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Episode #2226
Patients, Providers, and the Cost of Caring
Brown: North Carolina is home to a rising number of individuals who live without health insurance. What is causing the rise in the number of uninsured and what sort of challenges does the healthcare industry face as a result of this special group of patients? We’ll explore these issues next on Black Issues Forum.
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Brown: Good afternoon, everyone, and welcome to Black Issues Forum. I am Natalie Bullock Brown. There is a crisis in healthcare and it concerns the growing number of people that are uninsured in the United States. According to information from the North Carolina Healthcare Safety Net Taskforce the number of uninsured individuals has risen dramatically in North Carolina as a result of the downturn in the economy and that has led to an increased number of people seeking healthcare from free clinics and other “safety net providers”. In addition there has been no increase in federal or state funding to support these organizations. These facts have not only caused significant strain on the healthcare safety net providers but also influence public perception about who is insured, who is getting cared for and who is paying for it. We are talking about the cost of caring this afternoon.
And right now I would like to introduce our very knowledgeable panel of guests here to help us answer these questions and look at this issue more closely. We have with us Jeff Spade of the North Carolina Hospital Association. He is Vice-president there and chair of the Governor’s Task Force for Health Carolinians. We also have with us Evette Patterson who is Nursing Director for Piedmont Health Services. And last but not least we have Dr. Pam Silberman, President and CEO of the North Carolina Institute of Medicine. Welcome, all of you, to Black Issues Forum.
We want to start off by taking a look at who’s covered or more importantly who is not covered by health insurance in North Carolina and we have a graphic that will help us to understand this a little more closely. According to a 2006 report by the North Carolina Institute of Medicine and Task Force on Covering the Uninsured more than 1.3 million non-elderly people in North Carolina lacked health insurance coverage in 2004. That is nearly 17% of the non-elderly population and includes both unemployed and working individuals, wealthy and low-income individuals, men, women and children of all races, ethnicities and ages.
Now of those the two groups most likely to lack coverage are low-income individuals with incomes below 200% of the federal poverty guidelines and those who have a family connection to a small business with fewer than 25 employees. More than four-fifths or 83% of the uninsured fall into one or both of these groups. And then there are those families that both have an income below 200% of the federal poverty guidelines plus a connection to a small business. Now I am going to come back to our panel and ask exactly what this means and I am going to start with you, Dr. Silberman. Can you give us a little bit of context for this?
Silberman: Sure. What we find in North Carolina is that most of the uninsured fall into one of those two groups or fall into both of the groups. And that’s low-income people and we define that as having incomes below 200% of the federal poverty guidelines which is about $40,000 for a family of four or people who are connected to small businesses with fewer than 25 employees. The reason for that is pretty obvious. Health insurance is very expensive. And for low-income families it is very hard for them to afford coverage and they oftentimes work for businesses that don’t offer health insurance coverage. The small business side of it is sort of the same thing. Oftentimes small businesses can’t afford to buy health insurance coverage for their employees so they are much less likely to offer health insurance coverage and that’s why there are employees who work for small businesses who don’t have health insurance coverage.
Brown: Ms. Patterson, let me bring you in. And talk a little bit about I guess the sort of patients that you see. I mean, the graphic that we looked at said that we are not only talking about low-income but we also are talking about the wealthy as well. There are some wealthy who don’t have health insurance and this affects, you know, men, women, children. Talk a little bit about what your experience has been with the uninsured.
Patterson: Okay, with Piedmont Health Service we are a community health center. So we are considered to be a safety net provider. About 50% of our patients do not have insurance. We do have Medicare, Medicaid insured patients but about 50% of those patients that come to us for care, they do not have insurance. So I understand exactly the problems that you are talking about. And one of the things that we have to do is to figure out how to give them care and many of them are put on a sliding scale fee and of the 50% that are not insured we have a sliding scale fee and our lowest sliding scale fee is for those that are 200% of the—100% of the poverty level or below. And about 50% of those patients that are uninsured fall under 200%. We only have a small percentage of our patients, only 2% of our patients are above 200%. So most of our patients are the poverty patients that we are dealing with—200% or below.
Brown: Just let me—Mr. Spade, because I am calling everyone formally—but can you just define a little bit more specifically what we are talking about when we deal with the federal poverty guidelines and what 100% of that is and what 200% of that is. And, really, what are we talking about in terms of how people are able to live based on whatever their income is reflective of those percentages.
