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Give Me Shelter
Growing number of uninsured patients prompts nurses to become involved in finding ways to expand coverage and improve access to care

By Cathryn Domrose
August 12, 2004

More than once, Isabelle Felder Gillis, RN, BSN, PHN, has found herself on her couch at 5 AM, coffee in hand, making phone calls to find a hospital bed or an appointment for an uninsured patient who needs care. An increasing number of uninsured patients and a shrinking pool of resources mean Felder Gillis, medical clinic manager at the Native American Health Center in San Francisco, must get up before dawn to secure health care for her patients.

“Uninsured patients distort everyone’s concept of office hours,” she said. Despite her early rising, she often ends up with a spot on a waiting list rather than a bed or an appointment.

For Felder Gillis and many other nurses, the nation’s health insurance crisis is not just a newspaper story or a political debate. It’s a frustrating and heartbreaking reality they face every day.

Although almost all nurses working in hospitals receive health insurance benefits for themselves and their families, not all retired nurses and nursing students have adequate, affordable coverage. Nurses who work as independent practitioners or who run clinics feel the financial crunch when they treat uninsured patients who can’t pay but who have nowhere else to go.

Nurses in hospitals worry about sending home patients who won’t receive follow-up care for illnesses such as cancer or diabetes. In emergency departments and community clinics, nurses feel the strain of treating increasing numbers of people who have nowhere else to go. Home health nurses spend hours of their days looking for ways to help uninsured patients pay for their health care.

“How much nurses are affected depends on what their role is,” said Sara Jarrett, RN, EdD, MA, MS, associate professor at the Regis University department of nursing in Denver. “They’re all affected in different ways.”

Nurses’ opinions about the best way to solve the problem of the uninsured vary considerably, like those of the rest of the country. But most agree on two things: The discussion must be continued and nurses, as frontline health care providers, must take part in it.

Statistics show a health insurance problem in the United States of staggering proportions:

> Nearly 44 million people in the United States do not have health insurance. About one in five adults and one in 12 children did not have coverage in 2002, according to U.S. Census figures. About 85 million people did not have coverage at some point between 1996 and 1999, according to a study published last winter in Health Affairs.
> About 18,000 people die unnecessarily every year because they don’t have health insurance, according to Institute of Medicine reports. The reports estimated that the poor health and early deaths of uninsured adults cost the country some $65 billion to $130 billion annually.
> Some hospitals have closed or limited services because they could not afford the financial burden of caring for the uninsured, the reports stated. Tax dollars paid for an estimated 85% of about $35 billion in unreimbursed medical care in 2001. That figure is expected to rise to $41 billion in 2004, according to a report from the Kaiser Commission on Medicaid and the Uninsured.

Between 2001 and 2002, the number of uninsured Americans rose by nearly 2.5 million, according to census figures, and many expect it to increase. Employers pay for most health coverage in the United States, but pointing to rising premium costs, many say they no longer can afford full coverage for employees and their dependents.

Health care costs are the most cited reason for bankruptcy, said Catherine Dodd, RN, MS, district director for House Democratic Leader Rep. Nancy Pelosi (D-Calif.) and former regional director of the U.S. Department of Health and Human Services under the Clinton administration. “Everyone has a story, everyone knows someone who has been burdened by a major illness or an injury.”

Because of the nursing shortage, almost all nurses who work for hospitals have health benefits, said Deborah Burger, RN, a diabetes care manager at Kaiser in Santa Rosa, Calif., and president of the California Nurses Association.

But Burger said she knows two retired nurses who have returned to work a few days a month to pay for their insurance plans. One who has two preexisting conditions — high blood pressure and high cholesterol — pays $900 a month for her health insurance, Burger said.

Many student nurses in California do not have health insurance, said Patricia McFarland, RN, MSN, executive director for the Association of California Nurse Leaders. “We’re very concerned,” she said. “We really have to see what we can do to get more health care insurance for nursing students.”

Advanced practice nurses are experiencing the effects of insurance programs — private and public — that do not reimburse them for the actual cost of care or put limits on the kind of care that will be reimbursed, Jarrett said.

