Addressing inadequate health coverage

Thursday April 4, 2013

Almost every week, here in Vermont, patients come to see me who are "self-pay" -- a euphemism for having no health insurance. Sometimes they have delayed seeking care, because of their lack of insurance, until a relatively small problem has progressed to becoming a dangerous one.

Numerous other patients I see aren't "self-pay," but have "under-insurance." High deductibles, co-pays, and "co-insurance" (another euphemism) require some patients to pay more than they can afford, creating an obstacle to receiving appropriate healthcare.

Alone among industrialized democracies, the U.S. fails to provide some form of universal health coverage to its population. Vermont may lead the way in changing this, but one proposal on the table from Governor Shumlin may take us backward.

Thanks to the efforts of citizen activists, the Legislature, and the governor, Vermont has started moving towards a single-payer system, but that won't start until 2017 -- assuming no detours or delays along the way.

Until then, we have to live with the "Health Care Exchange" mandated by Obamacare. Governor Shumlin proposes to increase health insurance premiums and deductibles for 30,000 low- and middle-income Vermonters, as they enter the Exchange in 2014. His proposal will exacerbate, not improve, the problem of under-insurance.

As one example, a person whose gross income is $34,000/yr now pays $208/mo for Catamount Health with its $1,050 out of pocket limit. Under the governor's proposal for the Exchange, that person will pay a $244 monthly premium plus a $3750 medical out of pocket limit plus another $1250 out of pocket limit for prescription drugs.

So if this patient were to get really ill, he or she would spend about $8,000 on their care before insurance covered the bills. And these are annual limits, mind you. If a low income person needs ongoing treatment for, say, cancer, it's hard to see how he or she can ever hope to pay their bills or get out of medical debt.

Governor Shumlin says we "can't afford" to continue offering people the same low cost care they currently get on Catamount and VHAP. I believe we as a state can't afford not to continue making health care accessible, to thousands of people who are largely struggling to get by, and for whom a major medical expense could result in bankruptcy, homelessness or job loss.

There is a viable source of revenue for subsidizing health insurance here -- a tax on sugary beverages. While the governor opposes this tax, which would require 12 cents more for a can of soda, he does not mind asking low- and middle-income Vermonters to pay thousands of dollars more for their health care every year.

When patients face high out of pocket costs, they delay care. The health care "system" then sometimes has to spend far more to address advanced disease, and make someone healthy again.

A laryngectomy (surgically removing the voice box) for advanced vocal cord cancer, for example, is far more expensive, with a week or so in the hospital and extensive rehabilitation afterwards, than a much smaller outpatient procedure to remove an early cancer (and preserve a patient's natural voice).

The Health Care Exchange isn't perfect compared to single payer. But that does not absolve our responsibility to ensure affordable health care for all. Everyone needs affordable health care every single day. Governor Shumlin shouldn't ask low income Vermonters to wait for single payer in 2017, to address inadequate health insurance today, when a solution is on the table now.

Bill Wood, MD, runs Southern Vermont ENT. He writes from Putney.


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