Our Common Good

It felt, a bit, like stepping into a scene in “Mad Men”: A dimly lit room with three rows of chairs, all hidden behind a two-way mirror. There, experts watched focus groups shuffle in and out in 90-minute intervals. They pointed at logos they did like, logos they didn’t like and tried to explain the difference between the two. 

These focus groups were not under the supervision of Don Draper, but rather Enroll America.  And the nonprofit was trying to figure out how to sell a product that was never available in the 1960s: Universal health insurance.

My story in Wednesday’s paper looks at the how little the public knows about the Affordable Care Act, with those most likely to gain new coverage options least aware of the changes ahead.

Enroll America is one nonprofit trying to change that: It was founded last year with the express goal of maximizing insurance enrollment come 2014. Before that heavy lifting starts, they still need to figure out how to convince people to sign up.

Hence, the focus groups. Enroll America held 10 of them, across the country last week, all with Americans likely to qualify for new coverage options in 2014. I attended two in Philadelphia last week. I found them a hugely interesting window into how Americans think about health insurance, and what that means for the Affordable Care Act.

The knowledge gap was clear from the beginning: None of the 31 participants knew about the health law’s new coverage options, like subsidies for those earning below 400 percent of the poverty line, and Medicaid for the lowest income Americans. It was not, however, a complete knowledge vacuum: When a researcher asked how many people had heard about the mandate to buy insurance, a flash of hands went up.

“Virtually no one who is uninsured understand how health reform will affect their lives,” Ron Pollack, who chairs Enroll America’s board, told me after the focus groups. “While some focus group participants have heard the term Obamacare, literally none of them have an inkling about whether, and how, their lives will be affected.”

This is a huge challenge for the health-care law but it’s not necessarily surprising. The health-care law is complex, and the big benefits don’t even roll out until 2014. For most Americans, it’s hard to see a practical reason to become informed when the benefits don’t yet exist. 

Rather, what I found most interesting was the deep skepticism of the health law’s benefits as the researchers began to explain them.

The states least likely to join in the Medicaid expansion also happen to be among those whose residents are in the greatest need. The poor and uninsured in these parts of the U.S. will likely continue to go without unless their political leaders have changes of heart. Texas had the highest rate of uninsurance in the nation last year: 24 percent, according to census data compiled by the Henry J. Kaiser Family Foundation. In Florida, Georgia, South Carolina and Louisiana, it was 20 percent. Nineteen percent of Mississippians were uninsured in 2011. Nationally, 16 percent of people had no health insurance last year. In Massachusetts, which enacted a comprehensive health care reform program in 2006, only 4 percent of residents are uninsured. States that refuse to cover more poor people will do so despite the fact that Uncle Sam will pick up most of the tab. From 2014 to 2016, the federal government will pay 100 percent of the cost of covering newly eligible people, after which the share will gradually go down to 90 percent in 2022 and later years.

Mitt Romney doubled down on his suggestion that uninsured Americans can find the care they need in emergency rooms, telling The Dispatch that people will always receive the treatment they need, and do not die or suffer because they can not pay for care. He pointed to federal law that requires hospitals to admit emergency patients, repeating his advice that patients rely on the most expensive form of care reserved strictly for emergencies. Romney told the Columbus Dispatch:

“We don’t have a setting across this country where if you don’t have insurance, we just say to you, ‘Tough luck, you’re going to die when you have your heart attack,’  ” he said as he offered more hints as to what he would put in place of “Obamacare,” which he has pledged to repeal.

“No, you go to the hospital, you get treated, you get care, and it’s paid for, either by charity, the government or by the hospital. We don’t have people that become ill, who die in their apartment because they don’t have insurance.”

He pointed out that federal law requires hospitals to treat those without health insurance — although hospital officials frequently say that drives up health-care costs.

