One Patient at a Time
One Saturday a month, a close-knit team of surgeons, anesthesiologists and nurses troops into the operating suite at Kaiser Permanente Medical Center on Geary Street. Virtually everyone is clutching a tankard of takeout coffee, and most also have brought doughnuts to add to the communal pile on a corner table. The scene is boisterous and familiar, like a bunch of co-workers gathering for softball or a day at the beach.
But the kidding around subsides as soon as these volunteers change into surgical gowns and call the first patient. This is Operation Access in action, the byproduct of local health workers’ compassion for the sick poor--and deep frustration with government inaction on behalf of patients without health insurance.
Operation Access is a volunteer-based charity that provides free elective surgery to low-income working people who lack insurance and can’t afford to pay for treatment. The problems that bring them to Operation Access are minor in the grand scheme of medical crisis. Hernia repair, which takes about 15 minutes under light anesthesia, is one of the most common procedures. In each case, the patients, who run the gamut from laborers to nannies to graduate students, would be charged several thousand dollars to obtain the service privately--money they simply do not have.
Operation Access’ patients typically make between $10,000 and $25,000 a year, too much to qualify them for public assistance programs, such as Medi-Cal, the government health insurance for the very poor. At the same time, their income is too small to cover the cost of private surgical care.
Yet their problems can be disabling--even potentially lethal if allowed to fester. The list of procedures performed by Operation Access volunteers includes amputation of gangrenous toes and excision of localized mouth cancers, according to Betty M. Hong, executive director of Operation Access. The surgical teams take satisfaction in knowing they have saved patients from greater--and more costly--health problems. For their part, Operation Access patients are relieved to have found a relatively simple fix that enables them to return to work and normal life.
Such was the case with Pablo Larque, a house painter in Santa Rosa and father of two young children. Four years ago, Larque developed an umbilical hernia--a tear in the muscle wall of his abdomen.
“It started out marble-sized, but by the end it was pretty much the size of a tennis ball,” he said. “I had troubles at work because I couldn’t lift things. We paint exteriors and we have to carry big ladders, and even to carry a five-pound bucket of paint was painful.”
Larque wore a wide belt at work to try to cinch in the hernia and reduce muscle strain. But to no avail. Over time, his jobs dwindled because he couldn’t handle the heavy work. Earning only about $23,000 a year, he was struggling to make ends meet at home. On the advice of a friend, Larque sought help from the county health center in Santa Rosa, whose staff gave him Operation Access’ phone number. On June 5, his hernia was repaired at St. Rose Hospital in Hayward by volunteer surgeon Edwin Whitman.
“Dr. Whitman was wonderful,” Larque, 36, said last week. “I am fully recovered. I can pick up my kids, I can go swimming with them, and my work is going better than ever. There is no job that is too heavy for me.”
Larque’s dilemma--too poor to afford either health insurance or costly treatments--is typical of Operation Access patients, according to Dr. Douglas Grey, a thoracic surgeon at Kaiser and co-founder of Operation Access with Dr. William Schecter, chief of surgery at San Francisco General Hospital.
“If you were to try to get a hernia repair in the private market here in San Francisco, it would cost you about $5,000,” he said. “For someone making $15,000 or even $25,000 a year, that’s a joke, especially when the actual cost in materials--suture kits and the rest--is less than $100. Before Operation Access, these cases just fell through the cracks.”
Launched in 1993, Operation Access has expanded from its home base at Kaiser to 12 other Bay Area hospitals. There are now 185 medical volunteers registered with Operation Access to perform free care; the host hospitals donate supplies and operating rooms. From a handful of cases when Operation Access first began, the volunteers are now serving more than 200 patients annually. Schecter also has presented the model program at national meetings of the American College of Surgeons.The success and growth of Operation Access, however, is bittersweet to its founders. Neither Grey nor Schecter believes in volunteerism as a realistic solution to the gaps in the nation’s health-care system. And both have been dismayed by the current debate in Congress over measures to improve things for people who already have insurance, among them the proposals for a patients’ bill of rights and for the addition of prescription drug coverage to the government’s Medicare program.
