It is an unfortunate truth that many of those who are most in need of affordable healthcare are the least likely to be able to afford it. According to a study by the Henry J. Kaiser Family Foundation, most of the 46 million uninsured people in this country do not have access to employer-sponsored insurance. About two-thirds have incomes below 200 percent of the federal poverty level (about $44,050 for a family of four in 2008). Every year about one-quarter go without needed care for which they cannot pay and are also less likely to receive preventive care and services for major problems, creating even more serious health problems for many.
When these un- or under-insured people do seek care, they often face unaffordable medical bills with out-of-pocket costs comprising one-third of their care. And they are often charged more for care than those who are insured, a burden compounded by low to moderate incomes and few, if any, savings.
We should all be grateful to Dr. Renee Hsia (pronounced “Shaw”) of UCLA-San Francisco Emergency Medicine for using a personal relationship as a springboard to exposing the consequences that can derive from this situation.
Alerted to the cost of an emergency appendectomy when a friend underwent the procedure, Dr. Hsia and her co-investigators studied the records of nearly 20,000 patients in California who were hospitalized for acute but uncomplicated appendicitis in 2009. The first surprise was that the cost for the procedure ranged from a low of $1,529 to a high of—hold on!—$182,955. The median cost was $33,611, and you don’t need me to tell you that even that amount could come as a catastrophic cost to a patient with little or no insurance.
The second and less savory surprise was that charges were higher for Medicaid patients and the uninsured, as well as for older patients.
In the United States today, healthcare is often positioned as a commodity that can be governed by the rules of the marketplace. For this to work, it is necessary that both patients and care providers have a “reasonable sense” of what the product costs. Providers often do not know what the services they recommend cost, and patients with viable medical insurance are usually immune to these charges. The underinsured or uninsured, however, see “staggeringly high numbers” without knowing what they mean or if they are appropriate.
Some two-thirds of bankruptcies in the United States are due to catastrophic medical costs, so making the patient an educated consumer who can make educated choices must be a major part of any healthcare reform. The point at which these two studies intersect, i.e., when those who are least able to pay are charged the most, should be a red flag for anyone who is concerned about our society’s ability to access adequate healthcare without courting financial catastrophe.
I encourage you to read Dr. Hsia’s full report at http://archinte.ama-assn.org/cgi/content/short/archinternmed.2012.1173. Registration is required.
Loie Hanscom is the executive director of Picker Institute.