Portrait of the Uninsured:
The View from Grady Mermorial Hospital

by Daniel Adamson

America [must] fix a health care system that is badly broken . . . giving
every American health security - health care thatUs always there, health
care that can never be taken away.

-Bill Clinton, September 22, 1993.

From the windows of a nearby hous- ing project, an urban fortress coated in a shade of 1950Us green obscures the downtown Atlanta skyline. In these parts, and for much of rural Georgia beyond, Grady Memorial Hospital means health care for the indigent, the homeless, and the uninsured.

As a volunteer, donning my green smock in the mornings, I first noticed the humid, stagnant smell of sickness. Navigating my way through dim, densely packed hallways, I managed not to touch rusty doorknobs, and squeezed into one of GradyUs few elevators. One morning, an elderly man in street clothes, with napkins and paper towels stuffed into his mouth, stumbled into the elevator, coughing and wheezing, and found a place next to mine. Wide-eyed, I held my breath for the remaining floors. Tuberculosis, a deadly and drug-resistant infection transmitted through the air, was the talk of the town. Why hadnUt this man been seen by a doctor?

Serving over half a million patients a year, Grady Memorial is the largest hospital in the Southeast, and one of the largest in the nation. It channels about 150,000 of its patients into the Emergency Care Clinic, and gives hospital beds to another 33,000 inpatients. Grady has financial difficulties to match its size. Only 6.5 percent of GradyUs patients hold private insurance, and more than half carry only Medicare or Medicaid coverage. The hospital receives little or no money from the remaining third of its patients, the uninsured. The federal government threatens to reduce Medicare and Medicaid benefits - GradyUs largest source of revenue - and the income from its small constituency of privately-insured patients is insufficient to ameliorate staggering financial woes. Worse yet, GradyUs annual reports reveal a caseload that continues to drop dramatically: inpatient admissions declined from more than 40,000 in 1989 to 33,216 in 1994, a decrease of 17.6 percent. Half a dozen private hospitals, including one run by Emory University, surround Grady, and many privately-insured patients leave the hospital for its competitors.

Grady's 1994 deficit of $20 million indicates imminent financial ruin. According to Bill Custer, a health care economist from the Employee Benefit Research Institute in Washington, "the hospital is in terrible shape. [The insurance statistics of its patients represent] a horribly unhealthy mix, in terms of hospital finance. It's very unusual for a hospital to be that dependent on public-finance patients."

Grady's Chief Financial Officer, Susan Sciullo, insisted that the hospital has taken exceptional steps to cut costs: RThere has been a $7 million decrease in operating expenses, mostly from salaries, employee benefits, and contract labor. WeUve cut staff by 11 percent in the last 18 months.S Despite the recent decline in admissions, GradyUs current full-time staff to patient ratio ranges among the lowest in the region.1 Such dramatic cuts in hospital staff, while healthy financial practice, leave the remaining staff overworked, and the patients severely underserved. A short supply of full-time staff members has always plagued the hospital, resulting in often staggering inefficiencies. A 1991 federal investigation revealed that two patients in GradyUs Emergence Care Clinic died after languishing more than 20 hours without food or basic medical care. Likewise, a recent report by the Georgia Public Policy Foundation, noting that emergency-room patients must sometimes wait up to 36 hours for a bed, indicates that these two patients may not have been alone.

Atlanta's underprivileged go to Grady for health care; its demise should command the concern of local government officials and area residents. On the contrary, the Georgia Public Policy Foundation report described an RadversarialS relationship between the Grady Hospital Authority and the DeKalb and Fulton County Commissions, which have overseen Grady since 1956. GradyUs status as a magnet for uninsured patients throughout much of north and central Georgia prompts grumbling in the halls of county government. Fulton and DeKalb are forced to pick up the tab for all uninsured patients regardless of their county of residence, and have together contributed in excess of $100 million in each of the last four years, amounting to an average of 21.5 percent of their combined budget.2 Anita Anderson, a former Grady nurse who ran for County Commissioner in 1994, remarked that, while canvassing the streets in search of voter support, she Rlearned that this negative feeling about Grady is in south Fulton, downtown, and everywhere. It's deep among both the indigent and the people whose taxes pay for it."