Spade: The poverty guidelines just reflect the federal government’s attempt to try to put a number to whether or not people can have sustenance living. So that means do you have enough food to pay for—enough money to pay for your food, enough money to pay for your living arrangements and those types of things. And that’s what the federal poverty guidelines are designed to support across the country. 100% means that that is exactly where they have defined the poverty level, that is exactly the place where poverty starts. 200% would mean twice as much in terms of income per family unit then the poverty guideline would say so 200% of poverty would really mean twice the income level that would be defined by the poverty guidelines.
Brown: And I want to come back to you to talk a little bit about the work that you do but let’s look at another graphic that will further help to explain this federal poverty level guidelines. If you are a single individual making around $20,000 annually or perhaps a family of three with a combined household income of just over $34,000 or, say, a family of five making just over $48,000 annually, you are very likely to be among those in our state who do not carry health insurance. So with the work that you do at the hospital association in my reviewing the information in preparing for this show I understand that a lot—that, that the safety net providers would be emergency rooms at hospitals as well as outpatient, the outpatient departments of hospitals. How does someone coming in without insurance impact a hospital especially if they come in through the emergency room?
Spade: You know, hospitals as safety net organizations are there to be a support to everyone in the community. So hospitals serve anybody regardless of their ability to pay, background, status. And that’s why we have supported hospitals and their development and almost all counties in North Carolina have a hospital to support their needs. The emergency room, obviously, is a place where—it’s kind of a place of last resort if you need healthcare especially if you are not receiving regular healthcare which many uninsured people are not able to is to have a regular source or access to healthcare. Then the emergency room becomes one of those places that many people find themselves when their health conditions make it so difficult for them that they end up having to go see a physician in an emergency room. The problems with that is that it may not be the best place to have the care provided that you need. Like Piedmont Healthcare, that is probably a better place and those kinds of organizations that do that work are much better able to take care of a patient with basic health problems. But the other is it’s a very expensive environment. It is designed to be there for people with heart attacks, you know, major injuries. So that’s what that emergency room is designed to support and it’s a very expensive place to receive basic healthcare. So in terms of hospitals we really aren’t interested in having a lot of basic healthcare flow into emergency rooms. We’d rather work with agencies and community organizations to try to improve the availability of healthcare at a more appropriate setting.
The second thing that goes on in terms of hospitals and the uninsured is it is a burden in terms of operating a healthcare organization. I work with rural hospitals across the state and in rural communities the uninsured is a higher proportion. In urbanized communities, the uninsured is a numbers issue. They have a large number in our urbanized areas have large numbers of uninsured—Charlotte, the Triangle, Durham, those areas have huge numbers. And you go to rural areas the numbers are proportionately larger so by proportion you have more uninsured that might use a healthcare service. So in rural hospitals for instance you will see between 5-10% of their business is for people that have no insurance. And if you can imaging running a business for 10% of your business has no means of paying for the services of your business, you know, it creates some difficulties.
Brown: Right, let me—I appreciate the explanation because one of the things that comes to mind is that there is a perception perhaps and I am sure it is not necessarily just with the uninsured because, you know, that the people that make up that population sort of run the gamut as we learned. But there must be a perception that the best place for me to go, not only is the best place for me to go is the hospital but maybe people don’t even have a clue that there are these other organizations that can help them out. Dr. Silberman, what if anything is being done about that?
Silberman: Well, there is actually two things that I would like to say to that. There is an interesting study a couple years ago, it was a national study. And they did a survey of uninsured people and asked them if they knew about the safety net organizations that existed within a close proximity to where they lived and about 50% of the uninsured nationally did not know of these safety net organizations like community health centers or free clinics even when they were located within five miles of where the people lived. So we know, we don’t expect that it really is all that much different in North Carolina. In fact when we were doing our study on the safety net we found we could only document that about a quarter of the uninsured were linked to a safety net organization for primary care. So one of the things that is ___ of a safety net organization that we have been working on with the hospital association, community health center association and other groups is to try to develop a website where we would list all the safety net organizations, what services they offer, what their hours of operation are, whether they offer services on a sliding scale basis and have a website accessible so that people could find out from their own community what exists in their community and what services they can get. And we are hoping to launch that sometime this fall.
