Medicine

Cost of health care increases poverty around the world, and in the US

The title of the press release from the World Bank, “New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending”, about says it all. Or does it? Certainly, it summarizes the core information provided by that study, and that is pretty bad. Even in a world whose population this year reached 7 billion that is a big number (nearly 6%), and remember that it is talking about “…essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation.” This is not coronary artery bypass surgery (as essential as that seems to those of us who need it), or knee replacement (which may make it possible for us to walk with less pain), or even tight control of our diabetes (possibly less prevalent in populations that are chronically malnourished), still less entirely elective care.

We are talking about access to clean water and sanitation. We are talking about the fact that the greatest cause of death in the world is waterand that most of those deaths are in children. We are talking about the absence of the most fundamental aspects of access to health, not to mention health care and medical care. While not a focus of the World Bank report, in many places war makes it worse, adding to the lack of basic services an extraordinary need for major medical care. In his New York Times Op-Ed piece of June 21, 2015, Nicholas Kristof describes the chilling war being waged by the government of Sudan against its own people in the Nuba Mountains, with daily bombings of civilians. He describes the deaths and maiming of children, and the inadequacy of even the most committed physicians to help in the atrocious conditions that exist there. An 8-year old boy, who had just lost several siblings to the bombing, “showed extraordinary courage,” the lone doctor at the hospital remembers, “but he would scream every day from pain as his dressings were changed.” While he “persevered for weeks”, “flies were laying eggs in his wounds, and soon the burns were crawling with maggots. Dr. Catena says that he would cut out the maggots, and the next day more would return.”

Yes, most of these 400 million are not in the US, are in developing (a euphemism, perhaps) countries. But in the US there is great need also; every day in our cities we see people who have not had access to TB or HIV treatment, who have delayed care because they are uninsured and cannot afford the cost, until they are so sick that their treatment costs far more than it otherwise would have. We see women who do not come for antenatal care until very late in their pregnancies if at all, missing the chance to discover and treat relatively minor problems until they become major. Fortunately, it is uncommon in the US for them to not receive “skilled birth attendance” since the law requires hospitals to provide care when women come in in labor, but they often appear with no records of whatever prenatal care they may have had. An excellent post on the blog of Medical Care Section of the American Public Health Association (unfortunately, access is limited to APHA members), “For Medicaid enrollees, a choice: PCP or emergency department?”, by Sandhya V. Shimoga, describes the problems that Medicaid patients, particularly those newly covered by Medicaid expansion in those states that have done so, in finding primary care providers; they continue to have to use the ED instead, often (again) with conditions far worse than they would have otherwise had. This, of course, does not count the largely insured people in the US who elect not to immunize their own children, secure in the knowledge that most other people are and that they will have access to care if anything does go wrong. Which it often, by the way, does.

And then there are states like mine, Kansas, that have chosen not to expand Medicaid, so that people similar to those Shimoga describes in Oregon and California do not even have a choice. The people of this state, once proud of its education and health care, have seen their rate of uninsurance increase relative to the states which have expanded Medicaid (Kansas only state to increase number of uninsured: A how NOT to do it strategy, August 9, 2014). The “solution” backed by the Republican Party and state governors such as Kansas’ Governor Brownback, is to further decrease the number of insured people by suing on a wording issue in the Affordable Care Act (ACA, “Obamacare”) that might invalidate the federally-run insurance exchanges which have allowed low-income-but-not-desperately-poor people in states like Kansas to gain insurance coverage.

This is a bold strategy, likely to work as well as Governor Brownback’s experiment in reducing taxes on the wealthy and businesses in 2012, which left the state with an $800 million budget deficit this year (on a budget of only about $8 billion). Half was replaced with one-time funds (eg, raiding the state highway fund) and the other half, after a marathon legislative session that ended a month late, with the largest tax increase in state history. However, these were all regressive taxes, mainly a sales tax increase, that hurts the poor and middle class; the 2012 cuts stayed in place for the wealthy, so I guess in that sense it did work. Business pays less tax, and if you own your business (say, self-employed lawyers or doctors) you pay no state income tax although your employees do. Kansas spends less now than neighboring Nebraska, which has 2/3 as many people. Now if we can only get rid of those federally-sponsored exchange so even more people will be uninsured…

The World Bank report calls for universal health coverage. “The world's most disadvantaged people are missing out on even the most basic services," says one official, who adds that a “... commitment to equity is at the heart of universal health coverage.” The report said that 17% of people were pushed into poverty (<$2/day) and 6% into “extreme poverty” (<$1.25/day) by the cost of emergency health care. Few Americans make anywhere near that little, but the cost of living, and of health care, is much higher and the same trend exists here; medical expenses are the largest cause of personal bankruptcy (see Fox Business’ 2014 report).

“As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says another World Bank official, commenting on the study. Of course, if a country, such as the US, does NOT make a commitment to universal health coverage, this is not a problem.

Except, of course, for the people without health care.

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