Holes In Our Health-Care System?

What happens to children with chronic diseases who become adults with chronic diseases?

Over the past 2 weeks I had 2 rather disquieting experiences that demonstrate some of the flaws in the U.S. health-care system (I use the term “system” only for convenience since some would question whether we actually have a health-care system). Both situations involved patients with type 1 diabetes mellitus trying to make the transition between childhood and young adulthood. One patient is a young woman, we’ll call Kathy; the other a young man, Kevin. Both reside in Southwest Missouri and both have been patients of mine since they were diagnosed with diabetes as infants. Both have just finished high school. Kevin is college-bound and Kathy is interested in becoming a phlebotomist. Both have been on Missouri Medicaid long-term; their parents work but have rather low-paying jobs without health insurance.


Kevin turned 19 last week and no longer has any health-care coverage. He could obtain high-deductible health insurance through the State of Missouri “High Risk Insurance Pool” at about $800 per month. At present, the patient and family cannot afford the insurance plan thus putting Kevin in the category of “self-pay patient.” Hospitals and clinics use this term for patients who do not have health insurance or have a plan that will not cover health-care costs for the patient at that health-care facility or will not cover a particular diagnosis or procedure. The hospitals and clinics often equate “self-pay” with “no pay,” which is not always true. Regardless, medical facilities generally require a large down payment on the estimated cost of the care before service is given (emergencies are exempt, but one had better be sure it’s really an emergency- you need a medical degree to assess whether it’s really enough of an emergency).

Back to Kevin- he and his parents now have to pay for the diabetes care and supplies out-of-pocket which comes to about $4000 per year (he is on an insulin pump and does very well with his diabetes care). He had planned to attend the University of Missouri and was set to come for freshman orientation a few weeks ago. Unfortunately, the family did the math and determined that even with loans and what scholarships Kevin could obtain, the college costs and the health-care costs were beyond them. Ironically, had he gone to “Mizzou,” he was eligible for a fairly decent health-care plan at about $200 per month provided by the University. So for now, Kevin will attend a local technical school with a goal of obtaining training as a radiology technician. To keep costs down, he will live at home and work part-time. The only good thing about all of this is that he was able to get an appointment with a diabetes specialist for routine care. It was especially good that Kevin was no longer on Medicaid as that physician, like may others in the region do not accept Medicaid patients!


Miss Kathy is a nit more complicated than Kevin. She dropped out of high school a year ago and is working at a fast-food restaurant. She intends to get her GED this summer and is interested in becoming a phlebotomist. She is 17 and still on Missouri Medicaid. She has a great primary care physician in the Joplin area who is not afraid of Mediciaid patients. I saw Kathy in clinic the other day and recommended that she transfer to adult diabetes care since she is a young adult. I gave the family the names of several endocrinologists in the Springfield, Missouri area that I know and suggested the family set up a routine clinic visit with one of the physicians. I heard back from the family today that neither physician is accepting any Medicaid patients.

I could have called the physicians and begged them to take the patient but I was not in the mood for begging. I contacted a phycisian in the Joplin, Missouri area (closer for the family than Springfield, Missouri) who is an endocrinologist and she cheerfully agreed to see the patient. The Mediciaid coverage will run out in about 16 months. I hope that by then the patient will have a job with good health coverage.

What is my point?

I don’t mind spending the time to help sort things out for my patients but it’s getting irritating how difficult it is becoming. Medicaid patients are clearly “second class” citizens in the eyes of most health-care providers and medical institutions. Even at my academic medical center, it is a well-known “secret” that many attending physicians will not see Mediciad patients except in their resident physician teaching clinics. Not even professors are immune to class bias.

What is the problem?

There are lots of problems with the U.S. health-car system but one of the most serious is that physicians are not taking the “high road” in the care of patients with no insurance, or even worse, Medicaid. We as physicians have a reponsibility to care for patients whatever their health insurance status. For sure, Mediciad is a very bad system but that’s a different issue than providing patient care. We also need to consider the long-term costs of not providing high quality medical care to patients with chronic diseases, regardless of ability to pay; for example, as I discussed in an earlier entry, the costs of paying for the treatment of preventable diabetes complications, is much greater than just preventing them! What a mess we have.  In a future entry, I will attempt to offer some simple solutions to our health-care chaos.

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