Tale of Two Health Crises

Maria IJT CURRENTTwenty two years ago I received shocking news: I had Hodgkin’s disease, a cancer of the lymphatic system that affects primarily young people. At the age of 30 I began a long and to date successful effort to fight the disease and regain my health.  I was lucky: I had good health insurance, access to top doctors, friends and family with the wherewithal to help. I also had a good education that helped me navigate the health and insurance systems and also remain employed. I also had a home to go to after each round of chemo and, three years later, after hospital treatment for a recurrence.    “Scott” is not so fortunate. Twenty-seven years ago, at the age of 21, he lost his left leg after a car hit him.  A month earlier, he had lost his job as a forklift operator, and with that, his health insurance. Unable to afford his own home, he was living with his mother. The money he recovered from the driver of the car that hit him barely covered hospital expenses and the lawyer’s fees.

Through his state’s department of rehabilitative services, Scott was able to get a prosthetic leg. Finding work was challenging. For a year he had a job—and health insurance—with an office supply company, but when the company went bankrupt, he was out of work again. He worked as a migrant laborer for a while—with no insurance. When a relationship ended and he moved out, he had no place to go. He’s been homeless on and off ever since.  His family is too poor to help. He is bright and personable, but lacks the education that might help him get a job. He is on multiple waiting lists for housing but has no place to live but the streets. He is searching for work but with a disability and without a home he has so far been unable to find one. Now his other leg is showing signs of problems. What would have happened to me had I been in his place when I was diagnosed? I doubt I would be alive today.  Without health insurance, I would probably not have gotten the early intervention that helped save my life, or access to top doctors, or the latest treatments. Without a home to live in, I doubt I would have survived the depressed immune system and consequent infections that followed my treatments.  And if I were alive, I’d probably have had a much harder and longer time recovering physically and emotionally from the rigors not only of disease but of treatment.  The consequences of lack of access to health care are devastating. The average life expectancy of homeless people in the U.S. today is 30 years less than that of the rest of the population. Homeless people suffer disproportionately from both acute and chronic disease, such as diabetes, arthritis and lost limbs. Disability benefits are extremely difficult to apply for and receive: Except for about a one-year period long ago, “Scott” has never received them, despite his obvious disability. Health care reform is now on the table in Washington, D.C., and it’s long overdue. But to be meaningful, it must include people like Scott. Medicaid, the federal health care program for poor people, does not currently cover all low-income people; in fact, 70% of homeless people are currently uninsured. The program must be reformed, and barriers to it eliminated, to cover all homeless and poor people. It must include primary and preventive care for people like Scott, and not just because they need it desperately. Right now, emergency room care is the primary medical care available to homeless people. Without access to regular, easily available primary care, homeless people have no other recourse. Yet this is the most expensive care, costing an estimated 3-4 times as much as a doctor’s visit, and the most burdensome for all involved. It must include reasonable access to disability benefits for those who are disabled. Currently, about 40% of homeless people suffer from mental or physical disabilities, or both. Yet only 11% receive federal disability benefits due to barriers including address requirements, missing identification documents, or lack of funds to obtain birth certificates and other records required to apply.  Perhaps most important, it must include access to housing. Without a home, virtually no treatment will be effective—for the person, or for taxpayers. A 2004 nine-city study compared the cost of providing supportive housing to homeless persons, including those suffering from mental illness and addiction, to the cost of allowing people to live on the street. In all nine cities, supportive housing was significantly less expensive, and the health care costs were several orders of magnitude less expensive.  Supportive housing reduces health costs by reducing expensive emergency department visits.  For example, the study found that San Francisco hospital costs were over $2,000 per day, while supportive housing was under $50 per day.  We all need health care and we all need housing. It’s part of being human. I had this brought home to me dramatically when I received that diagnosis.

It’s time to recognize that these are also basic human rights.

Maria Foscarinis is founder and executive director of the National Law Center on Homelessness & Poverty, a not-for-profit organization established in 1989 as the legal arm of the nationwide effort to end homelessness.  She is a primary architect of the Stewart B. McKinney Homeless Assistance Act, the first major federal legislation addressing homelessness, and she has litigated to secure the legal rights of homeless and poor persons.  Ms. Foscarinis writes regularly about legal and policy issues affecting homeless and poor persons, and her work has appeared in legal journals, general audience publications, and books. She is a frequent speaker at conferences and other events, and is frequently quoted in the media.

