantee
basic healthcare - and the crisis is deepening. In the three years since
George Bush took office, the ranks of the uninsured have risen by 10%,
or four million people. The government will pay if you are destitute but
not if you earn enough to keep above the poverty line - about $18,000 (£10,600)
for a family of four. In theory, employers are supposed to provide health
insurance but more opt not to, and buying cover individually is either
very expensive or impossible if you have a "pre-existing condition".
-
- Consequently, 15% of the population, most of them the
working poor, live in the fear that an accident or sudden illness could
plunge them into debt. The uninsured will typically put off going to see
a doctor in the hope that their medical problems will pass. They tend to
seek treatment only when their condition is critical.
-
- Almost everyone in US politics, including all the candidates
in the presidential campaign, agree the situation is unacceptable but differ
widely on how to fix it. A succession of presidents, from Harry Truman
more than half a century ago to Bill Clinton in 1993, have floated grand
schemes for achieving universal healthcare coverage, but each time they
have been defeated by resistance from the medical profession, employers
and the tax-averse.
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- "I think the problem is the extent of income redistribution
it would take to make it happen," said Karen Davis, the head of the
Commonwealth Fund, an independent health and social policy foundation.
"The greatest sentiment for change comes when the economy is bad,
but that's also when resources are at their shortest."
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- There are public hospitals across America, but their
size and number are tiny compared to the scale of the problem. Chicago
has Cook County hospital which is overwhelmed in most departments by the
sheer volume of needy patients. But it does have a world class emergency
room and excellent trauma specialists.
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- Rose Shaffer, however, did not have the good fortune
to suffer her heart attack near the Cook County ER. The ambulance did what
it was supposed to - take her to the nearest trauma centre, at South Suburban
hospital, part of a Lutheran-run chain called Advocate Health Care. Two
days later, she was transferred to another Advocate hospital, Christ medical
centre.
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- Charity
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- Christ's is the biggest hospital in its region, and its
illuminated cross soars over Chicago's southern suburbs like a beacon -
a vivid symbol of what President Bush calls faith-based charity. As a non-profit
organisation Christ's is supposed to offer care to the needy, but there
is no state requirement for just how much charity it should mete out. Mrs
Shaffer said that when she was recovering from her heart attack, a hospital
official told her she would be sent application forms for charity assistance.
They never came. Instead, she received a bill for $18,000 - $6,000 for
each day she spent at Christ's.
-
- According to the Service Employees International Union
(SEIU) which has investigated Advocate and other "charitable"
hospitals in the Chicago area, Mrs Shaffer's bill would only have been
$8,500 if she had been insured. Medical insurance firms typically negotiate
heavily discounted rates for clients. The uninsured have no such leverage,
and according to SEIU's hospital accountability project, end up paying
on average 139% more than the insured. Joseph Geevarghese, the project
director, said: "When these people go to hospital they lose their
home." The hospitals often see the uninsured ("self-pay"
in the jargon) as a profit opportunity. In the words of an industry consultant,
Michael Zimmerman, "self-pay now stands alone as the financial category
that will provide the biggest bank for the buck".
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- "It can and should be a cash cow for the hospitals,
but it is not," Mr Zimmerman wrote in a newsletter for hospital administrators.
He argues hospitals are not being tough enough when it comes to debt collection
from patients.
-
- Mrs Shaffer said there was no lack of enthusiasm in her
hospital's pursuit of her money. "The collection people were real
nasty," she complained. "They'd call on Sunday, they'd call at
9 o'clock at night. They'd call on the job. My voicemail was full. It was
harassment."
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- Advocate says it is no more aggressive than any other
hospital. In fact, according to Ed Domansky, a chain spokesman, the hospital
is obliged by federal law to make "reasonable efforts" to collect
debts, and to maintain a uniform price structure, which does not allow
giving automatic discretionary discounts to the uninsured. The SEIU, he
said, was picking on Advocate hospital because it was seeking to organise
its workers, and he pointed out the chain had recently expanded its charity
care, and made more effort to inform the uninsured about its availability.
-
- "This is not just an issue in one hospital or one
state," Mr Domansky said. "We believe the federal regulations
on hospital billing make the plight of the uninsured worse, and we would
welcome change."
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- Deep trouble
-
- It is not just the uninsured who can end up impoverished.
Richard Roche thought he had insurance. His employer, a cab company, did
not provide it, so he paid more than $400 a month for his own policy. When
he had to have a growth removed from his windpipe, his insurer agreed to
pay only a fraction of the cost. The hospital went after him rather than
the insurer and the bills eventually forced the 61-year-old into bankruptcy.
He had to sell his house and cashed in his life insurance. "They got
me. Once you get sick - that's it. You're in deep trouble."
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- Ronald Pollack, the head of a Washington pressure group,
Families USA, said: "This problem reaches deeper and deeper into middle
class and working families. For most Americans it has gone from an issue
of altruism for a discrete, disadvantaged population, to an issue of self-interest."
-
- The crisis has become an issue in the presidential campaign.
Remedies vary in cost and ambition, from schemes to expand Medicaid and
Medicare (the government-funded schemes for the destitute and elderly)
to cover the rest of the uninsured, financed by repealing the Bush administration's
tax cuts, to the far more modest market-oriented proposals put forward
by the White House itself, based on tax breaks for the self-insured.
-
- History suggests that, whoever is elected, little will
change. The hospital business and the $400bn insurance industry have too
much to lose, as do corporate employers who would be asked to foot much
of the bill.
-
- Much like an uninsured patient, the US knows there is
something wrong, but it is unable so far to face the cost of the cure.
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- Guardian Unlimited © Guardian Newspapers Limited
2003
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- http://www.guardian.co.uk/usa/story/0,12271,1077230,00.html
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