Insights in Public Health

Abstract

Hawai‘i had high insurance coverage rates even before the Affordable Health Care Act and continues to have a high percentage of the population with health insurance today. However, high insurance rates can disguise wide variation in what is covered and what it costs. In this essay, an Australian Masters in Public Health student from the University of Hawai‘i considers the strengths and weaknesses of insurance coverage in the US health-care system when her friend “Peter” becomes seriously ill.

Peter walks into the kitchen we share in our campus dorm, and I smile, relieved. I had seen him the previous evening and he wasn't himself, but I couldn't work out what was wrong. Stomachache? Depression? Fatigue? He'd given vague answers and seemed uneasy. I had urged him to see a doctor in the morning, and made him promise to meet me for lunch. I quiz him while I cook him an omelet, and it turns out he hasn't seen a doctor yet, and he doesn't seem to remember our conversation from the previous night. He trails off halfway through sentences and struggles to find the right words; he's usually gregarious and articulate. At one point he asks me for more soup, pointing to the stove. “You mean more omelet?” I ask, growing more concerned. “I'm worried about you. Let's go see a doctor. I'll come.” Peter is hesitant.

“I don't know. I don't know if they take my…you know. If I can go there.”

“Your insurance? Let's sort that out over there. We can try a different clinic if we need to,” I reassure him.

I send him off to get his wallet while I wash up, but he comes wandering back. He's locked himself out of his room — an irritatingly easy thing to do in our building. I tell him to go talk to the front desk about a new key, and ask for his room number so I can meet him there. He stammers out some numbers, but stops, confused. He's been living in that room all year and he can't remember the number on the door. I feel hot, then cold. I tell him to forget about the wallet and the key, and practically march him over to the campus health service. The receptionist asks what we need. Peter dithers. “I just…don't feel good,” he says. I take over and explain the situation, trying to convey the seriousness of Peter's symptoms without letting him hear that I'm panicking. The receptionist has other concerns. “We really need to know his insurance details before he can see the doctor.” I stare at him blankly. I'm a fish out of water, an Australian encountering the American health-care system for the first time. I think of the credit card in my wallet and the savings in my bank account. How expensive could it be? “If I can just pay for it, will that do?” Peter stares at an intake form, pen hovering over the space where he's meant to write his birth date. “I'm not sure,” he says, “I can't remember.” The receptionist seems relieved at my suggestion. “I'm sure we can sort something out — let me talk to my supervisor.”

As a Masters in Public Health student, my textbooks tell me that each developed country has its own distinct system of health care that covers four key components: financing, insurance, delivery, and payment.¹ To be honest, I'd expected “Introduction to Health Systems” to be a boring class, but we start with international comparisons—the four components vary greatly, shaped by each country's historical, political, cultural, and economic forces—and I find the variation fascinating. As an Australian, I'm surprised to discover that French doctors still make house visits; a Canadian might be shocked that Australians can get elective surgery faster if they have private health insurance. I find it odd to imagine my employer contributing to my health insurance, which is common in Germany; someone from England might find it strange that many Australians need insurance to cover ambulance costs.^1,2

My American classmates are also surprised by the variation. Several of them confess that they had thought that developed countries had only two types of health-care system: “universal health care” and “the American way.” They're not entirely wrong. While the four key components may look different in each country, and there's a myriad of possibilities when it comes to health system design, it is true that the United States is the only developed country that fails to provide all citizens with an adequate level of health care without financial burden.