The structure of Georgia's current health care system only aggravates Grady's financial turmoil. Georgia Attorney General Mike Bowers recently instituted a plan calling for free competition among several newly-founded Medicare/Medicaid health management organizations (HMOs). The legislation may provide more options and better service to many of GeorgiaUs underprivileged. It will, however, do little to remedy the underlying problem, since AtlantaUs underprivileged frequently lack Medicaid coverage. According to the Fulton County Department of Family and Children Services, no Medicaid coverage is available to Rthe average citizenS in the state of Georgia. Even with an income below the national poverty line of $645 a month for a single adult, the vast majority of state residents would still not qualify for publicly-funded insurance. While Medicare covers all individuals over 65, Georgia provides Medicaid only to children in families below 185 percent of the national poverty level, pregnant women below a similar income cutoff, and institutionalized beneficiaries with incomes below 300ercent of the same level. Without insurance, GeorgiaUs poor are unlikely to receive any preventive medicine. Without preventive medicine, their conditions are likely to be worse when they finally show up at Grady.

A Portrait of the Uninsured

According to Families USA, a nonprofit, Washington-based policy group, more than 37 million Americans have no health insurance.3 Moreover, incomplete health care coverage is a growing problem: more than 100,000 Americans join the ranks of the uninsured every month. A full 23 percent, or 8.4 million, are children. In addition, one in five Americans, some 51.3 million people, were uninsured for at least some period of time in 1994.4 Even temporary lack of coverage is a serious dilemma, for if an uninsured individual becomes ill during even a single month without insurance, not only can he expect inferior treatment, but he can also become permanently uninsurable. Though AmericaUs uninsured are not exclusively poor, a full sixty percent are below 200 percent of the federal poverty level. The crisis at Grady Hospital is in part due to an abundance of the uninsured in southern states: while one third of Americans live in the South, a full 43 percent of the countryUs uninsured live in this region.

According to Melvin Konner, professor of Anthropology and Neurology at Emory University, and author of several books including Medicine at the Crossroads, and Dear America: a Concerned Doctor Wants You to Know the Truth about Health Reform,

The biggest differences you see between care of the insured and of the uninsured are not in the hospitalUs acute care. When the uninsured go to Grady [with a medical crisis] . . . they usually get good treatment. What they don't get is all the treatment before they get to that point. They don't get the opportunity to . . . have their blood pressure under control before they have a stroke, or to get their diabetes under control before they go into a coma.

Echoing Dr. Konner's comments, a 1993 survey of health insurance sponsored by the Kaiser/Commonwealth Fund revealed that hospitals provide far less primary and preventive services to the uninsured, who are more than twice as likely to have no regular source of care. Seventy-one percent of uninsured adults, compared with only 21 percent of the privately insured, reported that they had postponed necessary treatment during the previous year because they could not afford it. More strikingly, 34 percent of uninsured adults, as against 7 percent of the insured, actually went without necessary medical treatments during the previous year because of financial concerns.5 A study described in Dr. KonnerUs Dear America, reported that, R250,000 seriously ill patients a year are turned away from or out of American hospitals and told to go elsewhere, an estimated 87 percent of them for lack of means.

More often than not, an uninsured patientUs condition will be more severe, and more difficult and costly to treat when he finally does see a doctor. Two recent studies published in the Journal of the American Medical Association reveal that the uninsured are twice as likely to be hospitalized for diabetes, hypertension, and other conditions preventable through regular treatments or immunizations.7 Three times as often, the uninsured die in a hospital bed, largely because they receive fewer optional procedures."

The Path to Universal Coverage

Universal health care coverage does not exist in the United States today because a significant portion of the working and nonworking population is too poor to purchase coverage without outside assistance from employers or the government. The astoundingly high costs of modern medical treatments, and the profit-seeking motives of leading insurance companies, lead to the high insurance premiums and incomplete coverage that characterize the American health care system. Even if health care costs dropped, and not-for-profit, state-run administrations replaced the insurance companies, the potential expense of expanding health care coverage to include all Americans would still worry health care economists.

The exact cost of universal coverage is difficult to estimate. On the one hand, given health care coverage, the previously uninsured can be expected to expand their use of preventive services, incurring a cost of additional services known as the Raccess gap.S Proponents of universal coverage use this term to illustrate the extent to which uninsured Americans are restricted in their access to health care services.

Undoubtedly, these extra visits for preventive care would be very costly. One study reported in Health Affairs, a leading review of health policy, projected that bridging this Raccess gapS would cost $19.9 billion per year, a 2 percent increase in overall health care spending. On the other hand, preventive medicine often proves far less costly than treatments necessitated by acute crises. Even patients without insurance receive emergency care, and the savings from the decline in expensive, acute treatments for the uninsured - such as liver transplants and coronary bypass surgery - may well be greater than the concomitant increase in spending on their preventive care. Moreover, proponents of universal coverage cite the indirect economic benefits of a healthy population, including increased productivity at the workplace.

The costs and benefits of universal health care remain a complex matter difficult to determine in advance. Not only would a completely accurate calculation have to reflect the relative costs of preventive and acute care, it would also have to take into account the start-up costs - spread over years - representing payments for initial preventive care before the savings from a diminished need for acute care are realized.

