31 March 2009

The Uninsured

Long-time readers of this blog know that the crisis of the uninsured is probably the issue I care more about than any in medicine.  I care so much because I hate seeing these poor folks come into the ER with the consequences of their inability to find a doctor, and because I don't like not getting paid for what I do, and because the system that allows working people to fall into the gap between insurance and medicaid is so staggeringly unfair.

Doc Rob has a thoughtful and moving piece over at his place, from the office doc's perspective:

The Uninsured | Musings of a Distractible Mind
This is when one of my billing staff comes to me with the “what do you want to do?” question regarding them. Most of these are people I know. I don’t think of them as customers, I think of their kids and parents. I think about the medical struggles they have faced or the tragedies they have endured. I like my patients. Playing “hardball” is not that easy when you have an emotional attachment to your “customer.”
I don't have that problem, fortunately.   Unlike Rob, I am a commodity, and I am OK with that, and my interactions with patients are mostly one-shot affairs.  

But it puts a much more human face on "the uninsured," instead of viewing them as a nebulous mass of the great unwashed.


  1. I acknowledge your take on this, but believe that the problem is less widespread than you and the politicians would have us think. Many are uninsured by choice, and since the ER will ALWAYS see them 24/7, there remains a disinsentive to "bother" with health coverage. The attached video shows many of the OTHER faces of the uninsured..


    Pattie, RN

  2. Pattie,

    You are right that many people are uninsured by choice -- though there is disagreement over what proportion of the uninsured that actually reflects.

    Which brings up the question of whether that is OK, as a matter of policy, to allow people to opt out of health insurance. Sure, from a very libertarian perspective I can see the objection, and I respect it.
    One way to view health insurance as a social compact in which, not knowing in advance who is going to get ill, all pay into the risk pool to hedge against the possibility that they are going to need it. In that case, it is destructive to allow people to only buy in when they know they need it. It's like saying that auto insurance is not required, but if you get in an accident you can purchase a policy after the fact. It only works if everybody has to have it -- but only those who get in an accident benefit.

    Another way to view it is that since we all are likely to need expensive health care at some point in our lives, being mortal after all, that insurance is a useful way to amortize the cost over the entirety of your productive career. Again, if people are not paying in ahead of their need, they will not be able to bear the cost of their illness in full when/if they need it.

    My point is that there are logical arguments in favor of mandatory coverage - to remove that disincentive to "bother" with purchasing it.

  3. Hospitals in IL were being taken to court for overcharging and aggressive collection practices for uninsured patients. As of April 1, uninsured patients will no longer be billed list price for hospital services. Not sure how this will affect admission through the ED, though.

  4. Thanks for the link. My post was simply my personal experience. I am seeing a whole lot more uninsured than ever before. Most people have insurance, but in this suburban practice it is certainly over 5% and probably close to 10% of my patients (which is a lot). Of those, more than half are involuntarily uninsured. Most don't work and can't afford COBRA.

  5. There was a great Frontline on last night about the the uninsured in America. It focused on individuals who w anted insurance and could not procure it along with a few individual cases.

    It also went into detail on the MA system compelling Universal Health Insurance - how Industry is not meeting the requirements and how they have had to back off the mandate.


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