Of course, there have been exciting changes to health coverage in America. We start each class with a look at the week's headlines in health policy: which states have agreed to expand Medicaid, the latest Supreme Court challenge to the Patient Protection and Affordable Care Act (ACA), and the fall-out from the collapse of Hawai‘i's health insurance exchange. Despite ongoing uncertainty, it is clear that the ACA has greatly improved coverage: nearly 17 million previously uninsured people now have insurance or are covered by Medicaid.³ A survey by the Commonwealth Fund found that more than six out of ten people who had used their new insurance for medical care or prescriptions would not have been able to afford their care before the ACA.^3,4,5 These results are undoubtedly a “good news” story for public health, but even if all the ACA measures are fully implemented, America will still lack universal coverage. An estimated 25 million working-age adults were uninsured as of May 2015 and, compared with the overall population, those who remain uninsured are disproportionately younger and poorer.⁴

Once a doctor hears about Peter's symptoms we're advised to go straight to an emergency room. A friend of Peter's drives us — he'd also been concerned about Peter's change in behavior. We wait, making awkward small talk. I look around, trying to shake the surreal feeling that I've stepped into a clichéd American hospital drama. A rail-thin woman waits in the corridor, picking at her skin, complaining loudly about the bugs that are biting her. A scruffy man in a wheelchair smiles cheekily at the nurse who asks, “Did you fall? Is that what happened? You fell?” “Yes,” he replies, “I fell for you.” The machines beep and whirr. A young doctor struggles to find the words to tell Peter the bad news, but moves briskly on from her condolences. “We're going to have to find your insurance details before we do anything else. We can treat you here, but if it turns out you're with the other HMO you'll need to be moved to their hospital soon. If you're treated here they might not pay.” Peter can't remember the names of his sisters. He can't remember the topic of his PhD dissertation. And now he's trying to remember his health insurance details.

I quickly learn there is a phrase essential to understanding the American health-care system that is not found in my public health textbooks: “good insurance.” As in “I thought I'd better get tested before my good insurance runs out” or “I know the company pays well but I don't know if it provides good insurance.” Saying that more people now have health insurance disguises the enormous variation in who gets what, and what they pay for it. The ACA does not fully address the growing problem of “underinsurance,” which is when people have insurance for the full year, but they have high deductibles or out-of-pocket expenses relative to their income.⁶ To say that families face bankruptcy from health-care costs is not an exaggeration. A 2007 study showed that medical costs contributed to 62% of bankruptcies. Not only did 78% of these people have health insurance (at least when they first got sick) but most were middle class, with houses, jobs, and an education.^7,8 In recent years, rapidly rising health costs and relatively stagnant incomes have exacerbated the problem of underinsurance, and in 2014 around 31 million people with health coverage were underinsured.⁶ Even in Hawai‘i, a state justifiably proud of its high insurance rates, an estimated 22% of people under age 65 were: uninsured (9%) or underinsured (13%) in 2012.⁹ A Commonwealth Fund study found that, for people who were underinsured, illness led to difficulties paying medical bills, depleted savings, and for 7% of them, bankruptcy.^3,6 Bankruptcy due to medical costs is far from receiving health care “without financial burden,” and it is something that is virtually unknown in other developed countries.²

When discussing the insured, uninsured, and underinsured, it is easy to lose sight of what these numbers actually mean for health. People who are underinsured don't just experience financial strain — they also fail to receive the health services that they need. Like Peter, they see seeking medical attention as something to approach with caution, they're not sure if they “can go there.” In a survey of underinsured people, 44% agreed that they had skipped needed health care, which included not seeing a doctor when sick, failing to fill a prescription or not seeing a specialist when recommended by their doctor.⁶ One reason that Hawai‘i is one of the healthiest states in the United States is that it has relatively high rates of insurance, but Peter's story shows that insurance coverage does not necessarily mean ready access to care.¹⁰ Overall, Americans are more likely than people in other developed countries to report missing medications and skipping care due to concerns about cost.¹¹