Brown: Ms. Patterson, what sort of things does your organization do to reach out into the community and let people know that, you know, we are here for this specific reason to help you especially if you don’t have health insurance.
Patterson: Well, really we don’t really have to do very much outreach. We really understand what they are saying with the strain on the hospital systems and that kind of thing. And we experience the same kind of strain even as a safety net provider because only about 25% of our funding comes from federal government and the rest of it comes from our patient payments and those kinds of things. And so when we have such a high percentage of uninsured patients it makes it very difficult for us to provide the care. We are continuously increasing the number of patients that we see but without any increase in the federal dollars that are coming to us. So we are having to unfortunately provide the care, you know, as my medical director often says, on the backs of our patients because we don’t have—we have a limited amount of resources and we do everything that we can to increase our resources but the federal government is not providing us with more resources. So we are not, you know, publicizing, you know, our care. We do try to participate in community activities, you know, some of our centers have been very involved in church faith based health fairs. And we will participate when asked to be involved with those types of things. One of our providers is very involved in the Latino community in the Carrboro area so we are involved with that kind of thing. But we are having a difficult time trying to provide care to the increasing number of uninsured.
Silberman: Can I just add—can I say something? That is a real challenge that we all face in the state because if you do outreach you bring more people in but if there is not the resources to help support that it becomes much more difficult for an organization to operate. There have been since the safety net report, the general assembly has allocated some monies to help support safety net organizations and there have been some foundations that have put money into safety net organizations but it’s not enough to meet the growing need.
Brown: Let’s shift the conversation a little bit to talk about as we deal with perception of I guess the uninsured, about where they can go, let’s also talk about what in general North Carolinians think about who the uninsured are. And, Jeff, I’ll direct this at you, is there a particular group of people, whether racial, bi-racial background or even by sex perhaps that is generally thought of as the main population of the uninsured.
Spade: I don’t think you can get that categorical about the uninsured and with a state like North Carolina which has a large amount of diversity across the state from the mountains to the coast, the uninsured are different in every one of those communities and areas. I do like the work that you did early in the program where you said low-income is one of the major definers of that group of people, and I think that that is the way I would usually think about, is where in our communities in North Carolina do we have low-income populations. Those are the disadvantaged populations. Those are the populations that have higher chronic disease which is usually a big problem when you are dealing with folks who are uninsured, if you have chronic disease you need a lot of support in healthcare and you got to worry about how to provide that support. Those are people who have less education. People have lower incomes and maybe jobs that don’t allow them to have access to health insurance. So that is a really great way to think about where uninsured people and who they might be in any community. What should we worry about? Uninsured children. You know, we would think where we have large pockets of children who are uninsured is a problem, we got to address children that are uninsured. They are going to be from low-income families, obviously. So that’s a way I usually will focus and help organizations I work with to focus on where the uninsured are. There are disparities in racial make-up so that you might—and low-income, I think if you just say low-income there is a higher proportion of low-income that is in minority breakouts, in the Hispanic, African American minorities, you will see proportionately a higher proportion of those populations in low-income categories. So that is a great way to think about it. Low-income and then within that low-income mix where do you find groups of people that really need help? In the mountains it might be one type and it really won’t be a racial minority for the most part in the mountains. On the east part of North Carolina that will be a very strong component of the uninsured.
Brown: We have another graphic that we’d like to look at that deals specifically with the uninsured, based on broken down by race. And according to the 2001 census bureau report, at first glance it appears that the majority of the uninsured population is white. However, minorities are disproportionately represented in the uninsured population just as Jeff, Mr. Spade was saying with Latinos being the least likely to be insured although they represented 12.5% of the US population they accounted for about one-quarter of the uninsured population and even though African Americans represent at 12.3% of the US population this group accounted for one-sixth of those uninsured. I want to talk about how—because I am sure we all know that the Latino population in North Carolina is growing very rapidly and so there are probably some interesting things to look at as far as how they impact the uninsured population. But I wanted to come back to you, Mr. Spade, and also you, Ms. Patterson with a question about how people, how the health of the uninsured ultimately impacts the entire system and especially those of us who may have insurance and are covered and don’t really—well, I guess—I’ll leave it there. How do the uninsured especially if they are unable to get consistent healthcare, how do they impact the larger system and the larger population? Let’s start with you.
