Barriers to Adequate Health Care for Poor Cited

The health of poor people deteriorates if they are required to pay, even partially, for their medical care, yet government agencies claim their cost-cutting measures are successful when dollars are saved, a health researcher told a gathering of physicians at UC Irvine Saturday.

Any “barrier to care”--such as payment by the poor, bureaucracy or long lines--that is intended to reduce the cost of providing health care to the poor “runs the risk of deleterious health effects,” said John Ware, summarizing a Rand Corp. study on the effects of cost-cutting measures on health.

“That’s an important message that’s being lost,” added Ware, senior research psychologist with Rand and adjunct professor of medicine and public health at UCLA. When government agencies whittle away at the cost of care for the medically indigent, they measure success in dollars saved, without consideration for the health of the poor involved, he said.

Call for National Policy

Ware spoke to the annual meeting of the Society for Research and Education in Primary Care Internal Medicine’s Southwest region. The group’s topic was “Health Care for the Poor: Falling Through the Cracks.” Other speakers at the session called for a national health care policy to address the medical needs of the poor.

The Rand study of four communities nationwide showed that the health of sick poor people in cost-sharing medical plans suffered, Ware said. “This should be considered by states about to require payments by the poor,” he said.

By contrast, he noted, requiring the economically advantaged to make payments for health care did not appear to have negative effects on their health, he said.

Ware said the Rand study also determined that poor patients enrolled in a health maintenance organization (HMO) in Seattle did not fare as well as the economically advantaged. While he warned against generalizing the information from the study, he said the poor enrolled in the health organization “appeared worse off,” spending more days sick in bed and suffering from more serious symptoms.

Data to Be Published

“It’s clear something entirely different is going on for the poor than the non-poor” at HMOs, he said. The data about care of the poor at the Seattle health maintenance organization has been submitted to scientific publications for review, he said.

In a panel discussion, medical instructors from Orange and Los Angeles counties discussed how the poor have suffered from recent cutbacks in assistance.

Dr. Howard Waitzkin, UC Irvine professor of medicine and sociology, offered several examples because, he said, “the wrenching, emotionally draining experience of trying to deliver care (to the poor) . . . tends to be masked” by the dry data of studies.

He spoke of a 31-year-old insulin-dependent diabetic who had been suffering severe headaches, but doctors could not order a sophisticated X-ray because Orange County’s health plan for the medically indigent would not pay for it. The man was later brought in, delirious, at UC Irvine Medical Center’s emergency room, where it was learned he was suffering from a brain tumor, Waitzkin said.

Not ‘Life-Threatening’

Another patient, a 29-year-old woman with a lump in her breast, could not have the mass biopsied to determine whether it was cancerous because her condition was not considered “life-threatening” under the county’s plan, he said. Still another woman, a diabetic with deteriorating vision, was denied laser treatment to correct her problem, and now “she’s continuing to go blind,” Waitzkin said.

Dr. Lloyd Rucker, UCI assistant professor of medicine, blasted Orange County’s health benefits for the poor, adding that San Francisco spends 10 times more on the poor, per capita, than Orange County does.

The poor suffered in 1982 when the state, facing a budget crisis, turned over to the counties the responsibility of providing for the medically indigent and gave the counties only 70% of the previous year’s funding to finance the health care, Rucker said. The problem was worsened locally when Orange County placed harsh eligibility requirements on receiving that aid, he said.

Now, debt-ridden UC Irvine Medical Center, the county’s chief provider of care for the poor, is negotiating with American Medical International, a private, profit-centered hospital chain, and Rucker said he fears care for the poor will suffer further.

Financial Criteria

Orange County is being “touted as a model because it appears to save money,” Rucker said. “But when the only criteria for success is financial, the medically indigent will suffer.”

Richard Brown, associate professor of public health at UCLA, said medical care to the indigent varies widely throughout the state. Santa Clara County “treats everyone in need and worries about the bills later,” he said. Counties with the most liberal view toward financing health care for the poor tend to own public hospitals to assure that the medical needs are met, he said.

Dr. Martin Shapiro, assistant professor of medicine at UCLA, urged doctors at the meeting to be vigilant on the issue.

“We have a duty to collect data” about the effect that cost cutbacks have on the health of the poor, he said. “If we don’t do it, no one will.”