“All this energy expended into drug coverage and the patients’ bill of rights totally ignores the fact that millions and millions of Americans have no insurance and no rights at all,” Grey said. Added Schecter: “The uninsured have just sort of dropped off the political radar.”
The idea for Operation Access was born in the heady days of the national health reform movement, when it seemed certain that some version of President Clinton’s Health Security Act would be adopted, guaranteeing all Americans access to medical care. Grey and Schecter intended their modest volunteer effort as a short-term, stopgap measure until federal health officials implemented a comprehensive solution.
The political process, however, did not play out so neatly. Clinton’s ambitious proposal took a partisan beating and was dead by late 1994. Congressional efforts since have been modest, the only notable success being an expansion of health insurance coverage for children. Operation Access’ patient load, meanwhile, has surged, as has the number of uninsured Americans nationally, from 36 million to nearly 43 million. That number is expected to rise still further, if the national economy continues to weaken.
And a study released last week showed that physicians are shying away from providing charity care for the poor and uninsured. The Center for Studying Health System Change, a Washington, D.C.-based organization that monitors health insurance coverage nationally, found that the proportion of doctors providing charity care dropped from 76% to 72% from 1997 to 1999.
“The outlook is very pessimistic,” said Paul B. Ginsburg, the Center’s director. “Both the deteriorating economy and the fact that the health care premiums are going up very rapidly suggest that it is going to get a lot worse.”
The relationship of the economy to health-care access is acutely visible in San Francisco, where Internet business failures and general belt-tightening in the technology industry have shrunk local tax revenue.
That reduces funding available for municipal services, including San Francisco’s extensive, storied health care “safety net” for poor and uninsured residents. Called the Community Health Network, it is nationally renowned for its flagship public hospital, San Francisco General, and network of 24 neighborhood community clinics. Community Health’s most recent budget topped $500 million for a city of fewer than 1 million residents. Yet local newspaper headlines repeatedly pound home the message of budget shortfalls, burgeoning staff vacancies at health facilities and service cuts.
Simply put, the city’s tax revenues are insufficient to keep up with the growing number of needy patients, local health officials say. Indeed, in the latest statewide survey, San Francisco emerged as the county with the highest proportion of uninsured residents: 34%. Los Angeles County came in second with 32%, according to the March 2001 report by UCLA researchers at the Center for Health Policy Research. Overall, 22.4% of California residents lack health insurance, compared to 17.4% nationally.
The numbers are discouraging, even to the most ardent health reform advocates. Some observers say congressional inaction is a byproduct of exhaustion with a problem that appears insurmountable. That feeling of helplessness is shared by the electorate, opinion polls indicate, which no longer cite health reform as a top concern.
Those who deal directly with the people behind the numbers, however, are less able to sidestep the issue. The plight of uninsured patients presents itself in different and often highly personal ways for those whose professional mission is to care for the sick.
So it was for Operation Access’ founders. In the case of Bill Schecter, it was the endless queue to which he is obligated--as surgeon-in-chief at budget-strained San Francisco General--to assign patients with non-life-threatening surgical needs. For Doug Grey, it was the maddening absence of a local charitable outlet for his skills in the members-only Kaiser system, even as he regularly saw colleagues flying off on surgical missions to foreign countries.
All of Operation Access’ physician and nurse volunteers have equally personal explanations for why they stepped forward. The pall cast by the numbers--daunting to some--is exactly what propels them back into the operating suites on Saturday mornings. To do nothing would be more stressful. “We are the first to admit that our solution is a very, very small part of the global solution,” said Grey. “But we are not going to sit on our hands and say it is for someone else to do.”
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A Snapshot of Americans Who Lack Insurance
How Many:
California: 7 million (24% of the population) lack insurance.
United States: 42.5 million (18% of the population).
Facts About the Uninsured:
* 83% include working people and their families.
* 65% earn less than $26,580 for a family of three.
* 40% have no family physician or other regular source of health care.
* 40% report going without a recommended medical test or treatment.
* The uninsured are more likely than insured patients to be hospitalized for conditions that could have been avoided, such as pneumonia and uncontrolled diabetes.
* They are more likely to be diagnosed with late-stage cancer.
Sources: Urban Institute, Kaiser Commission on Medicaid and the Uninsured
