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The Cost of Willful Ignorance

By Dr. Sachin D. Shah
. 2 Comment(s)

Meaningful access to health care in the United States begins with health insurance.  It’s no secret, despite our often willful attempts at ignorance: the uninsured in America simply do not receive the same level of care as their insured counterparts. 

Uninsured children with asthma receive fewer office visits, prescriptions, and preventive checkups than insured children, and have worse control of their asthma.  Patients with lung cancer without insurance are more likely to die than insured patients.  Without access to regular preventative health care, their disease is diagnosed at a more advanced stage that is less amenable to treatment.  Uninsured working-age Americans admitted with heart attacks were 52 percent more likely to die in the hospital than the privately insured; those who had suffered a stroke were 49 percent more likely to die in the hospital.  These are not subtle differences.

In 2009, a record 50.7 million Americans (16.7 percent) were uninsured, up from 46.3 million (15.4 percent) in 2008.  In the first quarter of 2010, an estimated 59.1 million people had no health insurance for at least part of the preceding year.  Americans without health insurance are seven times more likely to forgo needed medical care because of cost, and are actually charged significantly higher fees than those with insurance for the same care because of insurance plan discounts negotiated with health-care providers.  Unpaid medical bills remain the leading cause of personal bankruptcy in the United States, and half of the uninsured owe money to hospitals.  A full third are being pursued by collection agencies.  How much stronger of a disincentive to pursue health care could we construct for those without insurance?

There are many who argue that this disincentive is an effective method of controlling costs.  The larger the share an individual has to contribute towards the cost of their health care, the argument goes, the more efficient the use of these services.  Higher costs should lead to more measured use of health care--you won’t go to the doctor unless you really need to.  This should be particularly true for the uninsured patient, then, who is responsible for all of his health care costs.  And after all, the uninsured American does spend well below half per capita (in absolute terms) what his insured neighbor will annually on health care.

But the assumptions inherent in this argument are dangerous.  It’s both intuitive and proven that the more people have to spend for their health care, the less they will use.  What’s crucial to consider, however, is that people cut down equally on both necessary and unnecessary care.  And that’s the point.  The average non-physician does not know what constitutes the difference.  Maybe the mammogram my uninsured patient forgoes because of cost would have been completely negative, and she thus saved the health care system $275.  But maybe it would’ve detected an early, localized cancer that could be quickly resected, thereby saving the system the tens of thousands of dollars for chemotherapy, radiation, and surgery required for metastatic disease detected much later (to say nothing of the emotional toll for the patient and her family).  There’s no way for most people to be able to make the judgement for themselves.

Unfortunately, even for the insured, annual premiums for employer-sponsored health insurance continue to rise.  Since 2000, the average premium for family coverage has increased 114 percent as employers shift the cost burden to employees in an effort to contain the spiraling costs of health care.  Household spending on health care as a percentage of personal income continues to rise, and disproportionately affects the poor.  While these measures may succeed in temporarily curtailing short-term health care spending, the imprecision of this short-sighted approach is certain to have even costlier long-term consequences.

As a primary care physician, I witness daily the disastrous consequences of delayed medical care: uncontrolled diabetes leading to renal failure and dialysis, untreated hypertension leading to strokes and heart attack, unfilled asthma prescriptions leading to emergency room visits and hospitalizations.  Lack of health insurance leads to poorer health for the individual at a higher cost to the health care system, perpetuating a painfully vicious cycle.  Poorer health outcomes mean the uninsured are sicker as a population.  And because they are sicker, they cannot get better jobs.  Without better jobs, they cannot afford health insurance--which makes them sicker.

From my perspective, it seems clear: true efficiency in the health care system starts with regular access to primary care and preventative health services.  Without health insurance, however, such access is severely limited.  Measures that expand coverage in our population, like the Patient Protection and Affordable Care Act (PPACA), which the CBO estimates will decrease the ranks of the uninsured in our country by about 32 million by 2019, are of enormous importance to improving access to health care, reducing costs, and improving quality.  The obsessive, misguided attempts to repeal such desperately needed reform, especially with no proposed alternative, are irresponsible and frankly baffling to me.  The trajectory we have been on--one opponents of the PPACA would have us return to--is not only unsustainable, it is unconscionable.

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  1. Margaret Ferriter Campbell, MD

    There are personal stories attached to the statistics quoted in this article. Physicians and nurses tend to fall into one of two groups: those who blame patients for ignorance and misbehavior; and those who blame an inadequate and encumbered system for the impediments standing in the way of appropriate and timely care. There is truth supporting each perspective.

    There will always be patients who have insurance and who still do not get the care they should get in a timely fashion. An example is a man I met last week socially. He is insured by Medicare as well as a supplement policy. He has no reason not to go to a doctor other than his own fears. He purchased an expensive herb online and is applying this to his skin cancer instead of going to see a doctor. This is not a good thing and he will likely end up with an expensive surgery that could have been avoided with timely intervention.

    There will always be those who overuse medical services (the noncompliant 'frequent flyers' who visit the hospital every few weeks due to our inability to force compliance --due to their rights to refuse to comply). A particular dialysis patient comes to mind. He routinely skips dialysis on Fridays --only to show up in the ER on the weekend looking for better room and board than his trailer provides. He gets it because he can't breathe due to skipping his Friday dialysis session. Yet, he refuses alternate living arrangements (which have been offered) and he has even been known to live for a few days in various hospital waiting rooms.

    I see those patients detailed above. But I also see the young patient who comes in for care with very end stage renal failure --all due to not having health insurance (despite working full time )and not knowing she had hypertension for years. I see the heart attack patient who stopped all her meds because she was waiting to get Medicare and couldn't buy her drugs to prevent another heart attack. She died before she got there. Every day, I see about 4 or 5 patients who come to the hospital too late. They are suffering (even dying) unnecessarily --all due to being uninsured! So much waste of medically intensive services that might have been avoided with preventive care and/or timely and appropriate management of chronic diseases. So many humans thrown away by our society! Valuable human lives! And we blame them? We blame them because it is easier to blame them than to accept blame for our share of the harm our system inflicts unjustly.

    The effect that the Affordable Care Act will have on reducing this waste of dollars and lives is long overdue! The time is now to implement care for so many who have been kept out of the doctor's office due to a lack of health insurance. Yes, we will still have to deal with 'stupid' and 'noncompliant' and 'problem' patients. But lets not blame all of them. The system can be fixed so that it is not murdering average people who are not to blame for their illnesses!
    This is an important step in reducing the waste of dollars and more importantly, the waste of lives that are lost each hour -- due to the lack of health insurance.

    Margaret Ferriter Campbell, MD
  2. David Chapman DO

    I'm a retired physician. My wife is a retired RN. Due to health problems I was forced to take long term disability and Medicare.

    My wife and one of my children could not buy health insurance after my COBRA benefits expired due to pre-existing health problems. As a cancer survivor she can't afford basic screening exams such as endoscopy which could find a malignant tumor at a treatable stage. What does this say about our current system That encourages early diagnosis? This is especially true in a cancer survivor.

    I have experienced health care in this country as both a provider and consumer. I cringe when I read that “We have the best health care in the world". That is only true for the wealthy and insured. Although the new Health Care Law does remove some of the obstacles to access it falls far short of what this country is capable of. Single payer systems such as in many European countries make our system little better than a third world country.

    This should not be a political debate. This is a Great Country and it should be able to provide basic health care to all of its citizens.

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