Protecting health care access brings broad benefit

Bruce C. Holbrook is a certified public accountant and the president of Bruce Holbrook Consulting. (HANDOUT)

Why was a 53-year-old laborer admitted to our stroke unit? Extreme hypertension with bleeding into his brain was the diagnosis, so the why might include eating too much salty food and not taking blood pressure medications since we men are famously averse to listening to doctors and taking pills.

But the fundamental reason was that he was uninsured. Like 135,000 others in Hampton Roads, he did not make enough to afford private insurance and was not eligible for Medicaid. So doctor visits and medications to control blood pressure were just not part of his world, this being before Virginia finally voted in 2018 to accept Medicaid expansion. Prior to that, poor working age Virginians, unless disabled, pregnant or raising children, were by law ineligible for Medicaid, the health insurance which currently covers more than 1 in 4 adults and children in America.

Armistead Williams M.D. of Norfolk is a neurologist and served as stroke director at Sentara Norfolk General and Bon Secours DePaul hospitals. He is a former member of the Sentara Healthcare Medical Advisory Committee. (Jessica Jeremiah Photography)

Hospitals do not turn away uninsured sick people, but getting medical help means getting medical bills. When surveyed, nearly half of uninsured Americans said they avoided needed medical care in the previous year. When those bills do come, the uninsured face the choice between paying them and making their car payments or rent. One in 6 Virginians have credit reports showing unpaid medical bills, and those medical bills are the leading cause of personal bankruptcy in America. In an Oregon program where coverage was given by lottery, getting Medicaid insurance was shown to dramatically reduce a family’s chance of eviction. Moreover, a Johns Hopkins study found that uninsured persons treated in emergency departments were often charged “sticker price” — typically multiple times the deeply discounted charges negotiated by Medicare and private insurance —which had the perverse effect of making poor people support the health care costs of those who are better off.

So by seeking health care, uninsured people get pushed deeper into poverty. And now Medicaid, their best line of defense, is itself at risk. The why in the case of Medicaid is twofold.

First, at 9% of the federal budget (and with Social Security and Medicare untouchable), Medicaid is a target for budget hawks. Second, with the declared end of the COVID-19 pandemic on March 31, every Medicaid recipient must be requalified within 12 months. Medicaid enrollment grew rapidly during the pandemic, driving down our uninsured rate to an unprecedented 8%, and over the past three years it has been federal and state policy not to cut anyone from Medicaid rolls until the pandemic was officially declared over. Understaffed state agencies are now scrambling to update addresses and to reach out to more than 2 million Virginians and verify that they still meet guidelines. Those whose income now lifts them out of Medicaid can apply for insurance with subsidies through the Affordable Care Act, but all this takes time for submission and processing of paperwork.

“Churn” is the term for dipping in and out of Medicaid coverage as circumstances and finances change. Those of us with Medicare or private insurance can usually count on continuous coverage, but the 10% of people who used to lose Medicaid during part of any year could turn up at their pharmacy suddenly unable to pay for that next insulin dose. Since uninsured Virginians are more often in Hispanic or Black communities, lack of insurance contributes to health inequity including higher risks of dying from cancer, heart disease or stroke.

Never mistake Medicaid for an ideal health insurance: It covers fewer medicines and treatments than Medicare or private insurers and its low rate of payment often makes it hard to find doctors and mental health providers who accept it. View it rather as America’s way of underwriting a more universal bulwark against both illness and poverty. And remember that losing insurance can set off a cascade of disasters including untreated illness, eviction and bankruptcy. Furthermore, setting aside issues of justice, what is good for the health and welfare of people who live in poverty turns out to be good for the economy of everyone in our region.

Don’t look to balance state and national budgets by stripping Medicaid from the most vulnerable in our communities. Instead, increase resources for Virginia’s social services, faith-based groups and others who are working to maintain uninterrupted health insurance coverage for them. Help people who are poor stay insured, on their jobs, in their apartments and out of our stroke units.

Bruce Holbrook of Norfolk is president of Bruce Holbrook Consulting, Inc. Armistead Williams M.D. of Norfolk is a neurologist and served as stroke director at Sentara Norfolk General and Bon Secours DePaul hospitals. He is a former member of the Sentara Healthcare Medical Advisory Committee.

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