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  1. Thanks to the awesome articles on the blog I am quite serious in the following paragraphs and you also include truly aided us. We’ve just told several of my personal close friends concerning this about Facebook and they really like your content just as much as i carry out.

  2. Anne it is very easy to feel self rightous when your never held accountable. If you find a way to deliver the best care in the world at an affordable price then I am all for it. You can’t do it though. Instead you will make a bunch of promises, break them all, and leave us with care worst then we had to start with.
    85% of Seniors hasd no problem paying their own bills before Medicare. They where promised a new better plan that would protect them if they where in the hospital for a long time. It not only didn’t offer that long term protection, it skyrocketed cost and resulted in worse care then what they where getting.
    I don’t even need to detail the failures of Medicaid to deliver what it promised. If you find honesty to be hard hearted I could care less, I find lying hypocrats to be disgusting. To build false hope and take advantage of our needest is dispicable. If you can’t deliver what you promise then don’t make the promise!

  3. Nate has a soft head and a hard heart and his comments contribute nothing — but thanks Ms. Foscarinis for the great column.

  4. My experience is similar to that of the author. Despite life-long excellent health habits, I was diagnosed with a brain tumor about 12 years ago. I am here today (and able to continue contributing to society) only because I had the good fortune of being able to get the expensive neurosurgery that was required. I happened to have good health insurance at the time, which allowed us to keep our home and most of our savings intact. Our home and savings represent a lifetime of work by both my husband and me to contribute to society and to *not* be a burden on anyone else. Since the surgery, and despite my focus on seeking jobs with the best insurance available, my coverage is inadequate today for another such surgery. I fear that I, or someone like me, will not get the surgery they need because of an inability to pay.
    Only those who have never had the misfortune of a serious and undeserved health problem, or a child with such a problem, have the audacity to claim that Americans have no right to basic health care. It is absolutely a basic right, as evidenced by the fact that we provide basic health care to our worst criminals in the prision system.

  5. Peter your forgetting state premium taxes, regualtion and other artificial increases that create the 20%. I have said on here many times carrier loss ratios run around 80%, not all of the remaining 20% goes to the carrier.

  6. SteveH,
    Maybe Scott had an issue not revealed in the touching vignette that was comon to the story, like alcohol abuse.
    Maybe the office supply company went broke because of the absence of requiring EHR and the necessary computers to run it, too many taxes and too few government regulations requiring endless paperwork.

  7. “Anything ran through insurance cost 20% more then if you paid for it outside insurance. Can anyone please explain the logic in paying for preventive care through insurance and wasting 20%?”
    Nate, I thought insurance admin/overhead costs were about 5%, or that’s the number that’s come up in the past. That was the reason given for not cutting insurane companies out of the healthcare payment loop. By the way the local urgent care PCP I see charges the same for insurance or cash pay, and the state hospital (UNC) charges 4-5 times for cash pays over what they accept from insurance.
    I would also assume (advocate) that universal insurance would have a mandate to pay for coverage (not necessarily to insurance companies – my preference), IF costs are brought down. I will not be mandated to pay existing rates based on a broke system based on greed.
    Anyway, healthcare reform should be about healthcare reform, not insurance reform.

  8. “3.Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.”
    This is why people who don’t understand insurance should have their mouths taped shut and sat in the corner till the healthcare debate is over. These people are TRYING to find ways to waste money.
    I think we all agree everyone should have preventive care. Inteligent people would want that care to be as cost effective as possible so people first get the care and second it doesn’t break the system.
    Anything ran through insurance cost 20% more then if you paid for it outside insurance. Can anyone please explain the logic in paying for preventive care through insurance and wasting 20%?
    There are 303 million people in the us. If each had $150 in preventive care that would be 45 billion dollars. If insurance paid for it that would be 9 billion dollars wasted. Thats not 9 billion spent to improve care, or offer better service that is just 9 billion thrown down a hole.
    Lynn why do you want to waste 9 billion dollars for no good reason?
    Why do reform adocates never define Exorbitant, I have a feeling Lynn is talking anything over a few hundred, again a huge waste of money.
    “Discrimination for Pre-Existing Conditions”
    Yes I see no mention of reverse discrimination where people wait till they are sick to buy insurance, is that still going to be allowed? The only reason pre-ex exist is becuase people tried to game the system. To blame the insurance companies for pre-ex shows a complete lack of serious intent to fix the problem. Pre-ex is the solution to a problem, until you fix the original problem you have to have pre-ex.

