Uninsured Lecture #3

Risk for Being Uninsured

-Increased in families WITHOUT full-time workers -Smaller-scale employers with limited budgets Less likely to offer insurance benefits -Families living below poverty line May or may not be covered by Federal programs Increasing number of "moderate-income" families are included - "working-poor"

Consequences of Being Uninsured

-Lack of coverage often defines the person's ability to seek care -Causes health disparity - less access to care leads to greater risk of disease complications and death -Cumulative health risk - over time unaddressed health issues worsen -Access to preventive care is lost Immunizations, vision and hearing screening -Insured patients are MORE likely to receive care that matches recommended medical and State guidelines

Public Hospitals

-Primarily Urban Institutions developed from non-profit charity hospitals -Catholic Health System Some owned by State, local or other institutions Only option for health care for the uninsured/underinsured prior to development of Medicare and Medicaid systems **Unfortunately, many of these institutions have closed or have been consolidated into larger Health Care Networks** -Restructured for more funding opportunities -Some have closed due to caring for patients who were unable to pay -Uncompensated care -Low reimbursement for Medicaid/Medicare patients

Other Uninsured Populations

-Recent college graduates no longer covered under parent insurance plans -These individuals may consider themselves healthy and not in need of "routine" care and/or "wellness" visits -College loan repayment and living expenses take priority over health care -Contract workers Payed for work hours without employee benefits These individuals often have children who are NOT insured as well

Federal Health Programs

-Veteran's Administration and the Indian Health Service -Expand health care services to otherwise uninsured patients All health care and testing is provided in network of hospitals and clinics -MD and PA providers are part of this network Also used as preceptor networking and clinical rotation sites

Vulnerable Populations

-Working poor -Non-Medicaid covered unemployed poor -Children who are not included in parent coverage -Adults who cannot afford employer-sponsored coverage -Medicaid beneficiaries -Chronically ill individuals -People with disabilities -Mentally ill individuals -People with communicable diseases -HIV/AIDS -Tuberculosis -Sexually Transmitted Infections - (STIs) -Minorities -Native Americans -Veterans -Homeless people -Substance abusers -Prisoners

Consequences of Being Uninsured (pt.3 )

-Worse health care outcomes -Health promotion and disease prevention opportunities are missed -Treatment for pre-diabetes and pre-hypertension (prevents or minimizes cardiovascular risk): Kidney failure and dialysis Stroke Blindness Amputations **All require expensive care and monitoring as compared to prevention**

Consequences of Being Uninsured (continued)

1. Many individuals are without health insurance and skilled medical care for years 2. Annual screenings to detect asymptomatic disease are missed opportunities to treat and possibly cure disease 3. Chronic disease may worsen or become out of control 4. Children may suffer lifelong consequences -Hearing and vision screenings may delay speech and development -Scoliosis screening -Nutritional status may be compromised

Emergency Care (EMTALA)

Based on State law, individuals without health insurance CANNOT be turned away from institutions when they: -Require acute care or hospitalization -Are victim of a crime -Suffer catastrophic illness or injury -Whether a private or public institution the individual MUST be stabilized prior to transfer (from private to public institution) or discharge -This policy leaves gaps in care for certain patients who are not acutely ill

School-Based Clinics

Developed in the 1970s and expanded in the 1990s Provides care to insured, uninsured and underinsured patients Increases student access to patient encounters Provides both physical and behavioral health assessment and treatment

Community Health Care Systems

Developed to provide health care to the growing number of uninsured/underinsured Community Health Centers (CHC) provide primary care and preventive care with financial support from State/Gov't funding Many are Federally-qualified for funding (FQHC) May be eligible for higher Medicaid/Medicare reimbursement Some patients pay minimal amount based on income and ability to pay Purposed to serve low-income patients

Local Health Departments

Direct patient care provided by these facilities has declined over time Most focus on Public Health Prevention on communicable (TB) and sexually-transmitted disease (STI, HIV/AIDS) Public health interventions due to: Bioterrorism and natural disasters (Hurricane Sandy) Some centers continue to provide: Care for Homeless populations Maternal-child health interventions

Government -Sponsored Programs

Federally-funded programs are available for qualified individuals including: -Medicare -Medicaid -Retired military personnel -State Children's Health Insurance Program (SCHIP) *Many low-income individuals are ineligible for State-sponsored plans*

Ethnicity and the Uninsured

Health Care disparity is related to: Ethnicity -Hispanics have the highest rates of uninsured -Native Americans -African Americans Income disparity may account for some individuals

The "Safety Net"

Health Care without charge or based on reduced cost calculated by patient's ability is provided in public hospitals and community health care centers Patients cannot be refused hospital care or treatment for acute or life-threatening illness The Safety Net was designed to provide a wide range of health care to "Vulnerable Populations"

Consequences of Being Uninsured (pt. 4)

Individuals are MORE at risk of pain and suffering Specifically when care is otherwise available: Antibiotics antihistamines, wound care, corrective lenses, pain management, anti-hypertensives, anti-diabetic meds -Possible physical disability -Untreated diabetes may result in amputation and wheelchair -Decreased life expectancy

Uninsured and Underinsured

Issues include who will pay for the "burden of health care"? Concern related to U.S. moving to "Socialized Medicine" -This system may lead to burden on middle class -Higher taxes -Larger percentage of working-poor -If care is not delivered will it be MORE expensive to care for uninsured over time? -Limited access to quality care -Limited preventive care & screening -Expensive critical care for end-stage disease

The Working Poor

Some individuals opt-out of employer-sponsored health coverage because contributions for group coverage are deducted from their salary -Less take home pay -As a result, these individuals DO NOT receive routine health care -Some employers offer only partial/limited coverage -Professional care is sought only if symptoms are critical or cannot be managed through home remedies, borrowing medication from others or no treatment -Emergency rooms are often used as "clinics" for non-emergent treatment

Private Practitioners

Play an informal role in providing uncompensated care Also termed "Charity Care" More often aimed at individual who are patients of the provider but become temporarily uninsured Private MDs who accept Medicaid patients in addition to private patients -Comprise mostly rural and inner-city MDs

Community & Teaching Hospitals

Provide uncompensated care to those in need Clinical delivery sites include: -Community-based hospitals, and clinics Mission-based Private hospitals -Funding is supported by graduate medical education programs -Medical Schools, PA programs pay stipend for each student to serve clinical rotations and internships at these institutions

Summary

The U.S. population continues to increase and become more diverse Skilled health care workers will be needed to deliver quality health care PAs are considered a solution to address millions of patients newly able to have access to health care due to PPACA law enactment Upcoming year may lead to repeal and many changes to current healthcare laws that affect the under or uninsured Healthcare providers should be well informed about referral systems for uninsured individuals

Insurance Coverage and Non-Coverage

Until enactment of PPACA laws in January 2014 the underinsured and uninsured was one of the top priority issues in the U.S. -Over 40 million people were affected Medicare provides service for: 1. Over 47 million people for individuals older than 65 years of age 2. The disabled who have received Social Security cash benefits for at least 24 months -Individuals with permanent kidney failure - End-stage renal disease - dialysis Medicaid provides medical coverage for low income: -Individuals -Families with dependent children -Elderly individuals -Disabled individuals ***This leaves a gap for individuals who are ineligible for Medicaid due to income level from employment- "working-poor"***