Mouthpiece for the masses

Felder Gillis said her clinic treats some uninsured patients without payment because clinic workers see it as their mission to give the best care they can. But free care takes its toll on the clinic’s operating budget, she said. The clinic is part of the San Francisco Community Clinic Consortium, a group of private, nonprofit clinics that treat many uninsured people in San Francisco, said Mark Fantone, director of communications for the consortium.

Sue Omel, RN, MPH, MS, BSN, a public health nurse in Oregon, said she and her staff spend more and more hours each week helping parents fill out forms to obtain some sort of health coverage for their children and sometimes for other family members. Her caseload hasn’t increased, she said, but she and her staff of nurses have less and less time to spend on actual patient care.

“We spend a huge amount of time trying to advocate for families because they don’t have insurance,” said Omel, field team supervisor at the Washington County Department of Health & Human Services in northern Oregon. “The advocacy piece is becoming overwhelming.”

Nurses in emergency departments, where an estimated one in three patients are uninsured, find themselves in a similar situation. They must triage patients who come in for basic primary care and spend time away from real emergency cases, Dodd said.

Nurses in clinics, hospitals, and home health also must deal with patients who have advanced cases of illness that could have been prevented or easily taken care of had they sought care earlier. Reports by the Institute of Medicine found that uninsured Americans received about half the care of those with health insurance. As a result, they tend to be sicker and die sooner. About half of uninsured children visited a physician in 2001, compared with three-quarters of insured children, the reports stated.

Felder Gillis said she has seen patients with diabetes who might have been able to prevent some complications had they been diagnosed and treated earlier. Omel has seen uninsured parents who become ill with a condition such as diabetes or a mental health problem and don’t seek treatment because they can’t pay for it. “Our job is not diabetes care,” she said. Nurses in her department make home visits to care for infants and pregnant mothers with health problems. “But you can’t ignore that.” So she ends up looking for ways to get health care for parents as well as their children.

“People need to have health insurance because they can’t afford the catastrophic things that happen,” Myrna Allen, RN, MSN, CHE, chief operating officer of the American Nurses Association\ California. “The problem is, we don’t know how to pay for it.”

Some states are trying new ideas. Last year, the California Legislature enacted an employer mandate law, which comes before voters in a referendum this year. If voters do not repeal the law, starting in 2006, employers with more than 50 employees will have to either provide some sort of coverage to their workers and dependents or pay into a state purchasing pool to cover them. Employers with more than 200 employees must extend coverage to dependents.

Employee contributions will be limited to 20% of premiums or 5% of wages for low- and middle-income workers, and limited deductibles. The state-provided coverage probably will be some sort of expansion of California’s Medicaid program, Allen said.

Looking for cover

Nurses say providing access to health care is one of the most important responsibilities of a health care system. In this, many agree, the system has failed. They are not alone. Politicians, physicians, employers, insurance company executives, and the general public agree that the health insurance crisis needs to be addressed. The Institute of Medicine of the National Academies has called for universal health coverage by 2010.

But the question nurses and the rest of the country are asking is: What is the best way to provide universal access? Provide tax credits to help pay for premiums? Mandate health insurance the way some states do car insurance? Require employers to provide it? Establish a government-financed health care system, similar to the one in Canada? Should such a health care system be national or should it be up to each state to decide its own system?

Groups such as the Institute of Medicine and Cover the Uninsured have identified some approaches to expanding coverage for the uninsured, including:

Employer mandates | Employer mandates, also called “pay or play” laws, require businesses with a certain number of employees to either provide coverage to workers or pay a tax to enroll workers in a public plan.

Some critics of the proposal say it creates an unfair burden on employers and discourages them from hiring more workers. Others say it doesn’t go far enough and leaves some without coverage, or with coverage that stops if they are laid off or go to work for an employer who isn’t required to provide coverage.

Individual mandates | Individual mandates would require everyone to have some basic form of health insurance just as every driver must have car insurance.

Because many people without health insurance now are young and healthy, proponents of this idea predict premium costs would decrease because of increased competition for new buyers and the addition of healthier people to the risk-sharing pool. Opponents say this system would not be fair to people with preexisting conditions who would have to pay higher premiums because of “bad genes.” They also say there is no way to enforce the mandates, and most voters would not approve of a law requiring them to buy insurance.

Tax credits | Tax credits would let employers or individuals deduct the cost of health insurance premiums, either with a fixed amount of money or a percentage of the premium.