In efforts to remedy the crisis in health care affordability, about a dozen recent bills have carried proposals for universal or expanded health care coverage to Congress. President ClintonUs well-known plan called for all but the smallest employers to finance coverage through Rmandatory contributions,S alongside a system of subsidies to lessen their impact.9 Clinton's reliance on employer contributions stemmed from the fact that most nonelderly Americans already get health insurance through their employer (60 percent), while the rest either purchase it individually (9 percent), are covered by Medicaid (12 percent), or have no insurance at all. Both the Clinton plan and another sponsored by the Pepper Commission (after Representative Claudo Pepper) required most employers to pay 80 percent of the employee premium.

The Clinton plan also provided tax benefits for the self-employed in order to encourage their enrollment. Despite apparent political momentum early in his tenure, ClintonUs proposal failed to gain legislative support, in part because of lobbying and negative advertising sponsored by several leading insurance companies. Republican-sponsored plans for large-scale health reform have also failed to gain wide-spread support. Many of these Republican-sponsored plans, including those by Texas Senator Phil Gramm, and Illinois Representative Robert Michel, placed little financial responsibility on employers. While many Democratic alternatives sought to remedy the problem of affordability through mandated employer contributions, these proposals made no efforts to truly universalize coverage, instead aiming to expand coverage by providing additional tax deductions for individual insurance payments.

As Congressional focus has shifted from health care reform to other issues, the window of opportunity for a comprehensive reform of the health care system has closed. Each of the bills mentioned above surfaced some two years ago, only to be rejected. At present, there is a widespread unwillingness in political circles to employ any broad-based taxes as a means of financing expanded coverage. Federal legislators, in the midst of efforts to balance the budget, have avoided wholesale change and moved towards piecemeal revisions. For example, one bipartisan bill sponsored by Senators Nancy Kassenbaum (R.-KS) and Ted Kennedy (D.-MA), currently on the Senate floor, calls for an employeeUs health insurance plan to be transferable from one job to another. This bill would undoubtedly reduce the number of Americans temporarily uninsured. It does not, however, address the underlying problem of affordability, making no attempt to reduce insurance costs through employer contributions or tax incentives.

In his article RComparing the Options for Universal Coverage, Stephen Lang of Health Affairs points out that any proposal calling for universal or expanded coverage necessarily involves a transfer of wealth from the privately insured to indigent:

However it may be ignored or camouflaged, I believe that redistribution is at the heart of the health care debate. The concept of insurance, particularly health insurance, involves sharing common risk. Major health care reform inevitably will require a significant degree of personal and political commitment to sharing resources.10

As at Grady, health care for the poor often involves a transfer of wealth from suburban tax payers to the inner city. Though wealthy taxpayers and their legislators may be well aware that their taxes fund the health care coverage of the indigent, they often fail to realize that the implementation of universal health care coverage may actually decrease their future tax burden by shifting indigent care from acute to preventive medicine.

Our health care system has come to reflect both the best and the worst aspects of modern medicine. For too long, we have insisted on improving health care from the top down, through high-tech expertise available only to the wealthy few. A significant improvement in the health of AmericaUs underprivileged can only be accomplished through reform from the bottom up. To accomplish this, legislators and taxpayers alike must be capable of identifying with AmericaUs underprivileged, and in some instances be willing to sacrifice themselves in an effort to ameliorate the health of the poor. Dr. Konner, recognizing the principle of redistribution behind health care reform, lamented that he is not Roptimistic about what is going to happen to the poor in Atlanta or elsewhere over the next few years." His rationale: "The haves simply do not want to help the have-nots. America is in a selfish mood." YJE Endnotes 1Cited in Creative Loafing, Volume 24, No. 38, Feb. 10, 1996, p. 30 2John Sherman report on Grady Hospital, The Georgia Public Policy Foundation, 1995, cited in Creative Loafing p. 28, 30 Feb. 10, 1996 3Cited in Konner, Melvin, Dear America: a Concerned Doctor Wants You to Know the Truth about Health Reform, p. 13, 18 4Health Affairs Spring (II) 1994, 283-287 5Cited in Health Affairs Spring (II) 1994, 283-287 6Konner, Melvin Dear America (Addison-Wesley Publishing Co. 1993) p. 36 7 Journal of the American Medical Association, 267 p. 1255-1260 8 Journal of the American Medical Association, 265 p. 374-379 9 Health Affairs Spring (II) 1994, 85-100 10 ibid. 85-100

1996 The Yale Journal of Ethics. All rights reserved.
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