Does it take wealth to be healthy? Wealth helps when it's time to fill an expensive prescription, see a doctor, have a test or elective surgery; but, does personal wealth guarantee good health?
Almost all of my health care diaries has a comment that we wouldn't need so much health care if we lived healthier lives. That's true, but simplistic. Smokers, heavy drinkers, sugar and salt junkies can have more health problems, but don't underestimate poverty. Poverty pushes people around in ways you cannot imagine.
We have poor people, working poor people and people who live comfortably (a shrinking group to be sure) and those who are wealthy. All of these groups have high stress levels unique to their situation, but is it easier to be healthy if you're wealthy?
The answer is more yes, than no.
"Social class is simply the best predictor of health," says Nancy E. Adler, Ph.D., a professor of medical psychology at the University of California at San Francisco. "If you could know only one thing about a person and predict that person's health and longevity, you'd ask about social class. It's even more important than family history."
In cases where someone has bothered asking poor people about their health, research confirms the trend: The poorer you are, the less healthy you're likely to feel. That's the finding of a recent Columbia University study. And results of the CDC's National Health Interview Survey make the case even stronger. In 2006, nearly nine times as many lower-income adults (whose families earned less than $35,000 a year) reported being in fair or poor health as affluent adults (whose families pulled in $75,000-plus). Wealth and health go hand in hand.
The difference is that wealthy people are more likely to have the ability to get the care and help they need to get better. They are more likely to have effective insurance and more likely to be able to pay for what ever the insurance doesn't pay. Wealthy people with rheumatoid arthritis can afford to pay that $2,200 per injection for that incredibly expensive drug. People with advanced RA that have reduced mobility can also pay for house cleaning and lawn work and can have their food brought to them.
There's also some evidence that being wealthy and avoiding economic hardship seems to be correlative with avoiding health issues.
People who suffered hardship in just one or two of the periods reported less severe consequences, but the impact worsened as the number of episodes increased, suggesting what researchers called a dose-response effect of low income and social status.
Looking only at a subgroup of people who were young and healthy in 1965, researchers found that those who had more economic hardship had worse physical functioning in 1994, suggesting that illness was an effect of economic hardship, rather than the cause.
:::: ::::
Wealth and Health Policy
The inequities of our health and food policies center around personal wealth. We are looking at health care reform. It is time we address the inequities of health care access. The closed door meetings in the Senate concerning health care reform send a clear signal that they have no intention of rectifying these inequities. About 80 million Americans have Medicare and/or Medicaid insurance. These two, huge programs offer the best and the worst of the U.S. health care policy. They reflect a two tiered health care policy that clearly favors wealthier people.
Meanwhile, public insurance programs designed for the poor do not actually cover large segments of the poor. For example, because of rules establishing categorical eligibility for Medicaid, the government insurance program for low-income Americans, childless adults usually cannot qualify for public coverage. Federalism also generates geographical inequities: Medicaid eligibility standards vary by state, so low-income citizens' access to public insurance depends on where they live.
To add insult to injury, the uninsured, lacking the purchasing power that comes with being part of a large insurance pool, are sometimes charged higher prices than insured patients. Medical care is also a leading cause of bankruptcy in the United States, an issue not just for the uninsured but for under-insured Americans as well. Even well-insured and financially secure Americans can find themselves in financial distress if fate hands a family member an expensive, chronic disease. And in perhaps the most fitting reflection of the American health care system's dubious moral logic, the sicker individuals without employer-provided health insurance are, the harder it is for them to buy health insurance.
If you live in poverty your health insurance choice is:
No insurance
Qualify for Medicaid
Charity Care
Get qualified for Medicare (a 3-4 year process)
No Care
Medicaid is a safety net program where 50% of funding for it comes from the federal government and covers Tier I and Tier II services. The remaining 50% of the funding comes from the states for Tier I and Tier II services plus any Tier III services that are any other services offered by the state at 100% state funding. Medicaid is in trouble in our current economy. The individual states are 1.) Tightening Medicaid qualification, 2.)They are eliminating Tier III services, and 3.) They are reducing Medicaid reimbursements to providers. What we have are plenty of people with Medicaid, but fewer physicians and hospitals willing to see patients on Medicaid and Medicaid is covering less services. ...or, Medicaid recipients are people who have insurance that cannot get effective health care.
So, when I get notice that part of health care reform will be a greater expansion of Medicaid, I have a few questions.
- How is expanding the number of people on Medicaid going to improve their access to health care when the states are shrinking their Medicaid expenses?
- Is there going to be a change in the funding formulas to allow Medicaid patients access to more medical services?
- Will the emergency funding relief be a sustained federal funding initiative?
- What incentives will be put in place to encourage more providers to accept Medicaid patients?
