Cost, access to care widen the gap for the uninsured

An estimated 44 million Americans have no health insurance. There are programs in place to help them, but getting the word out is a challenge.

The medically underserved population in the United States includes 44 million people who are without medical insurance, according to estimates. Among this population are many people with chronic diseases who require periodic eye exams but do not get them because of lack of access. Another barrier among immigrants and other groups is language.

Communication is key to helping these people receive the eye care they need. This article explores the gaps in care and what ophthalmologists can do to help those in need of their care.

In an election year, it is hard not to be aware of the fact that there are 44 million uninsured people in the United States. The plight of the uninsured is likely to be cited by incumbents and challengers alike as an issue to be tackled in the coming year.

For health care providers and public health advocates, one frustrating aspect of the plight of the uninsured is that there are programs in place to assist those without insurance, but often awareness of these programs does not reach the people they are meant to serve.

“It’s often very hard for folks to find health insurance that they can afford, and it’s hard to get information on public assistance programs that can help low-income people,” said Kathleen Stoll, director of health policy at Families USA, an advocacy group for affordable, quality health care.

The uninsured are those who fall between the cracks of the nation’s health system. Uninsured people do not have coverage through their jobs or they cannot afford their share of the cost. Private-pay individual coverage is out of reach for most. Only the poorest qualify for government programs, and many low-income people do not know about these programs, said Ms. Stoll.

“It’s hard to imagine for someone who is on Medicaid to afford anything on the private side. Individual, private coverage is often unaffordable, especially for older or sicker people. For many people, there are no policies available at all,” Ms. Stoll said.

The number of uninsured people has increased in the past 3 years, Ms. Stoll said. Few options for affordable health care exist beyond employer-based coverage. For people who qualify, there is Medicare and Medicaid, but not all qualify, Ms. Stoll said. Medicaid qualifications vary by state, and some states are cutting back on the program, she said.

And even for those who qualify for Medicare, there are out-of-pocket costs that are hard for low-income people to pay. Many people on Medicare do not know that if they are low income, Medicaid can help them with these costs, Ms. Stoll said. And the new Medicare prescription drug coverage does not come close to covering all the costs of drugs, but there will be additional help for low-income people if they know to apply for it, she said.

Ms. Stoll recommended that uninsured individuals seek information to find out whether they qualify for other types of assistance. Through public programs, some with chronic illnesses or disabilities may even qualify for income assistance, she said.

“It’s always a challenge to let folks know that they might be eligible, and it’s always worth exploring. No one should assume that they won’t qualify,” she said.

To help people begin to explore the possible ways that they can secure health insurance coverage, Families USA has 50 user-friendly state “Guides to Finding Health Insurance Coverage.” The guides are available at www.familiesusa.org (click on “State Information” under Resources on the home page).

When Medicare is out of reach

For nearly a year, Phyllis Stewart, a retired nurse in Oxford, Ohio, and an EyeCare America patient, had cataracts. Her blurred vision made driving and other daily tasks difficult. “I would watch TV with binoculars to read the writing beneath the screen. I would read the newspaper with my glasses and a magnifying glass; I went everywhere with it,” she said. Mrs. Stewart knew she needed cataract surgery but could not afford it. Like many senior citizens, although she had Medicare Part A to cover her hospital expenses, she could not afford the monthly payment for Part B, which covers outpatient care. “I didn’t think I could pay for Part B. I had been going to a free clinic in our city for my medical problems, and that’s how I found out I could go to a vision clinic,” Mrs. Stewart said. At first, her local hospital tried to facilitate the surgery by including her in a low-income assistance program that would pay 90% of the surgery, but Mrs. Stewart said the surgery center did not approve the plan. She also tried to receive the surgery through one of Prevent Blindness America’s affiliates and was denied surgery because of a scheduling error. “So I finally bit the bullet to apply for Part B, but the hardest part was having to wait 6 months for the surgery,” she said. After applying for Part B, she was told the coverage would not go into effect until 6 months later, so Mrs. Stewart decided to schedule her surgery for that time. However, someone at her doctor’s office mentioned another program. “When I called to make the appointment for when my Medicare kicked in, I mentioned that I had been ready for surgery, and that’s when they said someone in the office knew about Knights Templar,” she said. Through the Knights Templar Eye Foundation, Mrs. Stewart found out about EyeCare America’s Seniors EyeCare Program. Mrs. Stewart was able to schedule the surgery immediately and had cataract surgery in her right eye in July and in her left eye in August of this year. “When that first surgery was done, the minute they rolled the head of my bed up and said ‘Open your eyes! You’re in recovery!’ I could see the two nurses at the foot of my bed, and they were clear. Just like the doctor’s pamphlet that said [the surgery is like] ‘moving the clouds away,’” Mrs. Stewart said. “That’s exactly what happened. The clouds were gone, and I could see them so clear.”