Supporters say tax credits allow some choice in health insurance policies, but would be affordable because they would only reimburse on premiums up to a certain point. Opponents say the tax credits would be too small and too complicated to induce people to buy insurance, especially those with preexisting conditions who had to pay higher premiums.

Expanding existing programs | Expanding existing public health insurance programs, such as Medicaid, Medicare, SCHIP, and community clinics, would provide coverage for more uninsured people.

Many say this is the easiest way to expand coverage without adding more bureaucracy or creating a new, expensive, and untried system. But opponents say current programs are confusing and inefficient and have been unable to enroll those who are eligible. Also, many states are cutting back or freezing spending on health care programs, and the quality of health care programs would vary from state to state, depending on their economic situations.

Single-payer system | A tax-financed health care system, similar to the one in Canada, would turn the government into the nation’s major health insurer, administering payment for private health care services.

Supporters of a single-payer system say it would guarantee health care coverage for everyone and be more efficient because the government would negotiate prices with health care providers and drug companies. Others point to inefficiencies and low reimbursements in current government-sponsored health programs and argue that such a system creates too great a role for government and gives it too much power in managing health care.

Cathryn Domrose

If voters sanction the program, California will be able to cover — at least by law — almost all of its population through a combination of Medicare, Medicaid, State Children’s Health Insurance Program (called Healthy Families in California), employer-sponsored insurance, and individual premiums, Allen said. But some providers already are turning away Medicaid patients because reimbursement rates are so low, she said. Others, faced with an influx of new Medicaid-type patients, may follow suit.

“We can see the writing on the wall,” she said. “It will be good in the fact that they have access. It won’t be good in the fact that they may not have access to providers if the reimbursement is inadequate for the services.”

Dodd calls the new California law a step forward, “but it’s what we’ve always based health care coverage on. It’s an employer-based benefit.” Which means, she said, that when the economy is not good, people will lose their jobs and their insurance coverage. “It doesn’t account for people who go in and out of the workplace,” she said.

Expanding existing programs such as Medicaid and Healthy Families would help her clients, Felder Gillis said, but she didn’t see how that would be possible in California, given the state’s budget restrictions. Oregon, which had a fairly good expanded public health plan, in recent years has dropped hundreds of people from its rolls because of budget cuts, Omel said, and, as in California, those people are competing for limited health care services.

Some nurses strongly support a single-payer, government-run health care system, similar to the one in Canada. Although no proposed solution is perfect, Jarrett said, she believes a single-payer system may be the best way to guarantee health care without restriction.

Other proposed alternatives, including mandates and tax credits toward insurance premiums, do not provide such guarantees, she said. People still could face high premiums because of preexisting conditions, or be offered programs through employers that had such high deductibles, they would avoid seeking health care.

“We’ve had a single-payer system since 1965,” she said. “It’s called Medicare. It’s not perfect, but it has worked.”

Others are not sure what the solution might be. Felder Gillis said she was vaguely familiar with the Canadian system. “I know there are some ups, but there are also some downs,” she said. “It would be wonderful if you could wave your magic wand and everyone would have all the health insurance they need. I don’t think there’s any one solution that’s going to solve the problem.”

View from the front

Many nurses are coming to realize that they need to make their voices heard in the discussion about health care access.

In the mid-1990s, the California Nurses Association voted to support a single-payer system and supported legislation calling for universal, state-sponsored coverage. Universal health care coverage has been a consistent issue for the association, which voted to support Ralph Nader in the 2000 presidential election because of his support for health care reform, Burger said.

The Colorado Nurses Association has created a task force on universal access to health care, Jarrett said, and plans to work with legislators to look at ways to achieve this. The ACNL is starting to look at the situation, too, McFarland said. “It’s bubbling up as one of our top concerns and priorities.”

As health care workers in the field who see the direct effects of not having insurance, nurses need to educate people about what is going on and start using their political clout, Omel said.

“Nurses have got to stay informed about what we have now and what’s being proposed. We need to organize ourselves around issues that are important to us.”

Nurses need to look at the debate about covering the uninsured and ask, “What’s the right thing for the patients that we see?” even if it means raising taxes or making other hard choices, she said. “Because if our patients’ lives get better, that’s going to make our lives better as nurses.”

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