:::: ::::
Elderly living in Poverty and the Elderly
The elderly and disabled have Medicare. Middle class and wealthier people on Medicare pay for a supplemental insurance and Medicare Part D to pick up what Medicare Parts A & B don't. People living in poverty can qualify for Medicaid as their supplemental insurance and get the designation as a Medi-Medi patient by providers. Again the inequities of this system become glaringly apparent to anyone who knows where to look. If you are too poor to qualify for Medicaid as a supplemental, you have Medicare as your only insurance, which is far superior to having nothing. Those patients are often pushed onto the so-called Medicare Advantage Plans, because some of these issues are resolved; but be aware, Medicare Advantage Plans are simple HMO's with all the pitfalls those insurances entail. You need to understand some of the esoteria of Medicare to get the full implication of the Medicare insurance situations.
Medicare has the patient responsible for paying 20% of the Medicare limiting fees which can add up in a hurry. Billing Medicare is rule intensive. Providers often try to collect these fees as soon as they can and are wary of rendering services they know they won't be paid for. It's not that the doctors don't care, they can't waive these fees by law. If a provider waives the patient's portion of Medicare charges and writes them off before carrying them on their books for 120 days and/or before billing for these fees at least 3 times, the provider is to refund this money to Medicare. In other words, Medicare tells the provider, if you are going to give a discount, that discount belongs to us. What's scary is the amount of bad advice providers get on this rule. Here's the official policy. The only way a Medicare patient avoids most of their copays is to go on a Medicare Advantage Plan or qualify for Medicaid as their supplemental insurance.
One other issue with Medicare is that no part of their reimbursement is to go toward overhead. The result is that Medicare reimbursements are a bit shy of what's needed to keep the lights on and the phones working in a doctor's office or hospital and organizations like the AMA, want to eliminate the Medicare limiting fees. That would allow providers to "balance bill" the patient for whatever Medicare doesn't pay; which would really exacerbate the differences between wealthy Medicare recipients from those who are less well off or live in poverty. Many doctors are opting to not see Medicare patients altogether because reimbursements are too low.
If you are comfortably on Medicare, you have a supplemental insurance. Providers have no problem dealing with you. They see you, bill Medicare and your supplemental insurance; which generally leaves the patient paying pennies on the dollar (out of pocket) for their care. As you may imagine; people with this insurance arrangment have fewer problems....that is until they need long term care - but that's another diary for another day.
The Medi-Medi patient isn't as well regarded, because the Medicaid limiting fee is below the Medicare limiting fee. The only time a provider gets any funds from Medicaid on a Medi-Medi patient is if it's in the rare case where the service is one that Medicare doesn't cover at all, but Medicaid does (i.e. a white cane for the blind or nursing home fees after 120 days).
If you don't have any Medicare supplemental insurance, you will most likely be required to pay for your portion of the charges before you leave the provider's office. Services you can't pay for will be delayed in favor of patients who have better reimbursing situations.
People with Medicare have varying success in accessing health care based solely upon their income. or Some Medicare recipients have insurance, but inadequate access to health care because they can't afford to use their insurance.
So, when I get notice that part of health care reform will not include changes to Medicare while at the same time, others are pushing for Medicare eligibility expansion, a few questions come to mind.
- Does the reform proposal eliminate the 2 year waiting period for disabled Americans to be eligible for Medicare?
- How will health care reform ensure all Medicare recipients' equitable access to health care?
:::: ::::
Private Insurance, Employer based Insurance, Group Insurance and the Individual Market
Inequitable access to health care becomes most obvious when we look at the private health insurance policies people acquire. More people are fearful of health care affordability and availability.
There are still people in the U.S. with health insurance policies that pay well and keep their policy holder's out-of-pocket costs to under 5% of their pre-tax income. There are still companies that pay 100% of all health insurance premiums for their employees. There are people with "cadillac" health care coverage. There are still people who can comfortably pay their coinsurance and copays. Those numbers are shrinking.
The more typical experience in the U.S. health care market in 2009 is to be one medical disaster away from bankruptsy. Inadequate coverage is "the sleeping giant of the US health care crisis". The idea of being "Insured But Not Protected: How Many Adults Are Underinsured?" was novel in 2005, but commonplace today.
In the 2008 Commonwealth Fund eight-nation survey of adults with chronic conditions, the U.S. stands alone with half of all adults forgoing medications, not following up on recommended care, or not going to a doctor when sick because of costs. Rates were high for the insured as well as the uninsured.
Do not look to the AMA for help, they have their own agenda. Do not look to AHIP, AARP, NFIB or PhRMA for effective health care reform either; they have their own agendas too.
The Illusion of Coverage is a serious problem that health care reform cannot ignore. We cannot stop with just getting people health insurance without looking at what those policies cover and more importantly; what they don't cover.
· Shifting more costs of care onto patients through high deductibles, co-insurance, and less comprehensive coverage creates significant health access and financial consequences.
· Confusing insurance company policies and procedures leave patients confused, in debt, reluctant to seek health care, and vulnerable to predatory scam products.
· Affordability of health insurance must be judged on more than premiums—it is necessary to consider the costs that people will face should they get sick.
People who have health insurance have a false sense of security about their ability to pay for health care. People think they are protected only to find out they have an uncovered health care situation. We cannot be fooled into thinking health care reform is ended when all are insured.
While no insurance practically guarantees no health care.
Having health insurance won't guarantee access to health care either.
Health care reform will be successful when we grant equal access to health care to everyone regardless of their ability to pay for their care.