Patterson: Preventive care is certainly the best type of care because you want to prevent some of those diseases from progressing and with the Latino community one of the biggest disease, chronic disease that they often have is diabetes. And so providing them with preventive care prevents them from having some of the more expensive problems that come along with the diabetes. So we want to provide that preventive care. But sometimes people have to make the decision between eating and buying my medicine so—that’s why it’s really nice to have safety net providers if that is an option for some patients. But one of the things that we have experienced at Piedmont Health Service is the increase of our Latino population. When you look at purely numbers our white population hasn’t really decreased any at all and our black population hasn’t really decreased. But the number of Latinos utilizing our care has significantly increased. So probably eight years ago we were only about 25% Latino and now we are about 50% Latino and in some of our centers we are as much as 70% Latino. And so it is very difficult. It makes a big strain on the healthcare services that we provide. And we have had to adapt to that. Having a larger percentage of Latinos and they are often not able to speak English we have also had to make sure we have providers that are bilingual, having other staff that is bilingual.
Brown: So it all adds to the expense. So affect on the bottom line.
Spade: In terms of broader healthcare system, you know, I can use hospitals as an example but we would like to say right care at the right place at the right time. And if you think about uninsured people, you know, if they cannot get good basic care in a place that’s accessible to them then they are getting wrong care at the wrong place at the wrong time. And that is a burden on the system because that care is usually much more expensive and less efficient. Let’s use the example of diabetes, if you let diabetes go untreated your problems will be blindness and poor circulation, poor circulation leads off into amputations and that means surgery in a hospital to have an amputation. So those types of costs get embedded if the right care isn’t provided up front, the preventive care that she is mentioning. And that is a broader burden on the whole healthcare system. Somebody is paying for that. That care is being covered. Increasingly we are not able to shift that burden around to different people that can pay for it. In the past we might have said there was a cost shift or shifting the cost of uninsured care to businesses but that capacity of our healthcare system to take care of those shifts is greatly diminished so those burdens are very real and they are a struggle and the more you find uninsured in a community, the greater that struggle is for the organizations that are caring for that group of people.
Brown: Dr. Silberman, so does that mean that possibly North Carolinians who are covered, who have health insurance may find that their co-pays or their total rates are going to go up in order to accommodate these increasing costs?
Silberman: We all pay for the uninsured and the care that they get through what Jeff is talking about, the cost shifting because the hospitals have to make it up some way. The healthcare providers have to make it up some way. They don’t take it out of their pocket. It has to be—those costs are spread to everybody so it helps—there is an increase in the cost, the healthcare costs due to what we are paying on behalf of the uninsured who can’t pay for it themselves. That leads to higher premiums. That leads to higher co-pays and deductibles and so it is spread among the general population but the increase in cost, I don’t want anyone to think that the increase in cost is just because of the uninsured. There is a lot of reasons for increased costs. A small portion of that is because we are also helping to pay for the uninsured.
Brown: Let me give you the last word, quickly, what can the uninsured do? What would you suggest to those who don’t have health insurance that might help this whole situation?
Silberman: I think the most important thing for the uninsured to do is to try to find a safety net organization where they can get primary care and prevention so that they get the regular care that they need with a provider that gets to know them and their problems so that they don’t end up in the hospital with conditions that could, problems that could have been prevented. But I think the broader issue is how do we provide health insurance coverage for everyone and that’s the real crux of the issue. There is a short term and a long term answer. The short term answer is get connected to a provider. The longer term issue is we as a society have to figure out how we are going to provide health insurance coverage for everyone.
Brown: All right. I thank you very much for all of your expertise today. We really appreciate you being here. So I would like to thank formally Ms. Evette Patterson, Dr. Pam Silberman and Jeff Spade for sharing their views and analysis with us. If you would like to learn more about the work or our guests or obtain a transcript of today’s show, please visit the Black Issues Forum website at www.unctv.org/bif. We would also like to hear your feedback and suggestions. So send us an email or you can call the BIFline at 919-549-7167. Be sure to meet us back here each Sunday afternoon at 4:30 for more compelling conversation. For Black Issues Forum, I am Natalie Bullock Brown reminding you to be encouraged no matter what. Have a good one.
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