Part of the reason the American health-care system is more expensive than other countries' systems is that it has the highest administrative costs.² The fragmented nature of American health-care financing means that health-care providers have to send their bills to many different payers, increasing the required number of administrative staff compared to a single payer system.² But complexity is not just a problem because of the costs; it is also a problem for people who need to wade through incomprehensible insurance policy documents. While this system offers consumers a lot of choice, it also gives them the burden of weighing up the risks and benefits and costs of different options — and facing the consequences if their choice turns out to be wrong. A rising problem is plans with higher deductibles, which reduce the monthly premium payment but greatly increase the cost when care is needed. This may be an appealing option for someone young and healthy, but when the unexpected and unthinkable occurs there is a risk that care could be become unaffordable.¹²

Peter's room is meticulously organized; his paperwork is kept in neatly labeled files. The tidiness doesn't ease my awkwardness, as I shuffle through the personal belongings of someone I've only known for a few months. Peter has a brain tumor and is scheduled for surgery tomorrow afternoon. His family is in the air, due to arrive in Hawai‘i in a few hours. While completing his PhD he was enrolled in an insurance plan through the university, but he submitted his dissertation in May. Now it's July and he's job-hunting. We know he has some insurance, but it's time to read the fine print. It's unclear whether his insurance will cover him for out of state treatment. It's unclear if he'll be able to re-enroll in his university plan. The only thing that is clear is that — in a best-case scenario — Peter is facing years of treatment and tubes and medical bills. With his permission, I hunt through his files, pulling out insurance paperwork, looking for some answers.

I felt sad and shaken for weeks. Sad for Peter and his family, sad reflecting on previous experiences with cancer, and shaken in the profound way that illness can shake us, knowing that what happened to Peter could happen to anyone, to wake up in the morning and find that your brain just doesn't work and your whole life is about to change.

I also felt angry — and mystified as to why Americans aren't angrier about their health-care system. But the Australian health-care system has plenty of problems and I rarely summon anger about that — because it is easy to think that the system you have is “just the way it is.” In a new country, I feel like the child pointing out that the emperor has no clothes, and I can't stop looking at the naked gaps. Like the new colleague explaining that she's relieved to finally start working because her recruitment process was delayed for a month, and she had no health insurance until her new benefits kicked in. Like the pregnant classmate who's hoping for a natural birth because “who knows what I'll end up paying if it's not.” Like the graduate students chatting about how confusing they find their health insurance policies — and wondering what happens if an ambulance takes them to the wrong hospital. For Americans these situations may seem familiar and reasonable, but imagine you come from a country where your job has no impact on your insurance, where it is possible to give birth without bills, and where the nearest hospital is always the right one. Imagine how disconcerting you would find these conversations.

Peter's mother thanks me warmly for taking him to the doctor, and I quickly change the subject, saying I'm glad he's able to get treatment on the Mainland. Peter's plan won't cover him out of state, but he's able to switch to a new insurer — something that would have been difficult or impossible before the ACA ended discrimination for pre-existing conditions. Peter loves Hawai‘i — and it's clear from the response to his diagnosis that his community loves him. But, of course, his family wants to take him home. She shakes her head when she hears I'm studying public health. She's a soft-spoken and polite woman, but at mention of insurance she can't hide her annoyance. “It's a terrible system here,” she says, “I just wish we just didn't have to deal with all this crap.”

From my textbooks, I learn public health policy jargon: moral hazard and capitation, physician extenders and supply-side rationing, Medicaid gaps and donut holes. From Peter, I learn about the uncertainty and insecurity that the American healthcare system can add to the already stressful situation of illness. The challenge of health-care policy is that there is no right answer, and even a good answer for today may not be a good answer when there's a shift in economy, demography, or technology. But there's often something missing in our discussions of health-care costs, and that's what it costs us as a society in terms of dignity and equality, and how much we're willing to pay in terms of peace of mind. Change has been hard, and change achieved should be celebrated, but I challenge Americans to try to see the system through a foreigner's eyes, and see where change is still needed.

It will be my task to break the news to some people, explain about the tumor and the surgery. Some people will ask for more medical details; others are more concerned about Peter's emotional state. But on hearing their friend has cancer, every single one will eventually ask the same question: does he have good insurance?