This part is all background, but you need to know it.
I went to nursing school at the University of Wisconsin-Milwaukee in the late 60s/early70s. During my last year, I took the required Public Health Nursing rotation in my last semester. The instructor wasn't so great, but my mentor, a Public Health Nurse in Milwaukee, was amazing. She talked to be about what public health nursing really was through the eyes of the community, particularly those in poverty, to give me an insight that the university never would.
She talked to me one day about the difficulty those in poverty have in accessing health care. At that time public hospitals and health care facilities were available in nearly all metropolitan areas and provided care to those with no insurance coverage. Getting to them, however, wasn't easy.
In Harlem (New York) the public hospital was a ten dollar cab ride away in those days. Ten dollars was a lot of money in the late 60s (minimum wage was $1.65 per hour and a decent new car cost under $3,000). If someone needed to see a doctor, they had to give up a huge amount of money for food, rent, or other necessities to access that care, so those decisions were always serious. In the community, the phrase Ten Dollars Sick, described how sick you had to be to go to the doctor (that meant you had to be incredibly sick).
She then reminded me how far away Milwaukee County General Hospital was for our own inner city residents (it was located in a Milwaukee suburb) and how those decisions are being made here and how difficult those were. People couldn't just get in their car (no car) and visit the doctor. A bus ride took an hour or more with the need to transfer bus lines more than once to get there.
That story has stuck in my mind throughout the years. When I found myself leaving the private sector after a few years, frustrated with the first procedure being a "wallet biopsy" (checking to see if a patient had insurance or the funds for their care), I left to work for Milwaukee County and saw finally for myself abd was grateful to finally have the opportunity to care for people without turning anyone away. We had a community clinic located downtown to make it easier for people to get urgent care and basic services, but anything else was only available at the main hospital. I worked at that downtown clinic when I began my career in public service.
I saw the faces of patients fall when I told them that they needed to see a specialist or have a test done at the main hospital. I knew how hard it would be for them to get there, even if I provided a bus ticket for their ride there and another for their ride home. But, they did have access to care back then. Hard to get there, but available, and the community clinics were still there for the basics.
Not for long, though.
I saw the pullback of services first from the community clinics as, first one, then all of the community health centers were closed for budgetary reasons. I fought along side of my union, our patients, and the Medical Director (an astoundingly great doctor) but to no avail. We called, wrote, and visited the County Board. We appeared at the budget hearings. So fierce was this fight that the Medical Director was fired (they couldn't touch the rest of us because we were Civil Service employees and they had not justifiable reason). We lost. Actually, our patients lost. They now had to travel all the way to the main hospital and clinics, endure long waits as that facility cared for not only their customary patients, but those who normally went to the community clinics. They were patient, kind, understanding just happy to get care without the hassle.
And then, in a little more than a decade the hospital and clinics closed leaving patients to beg care from local facilities. The low tax crowd won.
It was the start of something that was happening all over the country. I was one of the "lucky" nurses - enough seniority that I could transfer to another nursing position in the County. The bad news? I worked the last 7 1/2 years in a 2000 bed county prison, not the greatest job I ever had, but at least I could continue adding to my credited years of service towards retirement. Many weren't lucky, getting no job at all or getting only part time positions. And patients were totally screwed, even with the travel difficulties, the county hospital did give them care, tests, prescriptions, etc.
Public hospitals have closed all over the country. A terrible decision made to placate the low taxes crowd who didn't want to pay for services for "other" people.
The blowback of that, of course, is the requirement to provide emergency care to everyone. Following the closure of public hospitals, ER use has exploded accompanied by enormous wait times. And private facilities don't "eat" the cost of unreimbursed care. They shift it onto the bills of everyone else in the form of higher rates for services and care. Health insurance companies don't "eat" those higher costs either. They just raise and raise their rates, deny coverage, deny care, waste provider time in begging for approvals from minimum wage bean counters whose job is to avoid spending every penny if a palatable (or selllable) excuse can be found. After all, they have multimillionaire CEOs and executives that need huge salaries and bonuses.
Costs keep going up further as hospitals and health care services need to employ their own armies of staff to jump through all the insurance company hoops in order to get reimbursement. It's gotten so bad that the number of people in the billing department can equal the number of nurses actually providing care.
As the cost of insurance has gone up and up, many employers are converting their plans to high deductible/high out of pocket (junk) insurnace plans with huge employee costs for insurance or dropping benefits packages altogether. The number of people with no insurance is growing and growing and the "uncompensated care" is also growing. It's an endless loop.
And just imagine, it started with the short sighted decisions to close public hospitals. And it has continued with the escalating greed of the health care, parmaceutica and health insurance industries who sometimes just raise their costs not just in response to increased costs, but because they can or want to.
I see no end in sight.
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