The Value of Returning to a Community-Based Healthcare Delivery Model to Address the Uninsured Dilemma
By Chinyere Godfrey-Nwachukwu, BA(c)
On November 1st, Keith drove himself to the emergency room and like many uninsured individuals, Keith’s visit was financially devastating for him. In The Hospital: Life, Death, and Dollars in A Small American Town, Brian Alexander narrates the healthcare experiences of individuals comprising the community of Bryan, Ohio and at Community Hospitals and Wellness Centers (CHWC). Alexander, the CEO of CHWC, also brings to the forefront the experience of his employees, residents of the community CHWC serves, struggling to survive in an increasingly monopolized healthcare delivery landscape.
Although The Hospital is contemporarily written, it capitalizes on many readers’ nostalgia for local care which prioritizes patients over dineros. Community-based, non-profit hospitals often cater to locals from underserved communities most vulnerable to the social determinants of health (SDOH) and unlikely to afford the hospital’s services. CHWC was geographically predisposed to financial loss which contributed to their hemorrhaging money as they struggled to stay open. CHWC, like most community-based non-profit hospitals in America, struggled to not shutter its doors and abandon its local workforce, patients, and community. Or, to lose its identity while trying to avoid being swallowed up by bigger hospital corporations. Alexander shows the adverse roles SDOHs such as, economic instability, unfavored family background, low social class, income jobs, and access to quality education can play in the uninsured population. Additionally, he illuminates the effects of proactive mitigation of social determinants of health and securing insurance can have in achieving optimal clinical outcomes and access to quality care.
The book reflects the consequences of being uninsured in today’s America. Even with government efforts, on a national and local scale, to educate and improve access to healthcare, targeted individuals are still subject to factors influencing unaffordability. Naturally, private and employee-based insurance provide maximal coverage which, in turn, encourages people to seek and consent to treatments reassured that their hospital bills will not be a financial burden. On the other hand, individuals without insurance lack such confidence, and tend to avoid key healthcare services including preventative care which can result in more expensive and emergent care. Wealth and other SDOH maintain tremendous gravity in solving the seemingly unrelenting uninsured dilemma.
Since the early 2000s, there has been an upward trend in the number of uninsured individuals in America. In 2008, 44.2 % of Americans did not have health insurance (Tolbert). Affordability, along with eligibility both being the first and foremost cause of uninsurance is precisely the rationale behind low-income families making up the largest population. Studies show that people of color are disproportionately uninsured, especially low-income, non-elderly, Latinos (Gunja). These individuals are significantly more likely to live on food stamps, EBT cards, dollar store groceries, while risking their lives as essential workers and working long hours at low-paying jobs, often under harsh conditions, trying to feed, clothe, and provide housing for their families. Health insurance is an added expense that becomes devalued from a necessary expense for it not seen as essential as food, clothing, and shelter expenses. When asked to choose between these necessities, health insurance is seen as an unattainable expense in their budget.
SDOH serves as effective indicators when identifying the uninsured population and low-income status is one of the most prevalent SDOHs. In the book, Alexander does a great job modeling this, other SDOH variables, and their real-life ramifications. For example, the story of a couple, Shilo and Jimmy. Shilo and Jimmy had 2 children and, like Keith, they barely made ends meet. Jimmy went to a community college for two years, but due to a hefty amount of student debts, circumstances compelled him to abandon his pursuit of a degree and take up a driving job. Due to criminal charges connected to the car, he and his family were forced to move to a cheaper location.
Shilo, Jimmy’s girlfriend, was a high-school dropout. Her diagnoses, and their effects, of anxiety and depression placed her at a disadvantage supporting her family. Since she was unemployed, she qualified for government welfare services - food stamps (SNAP) and Medicaid. She, Jimmy, and their two children lived off these benefits to survive. Because their basic necessities were unmet, they prioritized food, utility bills, and shelter. Unable to afford a new car, Dollar General was the only accessible grocery store thus, restricting their access to healthy food options.
Alexander is certain that the reader can really place themselves in the environment of the stories. As we read of Shilo and Jimmy’s struggles we appreciate the implications of other descriptors such as their house reeking of tobacco, the instability of their relationship, and their non-shared child with whom Jimmy fathered with a heroin addict. All of these descriptors urge the reader to appreciate the ways in which their health is constantly being undermined by their environment and are the product of SDOH. These health problems are most frequently intensified by a lack of preventative care and are likely to progressively worsen over time ultimately leading to expensive inpatient and outpatient care. In their case, bills accumulated, adding to the unsustainable climate of their unemployment statuses and the needs of their children. Affordability is the number one cause of not electing and maintaining health insurance; much of the uninsured population live the same lifestyle as Shilo and Jimmy where money limits them from making choices that would actually reduce financial distress due to catastrophic health events.