  9. P.S. I would also suggest that we make our public programs far less complex if we want them to be effective. If you think private insurance companies have a lot of rules, do a little research on your state Medicaid program sometime.

  10. The unfortunate reality is, it is very difficult to separate those who genuinely need public assistance from those that want a “free lunch”. Our public programs have failed because our elected officials have not made a committment to protecting the integrity and original intent of the programs. Now we’re looking to increase the size of those programs with little mention of improving the way they are administered. Doesn’t sound like a winning approach to me.

  11. “2.Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.”
    Lynn, aren’t those alrady capped under existing insurance contracts? And will it “cap” what insurance companies can charge for premiums? If not then #2 costs (and #s 1-8) above will be passed on to premium payers, so only those who win the sudsidy lottery will see THEIR costs go down. My costs will rise AND my taxes will rise.

  12. Reform provides security and stability to those with or without coverage:
    1.Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
    2.Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
    3.Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
    4.Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
    5.Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
    6.Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
    7.Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
    8.Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won’t be allowed to refuse renewal because someone became sick.

  13. Peter once again you manage to lower expectations of your intelligence. No I don’t offer HSAs that would require an insurance license. No I don’t handle HSA accounts cause that would require being an apporved custodian.
    Do you ever tire of being a dumb ass? Is it really asking to much to have at least a slight clue of what you are talking about before you start typing?
    If HSAs took off I would lose a huge chunk of my business. Might not even be able to survive it. Try wrapping your simple little mind around that, someone advocating doing the right thing even if it comes at great personal cost. About the exact opposite of you progressives always doing stuff at great cost to others, maybe that is why you can’t grasp it?
    Sob stories are a dishonest way to sell anything. You hold up a suppoosed set of facts and based solely on those facts we are suppose to agree with you, even though we have no ability to question any of them.
    How is a family to poor to offer him an address to use, bath to clean up in and even a sofa to crash on? Sounds like the family doesn’t want him or he chooses not to take what is available.
    “The average life expectancy of homeless people in the U.S. today is 30 years less than that of the rest of the population.”
    And this is due to lack of housing and not their drinking, drugs, and smoking? Conditions that usually contribute to being homeless in the first place.

  14. “1. Why did Scott lose his job one month before his injury?”
    Indeed, why didn’t he wait until after his accident to lose his job. In fact, what did Scott do to make a car hit him?
    “3. Why did the office supply company go broke?”
    I can only suspect it was hit by a car driven by the same driver who hit Scott.

  15. Ms. Foscarinis, this is a tough one and I think there are many “Scotts”. I would hope that some day Scott could get all the care he needs, but until we control costs in this system it will be difficult to cover everyone without bankrupting state and federal governments. It’s not that Medicare or Medicaid is underfunded, it’s that they are over paid for because there is so much waste, fraud, abuse and
    over-utilization (doctor generated) in the system. We also have the highest prices as well. Healthcare reform MUST include cost control so that all the Scotts can get the care they need at rates we can afford. I want part of my health taxes going to Scott, but I don’t want any of my healthcare taxes going to prop up a financially corrupt and abusive system that pays BCBS executives millions in bonuses.

  16. “8. Would health reforn have prevented his accident?
    No MD (Did I really have to point this out?), but it may have meant he wouldn’t have to hire a lawyer to get the money for his care. See below.
    “9. Had the legal fees not scarfed up 30-60% of his award, would he have been self-sufficient and able to go to school to learn a new trade?”
    You want Tort “Reform” MD, which means at best his award would be capped to a point that did NOT pay for his required care, and at worst would mean he could not find a lawyer to take his case. See above.

  17. “Insurance included, high deductible with an HSA contribution underneath.”
    I see you made sure your product was government provided Nate – good for business eh. So just how could Scott afford the “high” deductible?