Emergency rooms serve as a place of last resort, but 45,000 Americans still die every year because they lack health insurance, or one every 12 minutes. Uninsured adults under age 65 are also at a 40 percent higher death risk. Hospitals may treat patients for emergency medical conditions regardless of legal status or ability to pay, but patients with chronic conditions that don’t require emergency interference are often unable to access needed care.

Romney’s health care proposal would leave 72 million Americans without health insurance and wouldn’t provide all uninsured Americans with a stable source of insurance.

Yeah, an ER is not going to help you recover from a stroke or provide cancer treatment.  Romney has obviously not experienced being under-insured, much less uninsured.

Mitt Romney’s health care plan wouldn’t just insure fewer people than “Obamacare” — it would make the uninsured problem worse than it would have been if the law had never passed, according to a comparison of the two plans by a research group with a history of pro-“Obamacare” studies.

The analysis by the Commonwealth Fund, a New York-based health care research foundation, found that under Romney’s health care plan, the uninsured population would soar to 72 million by 2022 — 12 million higher than if nothing had been done at all.

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President Barack Obama's health care overhaul has never been popular in Arkansas, a state where even most Democrats regard the law as politically toxic.

But with a quarter of the state’s working-age population uninsured, a governor who once said he would have voted against the law now wants to use it to widen government-funded coverage to thousands of additional families. And he’s relying on the move to help prevent a Republican takeover of the state Legislature for the first time since Reconstruction.

Gov. Mike Beebe, the first Southern governor to back the law’s expansion of Medicaid, has become an unlikely advocate for a central part of the overhaul that would expand Medicaid, a position made easier by the fact that he’s not seeking re-election.

"I think it’s good for our people because it’s helping folks that don’t have insurance now that are working their tails off," said Beebe, who is barred by term limits from running again. "They’re not sitting on a couch somewhere asking for something."

For decades, the primary goal of those who would fix the U.S. health system has been to help people without insurance get coverage. Now, it seems, all that may be changing. At least some top Republicans are trying to steer the health debate away from the problem of the uninsured.

The shift in emphasis is a subtle one, but it’s noticeable.

Many of the governors threatening to stymie implementation of the Affordable Care Act preside over states with high uninsurance rates, according to data from the Kaiser Family Foundation. (via High Uninsurance In States Prepping To Stymie The Affordable Care Act | TPMDC)

Many of the governors threatening to stymie implementation of the Affordable Care Act preside over states with high uninsurance rates, according to data from the Kaiser Family Foundation. (via High Uninsurance In States Prepping To Stymie The Affordable Care Act | TPMDC)

A few days ago, while awaiting the Supreme Court ruling on the Obama health-care law, I called a few doctor friends around the country. I asked them if they could tell me about current patients whose health had been affected by a lack of insurance.

“This falls under the too-numerous-to-count section,” a New Jersey internist said. A vascular surgeon in Indianapolis told me about a man in his fifties who’d had a large abdominal aortic aneurysm. Doctors knew for months that it was in danger of rupturing, but, since he wasn’t insured, his local private hospital wouldn’t fix it. Finally, it indeed began to rupture. Rupture is an often fatal development, but the man—in pain, with the blood flow to his legs gone— made it to an emergency room. Then the hospital put him in an ambulance to the University of Indiana, arguing the patient’s condition was “too complex.” My friend got him through, but he’s very lucky to be alive.

Another friend, an oncologist in Marietta, Ohio, told me about three women in their forties and fifties he was treating for advanced cervical cancer. A pap smear would have caught their cancers far sooner. But since they didn’t have insurance, their cancers were only recognized when they caused profuse bleeding. Now they required radiation and chemotherapy if they were to have a chance of surviving.

