Rationing health care in Texas
INDEPTH: HEALTH CARE IN GALVESTON
Galveston, oh Galveston
Rationing health care in Texas
Reporter: Frank Koller, CBC Radio | December 8, 2003
On December 8, 2003, U.S. President George W. Bush signed a $400-billion overhaul of Medicare, the American government-run system to help the elderly with medical care. The new provisions are designed to offer some relief from the soaring costs of prescription drugs in the U.S.
Galveston As the U.S. presidential election campaign heats up, health care is emerging as perhaps the major domestic issue. The already-high costs of private health insurance are rising monthly. But 44 million people – 15 per cent of the American population – have no health insurance coverage at all.
Texas – Bush’s home state – has the highest proportion of uninsured citizens. In Galveston, the situation is so severe the local hospital has been forced to deliver medical care based on patients’ ability to pay.
Income screening
Rosalyn McCray In the financial screening centre of the University of Texas Medical Branch hospital in Galveston, Rosalyn McCray examines the bank statements of a woman desperate to see a doctor. Irene Perez has also brought a notarized letter stating she and her disabled husband earn less than $8,000 a year.
They’ve never had health insurance. Perez hopes to prove she’s so poor the hospital will declare her “medically indigent.” And let her see a doctor.
“It’s very embarrassing because we’ve never in our 20 years of marriage asked for any help,” Perez says. “We own two shrimp boats and worked for ourselves until he lost both of his kidneys. We finally lost everything because I became incapacitated also.”
The University of Texas Medical Branch is the only state-owned hospital left in Texas. For a century, people who couldn’t pay for medical care have come here for help. Some drove a thousand kilometres to sleep in their cars while waiting to see a doctor.
But the public hospital was trapped by a shrinking state budget, soaring costs for prescription drugs – and a flood of uninsured people seeking help. So it undertook what it calls “rationing of medical care.” If potential patients don’t have insurance or a fat wallet, screening officer Rosalyn McCray must decide whether or not they’re admitted. Not everyone gets in.
Heartbreaking stories
“And it can be heartbreaking when you listen to people’s stories – it’s not that we don’t have compassion but you have to do what you have to do to keep the reimbursement going,” McCray says. The hospital saw trouble ahead in the late 1990s as the number of people without health insurance in Galveston began to soar. The new CEO, Dr. John Stobo, tried traditional cost-cutting methods. They weren’t enough. “And so we had to ration health care. That’s not something I came here to do,” Stobo says. “It’s not something I like doing. People initially asked, ‘why are you doing this?’ and my response was we’re not going to be able to deliver any health care if we become indigent as an institution.”
Galveston The new system took several forms. First, the hospital cut in half the number of people it admitted without insurance. Second, they started rigorous financial screening of potential patients – some say the toughest in the U.S.
Dr. Ben Raimer, head of community medicine, designed the original system. “We often liken it to flying on an airplane,” Raimer says. “You have a guaranteed opportunity to travel safely but you have a choice between first class and coach. There may be certain amenities that people choose to have in addition.”
But even when so-called indigent patients are admitted, the scrutiny continues. Almost daily, Dr. Karen Richardson, the hospital’s medical director, makes tough decisions based on a patient’s ability to pay. Today, she approved anti-cancer drugs for a patient on financial assistance – but only prescribed half as many pills as for a patient with insurance. The indigent patient’s case will be reviewed before more treatment is approved. Richardson says a paying patient has an easier time.
“No, that wouldn’t be a question [for a paying patient] that would have been taken care of,” Richardson says. “The medications would have been taken care of and the patient would have been on their way.”
Medically Indigent
In the screening centre, Irene Perez has proven she’s “medically indigent.” Even though she makes only $650 a month, Perez will still have to pay $40 to see a doctor, probably once a week. Rosalyn McCray, the screener, doesn’t think a $40 fee is too much.
“My gut tells me they’re not going to wait. She looks like she’s in quite a bit of pain,” McCray says. “And I don’t think the $40 will be too much of an issue. I think they’re willing to make that sacrifice because she looks like she’s in quite a bit of pain. Quite a bit of pain.”
In theory, this hospital’s not the last resort for the poor in Galveston. In theory, people turned away can get help at free street clinics and the county medical centre. Chief executive officer Dr. John Stobo admits he doesn’t know how theory plays out in the real world.
“Unfortunately, we don’t know that they’re getting the health care in the communities in which they live,” Stobo says. “We try to connect them to the appropriate care-givers but whether or not they get the care they need, I’m not sure … we just don’t have a good way to track it and, in some cases, I suspect they’re not getting the health care they need.”
Street clinic
The Jesse Tree is Galveston’s biggest free street clinic, helping hundreds of people in one of Texas’s poorest cities. Ted Hanley, the clinic’s founder, says $40 is an impossible cost for too many people. It’s creating a sense of helplessness among those who need help the most.
“My deep concern is for the quiet people out there dying because they have chronic illnesses,” Hanley says. “They’re not good self-advocates. They do get the medical care by the time their conditions are already so advanced there’s no coming back.”
One in seven without insurance
One in seven Americans don’t have health insurance and the proportion is increasing. Premiums for private insurance are going up more than 10 per cent a year. Dr. Ana Malinow, a pediatrician in nearby Houston, knows all too well the financial pressure that forced the Galveston hospital to ration care. Malinow says it’s unlikely to change soon.
“In a for-profit [system] there is no incentive to keep costs down, is there?” Malinow says. “So when people say ..oh … in the government we need to be fiscally conservative … blah blah blah … it’s all crap, because they know that what they want is to increase their profits and the only way to be increasing profits is for there to be more money in the system.”
No one at Galveston’s hospital boasts about the health care restrictions. No one waxes poetic about so-called “financial efficiencies.” Many are prophetic, however, that what they’ve had to do represents the cruel logic of a broken national medical care system.
“I can’t imagine there’s a hospital in the United States that isn’t facing this problem,” says Dr. Karen Richardson. “We also feel like we have an advocacy responsibility to shine some light on this issue and talk about what everybody else will soon have to do.”