  18. Dr. Rick I have to disagree with your generalizations, in fact I find them quit insulting. I have had a bad doctor or two over the past 30 years, would you be ok with me saying you are a failure because of their actions?
    Our nation has not failed with Health Care. There are tens of thousands of employers offering great insurance at affordable cost allowing their employees access to the greatest Health Care in the world. I and those participating in those plans think they are a tremendous success. We are talking about 100+ million people by the way.
    The moral failure is on the part of those like you who use the failure of Medicare and Medicaid as an excuse to destroy that which works for political and personal gain.
    It’s your projection of failure people are rising up against, government has failed to deliver the health care it promised, I’ll be damned if I trust them with mine.

  19. to be really blunt if the public will house, feed, cloth, and insure me why the heck am i sitting behind a desk 12 hours a day?
    If I am asking that question why wouldn’t every other able bodied person ask the same question if you got your welfare utopia?
    Do you really not see the day after and the consiquences of your proposals?

  20. Ms. Foscarinis,
    A couple of questions:
    1. Why did Scott lose his job one month before his injury?
    2. Was any factor in common between losing his job and his injury?
    3. Why did the office supply company go broke?
    4. How poor do you have to be not to help a relative?
    5. Scott’s other leg now with problems; does he smoke?
    6. Did Scott go to Vocational Rehabilitation?
    7. Did Scott ever pay for any of his ED care? If not, then it was the cheapest care of all. (A fact not lost on all levels of thieving government officials, elected and not.)
    8. Would health reforn have prevented his accident?
    9. Had the legal fees not scarfed up 30-60% of his award, would he have been self-sufficient and able to go to school to learn a new trade?
    10. Why do you overlook everything else that contributes to a homeless person’s status? Why is not the family required to do more than the government and everyone else? If the family does not help, does that not indicate the level of effort from the homeless person, at least in the family’s eyes?

  21. Thank you but respectfully disagree
    This nation has failed miserably with health care. And yes it is IS a moral failure.
    While of course I agree with more individual responsiblity I loathe victim blaming even more.
    Here are #4 basic messages for those who are trying to rectify this situation-
    – “Insurance companies routinely deny needed care”
    – “Medicines in the US are way too expensive”
    – “You will not be able to afford your health insurance premium soon”
    – “Grandmothers need our deepest love and respect both in life and in
    Dr.Rick Lippin

  22. It’s easy to say we need to do this or that. In an ideal world where money grew on trees this wouldn’t be an issue to provide health care services and housing. The hard part is admitting our past efforts at welfare were a failure of design, most people don’t suffer poverty they subject themselves to it, and no system of legislated charity is sustainable.
    When people make proposals like this they are long on what society owes these individuals but short or non existent on what these individuals owe society. Our past and current welfare plans have never been about helping those people but enslaving voting blocks and making Robin Hood feel good about himself. That’s why these programs have done considerably more harm then good.
    We need to immediately close all public housing projects, end unemployment insurance, and eliminate welfare and food stamps for all but the most seriously disabled.
    In its place we start public works, crappy jobs no one wants but paying you just enough to eat and put shelter over your head. Insurance included, high deductible with an HSA contribution underneath.
    It drives me nuts to hear local, state and federal politicians say we can’t afford to do this or that because we don’t have the money to pay people while at the same time we are paying 10s of millions of people not to work. Granted an underpaid public works employees isn’t likely to vote for you with 96% faithfulness when they have to work their ass off to get by but it is best for them and best for the country.
    1. We can start with crossing guards for every corner on school days.
    2. 100% of trash should be sorted with recyclables being recycled and organic waste going to facilities to turn it into gas or fertilizer. Remaining waste sent to plasma incinerators. I hope we can start digging up old landfills and reprocess that old waste.
    3. Litter patrols so we don’t have trash pollution.
    4. freshly painted and maintained public buildings and places.
    I’m sure we can come up with millions of more things that would improve this country if only we could afford the labor. If Steve is truly the honest down on his luck guy you claim he will jump at the opportunity to earn is place in society. The fact people don’t want to admit is there are millions of people who refuse to work for what they need. Your past and current efforts refuse to admit or deal with this fact. No programs can ever be sustained when people choose not to contribute when able.
    When you have a plan that holds the recipients responsible then come back and make your demands that we recognize human rights. Until then I appreciate you keeping your hand out of my pocket.

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