A colleague practicing family medicine in Las Vegas told me about his clinic’s cleaning lady, who came to him in desperation about her uninsured husband. He had a painful rectal fistula—a chronically draining infection. Surgery could cure the condition, but hospitals required him to pay for the procedure in advance and, as unskilled laborers, the couple didn’t remotely have the money. He’d lived in misery for nine months so far. The couple had nowhere to turn. Neither did the doctor. The litany of misery was as terrible as it was routine. An internist in my Ohio hometown put me on the phone with an uninsured fifty-five-year-old tanning-salon owner who’d had a heart attack. She was now unable to pay the bills either for the cardiac stent that saved her or for the medications she needs to prevent a second heart attack. Outside Philadelphia, there was a home-care nurse who’d lost her job when she developed partial paralysis as a result of a rare autoimmune complication from the flu shot that her employers required her to get. Then she lost the insurance that paid for the medications that had been reversing the condition.

Tens of millions of Americans don’t have access to basic care for prevention and treatment of illness. For decades, there’s been wide support for universal health care. Finally, with the passage two years ago of Obamacare, we did something about it. The law would provide coverage to people like those my friends told me about, either through its expansion of Medicaid eligibility or through subsidized private insurance. Yet the country has remained convulsed by battles over whether we should implement this plan—or any particular plan. Now that the Supreme Court has largely upheld Obamacare, it’s tempting to imagine that the battles will subside. There’s reason to think that they won’t.

Until you’ve had to do a cost benefit analysis to decide whether or not going to the ER or doctor is ‘worth it’…..you haven’t been gravely ill without insurance in America.


Even when I’m AT the ER/doctor I sit there & pick & choose my tests by figuring out which ones will help the most while costing the least amount of money. When I do go to the doctor, we try to decide what meds to use. Not by what may be the most helpful, but by what may be the most affordable to me. There are meds that would help me live a more ‘normal’ life……..but I can’t afford to have them.

I’ve refused to go get treatment until I’ve been septic from infection, or my lungs were so full of fluid that it was literally suffocating me, or when my fever stayed above 105 for 4 or 5 hours straight. I never go on my own, it takes somebody taking me in, kicking & screaming the whole way. I would rather be in pain & potentially die than have to go to the ER because I know I can’t afford to get proper treatment.

Read that one more time. I’d rather DIE than know I’ll have a zillion dollar bill for trying to get medical care in this country. I’m sorry, but don’t talk about trampling on your ‘rights’. I should have the right to see a damn doctor BEFORE I’m septic. BEFORE my pneumonia has me gasping for air. BEFORE I’m suicidal because the antidepressants aren’t working worth a shit (because I can’t afford the ones that do actually help).

Pretty much been my life since I had cancer and lost health insurance.  Remote Area Medical is coming to a nearby community in a week.  I will be one of those standing in line.

Here is a look at where each of the 50 states stand on implementing President Barack Obama’s federal health care overhaul, which the Supreme Court ruled Thursday can go forward with its aim of covering more than 30 million uninsured Americans.

Interesting info.  Looks like some states really need to kick their legislators in the butt and get them moving.

As Robin Layman, a mother of two who has major health troubles but no insurance, arrived at a free clinic here, she had a big personal stake in the Supreme Court’s imminent decision on the new national health care law.

Not that she realized that. “What new law?” she said. “I’ve not heard anything about that.”


Layman was hardly the only patient unaware that the law aims to help people like her, by expanding health insurance beginning in 2014. And this gets to the heart of the political dilemma for Democrats: Despite spending tremendous political capital to pass the law, the party is unlikely to win many votes from the law’s future beneficiaries, most of whom live in Republican-dominated states in the South and West. In fact, many at the clinic said they don’t vote at all.

And that assumes the law survives until 2014. The law’s design, with its major provisions kicking in four years after passage, was pragmatic politics at the time. The window would make the law’s price-tag lower and allow states time to set up new systems. But the delay’s result has been that the law has no natural constituency - its promises have not been clearly conveyed to the people it is designed to help.


Under the law, Medicaid will expand in 2014 to cover anyone earning up to 138 percent of the poverty level, or about $31,000 for a family of four. Many people above that income who lack employer-provided coverage will receive subsidies to help them purchase private insurance.