There is a misconception that the uninsured do not appreciate the implications of being uninsured. Without insurance, they must pay out of pocket, which can quickly add up to thousands of dollars worth of bills - even before treatment has been identified or begun. For that reason, most do not seek preventative care or early treatment-when symptomatic. This can cause an unequal utilization of healthcare services due to affordability (Shipman). Financial instability is a prime example of an unyielding SDOH factor that requires government intervention, hence the push for universal healthcare.
While uninsured patients try to avoid medical situations where they may incur bills, hospitals endure caring for uninsured patients who eventually do present for care -- often without any alternative choice. Hospitals are forced to find ways to subsidize the expenses of that care and patients’ debts. Until 1986, when Congress passed the Emergency Medical Treatment and Labor Act (EMTALA), hospitals were not required to give emergency medical care to those in need of service. EMTALA prevents hospitals from turning patients away from receiving emergency care (Stark & Stark). Despite the original holistic purposes of EMTALA, hospitals felt cornered and financially burdened. Subsequently, hospitals and healthcare professionals began to engage in unethical practices such as, patient dumping and reduced likelihood of physicians responding to calls when they are needed outside of their working hours (Ladd).
All the while, the government continues to recognize the public needs federal and state interventions in order to alleviate the burdens and their implications on patients and hospitals. Patients need the government to assist the uninsured in finding ways to elect and maintain health insurance as equally essential as food, shelter, and clothing. Hospitals need the government to address the mounting debt they face and inability to serve communities without either closing or increasing costs. EMTALA was a start but undoubtedly was not enough to stop the vicious cycle afflicting the uninsured population, hospitals, and the government. In 2014, the government implemented the Affordable Care Act (ACA) program hoping to overturn the insurance crisis. Surprisingly the same year it was implemented, the number of uninsured individuals fell by approximately 7% (Tolbert). Studies showed that states who adopted the insurance expansion had fewer uninsured people than those who did not not (Tolbert).
The ongoing prevalent question remains: if there are free or sliding scale health insurance options for those who cannot afford standard premiums, why are so many people still uninsured? According to the Centers for Disease Control and Prevention (CDC) and Congressional Budget Office (CBO), people reported their top 3 reasons for being uninsured were due to the affordability, eligibility, and the tasking process of Medicaid (Gunja). Recent economic instability, coupled with the loss of jobs, including employer based insurance, has worsened the insurance crisis. Populations that do not qualify for free insurance, or the sliding scale premium is still unbudgetable, now struggle to find affordable health insurance without their employer based affordable premium insurance (Shipman). To make matters worse, policy changes from presidential administrations have made the ACA scene unpredictable over time (Murphy).
Clearly, there is a dire need to change the system to be more equitable. The government needs to expand its collaboration to communities rather than focus stabilizing energies on hospitals and insurance industries. Community-based hospitals and the Community Health Workers (CHW) model offer tremendous importance to prioritizing representation of the local communities’ specific needs and individual’s SDOH in this fight. When patients have resourceful healthcare professionals within their communities, it will encourage trust and collaboration between patients and healthcare professionals, in turn the uninsurance crisis can be mitigated on micro-levels to conquer the uninsured crisis.
Chinyere Godfrey- Nwachukwu is a Boston University BA candidate class of 2024, majoring in Neuroscience and minoring in Public Health. She completed a remote summer internship with Bioethics Alliance the Summer of 2021 learning exploring hospital operations, governmental responses, and public health initiatives in response to the uninsured dilemma. Chinyere hopes to pursue a career in medicine and research.
Sources
Gunja, Munira Z., and Sara R. Collins. “Who Are the Remaining Uninsured, and Why Do They Lack Coverage?” Commonwealth Fund, August 28, 2019. https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage.
Tolbert, Jennifer, Kendal Orgera, and Anthony Damico. “Key Facts about the Uninsured Population.” KFF, November 12, 2020. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/.
Alexander, Brian. The Hospital Life, Death, and Dollars in a Small American Town. New York, NY: St. Martin's Press, 2021.
Ladd, Megan, and Vikas Gupta. “Cobra Laws and Emtala.” StatPearls [Internet]. U.S. National Library of Medicine, February 16, 2021. https://www.ncbi.nlm.nih.gov/books/NBK555935/.
Murphy, Brooke. “How Hospitals Are Protecting Their Bottom Lines in the Face of an Uncertain Future.” Becker's Hospital Review, April 4, 2017. https://www.beckershospitalreview.com/finance/how-hospitals-are-protecting-their-bottom-lines-in-the-face-of-an-uncertain-future.html.
Shipman, Debra, Tammy Vant Hul, and Jack Hooten. “Starving for Health Care: Ethical Issues Surrounding Uninsured Population.” Guest Editorial, December 2009. https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/026120013.pdf.
Stark & Stark. “Patient Dumping and the Emergency Medical Treatment and Labor Act (EMTALA).” The National Law Review, October 11, 2016. https://www.natlawreview.com/article/patient-dumping-and-emergency-medical-treatment-and-labor-act-emtala.