Opponents of the Affordable Care Act, such as Mitt Romney, say it should be replaced with a state-by-state approach. Romney’s home state, Massachusetts, is the pioneer - Romney signed a 2006 law that has extended coverage to nearly all residents.

But many other states have demonstrated little political will to help people obtain health coverage. In some, such as Texas and Virginia, the threshold for Medicaid eligibility is so stringent that parents earning $10,000 a year are too well-off to qualify.

States that have made an effort to offer subsidized coverage, as Tennessee did in the 1990s, have typically found that costs became unsustainable when people in poor health enrolled at higher rates than healthier ones. It is that problem that the individual insurance mandate in the national law, the crux of the Supreme Court case, is meant to address.


A 59-year-old Army veteran, [Dr. Matthew] Petrilla has developed a critical view of the country’s health care system after more than two decades of working in southeastern Tennessee. “In this country where we’re supposed to have health care, these people here don’t - they’re walking around on borrowed time,” he said. “No one in this country should not have coverage.”

He thinks he knows why some justices seem ready to overturn the law, regardless of the impact. “It’s because they’re not in the real world,” he said. “They’re up in Washington with their private insurance.  They should come down in the sticks and the foxholes, and see what it’s like.”

He acknowledged that some of his colleagues were less than thrilled about the law’s coverage expansion because Medicaid reimbursement rates are low (though the law brings them up slightly for primary care). But he said that doctors in rural Tennessee would have no choice but to see Medicaid patients, since so many patients would have that coverage. “I’m not going to starve to death,” he said. “I don’t know any doctors who’ve starved to death.”

While Ohio has a law that prevents foreclosures based on medical debt alone, it is legal for hospitals to garnish patient wages, attach bank accounts and get a lien on any future earnings, including from the sale of a house.


Nonprofit hospitals, including Mount Carmel, pay no federal, state or local taxes, giving them a competitive edge over their for-profit counterparts. In return, nonprofits are expected to offer a community benefit, including free and discounted care for low-income patients.

But despite the requirement, a study by the Congressional Budget Office found that on average, not-for-profits provide only slightly more uncompensated care than for-profit hospitals.

The federal health law passed last year attempts to address the situation by setting new rules for how a nonprofit hospital must report its charity care and serve poor patients. The rules have already gone into effect but are not being actively enforced.

Few patients who are sued by hospitals seek legal assistance, according to Kathleen McGarvey, a lawyer at Columbus Legal Aid, which currently represents six patients being sued by Mount Carmel.

She notes says that in these types of cases, the hospital usually wins by default, and the patient is accountable for the entirety of the bill, even if there are errors or duplicate charges. “I think for a nonprofit hospital, whose job it is to provide this community care, that it’s obscene that they’re going after folks who are at 100 percent of the poverty level,” McGarvey charges.

Nearly 45,000 annual deaths are associated with lack of health insurance, according to a new study published online today by theAmerican Journal of Public Health. That figure is about two and a half times higher than an estimate from the Institute of Medicine (IOM) in 2002.

The study, conducted at Harvard Medical School and Cambridge Health Alliance, found that uninsured, working-age Americans have a 40 percent higher risk of death than their privately insured counterparts, up from a 25 percent excess death rate found in 1993.

“The uninsured have a higher risk of death when compared to the privately insured, even after taking into account socioeconomics, health behaviors, and baseline health,” said lead author Andrew Wilper, M.D., who currently teaches at the University of Washington School of Medicine. “We doctors have many new ways to prevent deaths from hypertension, diabetes, and heart disease — but only if patients can get into our offices and afford their medications.”

In Mississippi, uninsured women have to wait over three months to get checked for cervical cancer. Partly as a result, women in Mississippi die from cervical cancer at twice the rate as the average American woman.

Geography largely determines whether US women will suffer from cervical cancer - and whether they will die from it.

Waiting to die: Cervical cancer in America