Societal costs

According to Cover the Uninsured, the uninsured include immigrants, children, minorities and retirees, as well as employed people who do not have health coverage through their employers. One-fourth of the uninsured live below the poverty level.

The percentage of non-elderly uninsured has increased from 13.7% of the U.S. population in 1987 to 17.3% in 2002, according to data cited by Cover the Uninsured. A similar percentage, 17%, receive coverage through public programs including Medicare and Medicaid.

According to 2003 Census Bureau data, almost 44 million people in the United States were uninsured in 2002, amounting to 15.2% of the total U.S. population. Most of these people are employed but receive no health benefits through their employers, according to Cover the Uninsured.

The societal costs stemming from health care for the uninsured are extensive. Care for the uninsured costs between $65 billion and $130 billion, according to an estimate by the Institute of Medicine.

Much of that cost is borne by health providers. According to data released for Cover the Uninsured Week in May, the uninsured will receive approximately $40.7 billion in uncompensated care in 2004. About 37% of that amount comes from physicians and clinics that serve low-income communities.

One of the obstacles to assisting this group of people is getting the message to them that help is available, Ms. Stoll said. To assist in raising awareness on this issue, in this article Ocular Surgery News highlights some of the programs to which physicians can refer their patients.

EyeCare America

B. Thomas Hutchinson, MD, chairman of the EyeCare America Steering Committee

EyeCare America is a public service program of the American Academy of Ophthalmology that provides access to medical eye care and examinations. Ninety percent of the care provided is with no out-of-pocket cost to the patient. The group focuses on senior citizens who are not getting the care they need despite their Medicare eligibility and people at increased risk of eye disease.

“EyeCare America targets people 65 and older who have not seen an ophthalmologist in 3 or more years and those who are at increased risk for eye disease regardless of their insurance or income,” said B. Thomas Hutchinson, MD, chairman of the EyeCare America Steering Committee.

The organization has programs that treat underserved patients with cataract, glaucoma or diabetic eye disease. In the seniors and diabetes programs, the focus is on elderly Americans. The group provides care at no cost under Medicare by waiving beneficiary copays and unmet deductibles.

“A special waiver provided to the organization through the U.S. government allows EyeCare America volunteers to waive copayments and unmet deductibles and accept Medicare as payment in full. This often results in no out-of-pocket costs for the patient,” explained Allison Neves, communications manager of EyeCare America.

The glaucoma program targets African-American and Hispanic communities since they have higher prevalence rates of glaucoma, she said.

“The EyeCare America infrastructure and volunteer ophthalmologists have the capacity to provide care for tens of thousands,” Dr. Hutchinson said. “With funding increases, our capacity to bring our message to our targeted audience significantly increases our ability to serve the underserved.”

EyeCare America operates through a network of 7,500 volunteer ophthalmologists nationwide, Ms. Neves said. Through the seniors and diabetes programs, EyeCare America volunteer ophthalmologists provide a comprehensive eye examination and up to 1 year of care for any disease diagnosed during the patient’s initial exam. The organization is funded by grants from Pfizer Ophthalmics, Alcon and the Knights Templar Eye Foundation, she said.

Prevent Blindness America

Prevent Blindness America works with numerous affiliates, chapters and other volunteer programs to provide vision screenings and patient education. Several groups target the underserved, said Betsy van Die, media relations director. Programs vary among the states and range from glaucoma screenings to eye care services for the homeless, she said. Prevent Blindness America also participates in the Sight for Students Program, funded by Vision Service Plan, which gives vouchers to low-income, uninsured children who cannot afford eyeglasses or eye care.

“We are constantly striving to reach more people. We screened more than 2 million people last year,” she said.

Although they only provide screening, volunteers follow up with patients if a potential vision problem was noted. They cannot refer patients to a particular eye doctor but can refer to one of Prevent Blindness America’s affiliates and other resources for information and referrals. There is also a financial assistance list, Ms. van Die said. No matter the person’s situation, the organization tries to find care for them.

Assistance programs

What you can do

¤ Web sites Cover the Uninsured Web site (covertheuninsuredweek.org/individuals), which has resources for finding health insurance by state and finding assistance programs. The Families USA Web site (www.familiesusa.org) has general information on health insurance under the Consumer Info section. ¤ Volunteer EyeCare America is always looking for volunteer physicians. Those interested can call 877-887-6327 or register online at www.eyecareamerica.org. Patients can call 800-222-EYES (3937). To assist in underserved areas, call the National Health Service Corps at 800-221-9393.

When a medical assistance program does not include medications, there are several industry-sponsored drug assistance programs available to people who qualify. The Pharmaceutical Research and Manufacturers of America has a directory of companies that offer assistance programs to obtain discounted or free prescription drugs (www.helpingpatients.org). Many of the programs offer a limited number of medications and have eligibility requirements. Pfizer, for example, has a program specifically for uninsured people who do not qualify for state aid.

NeedyMeds has created a similar directory. NeedyMeds has an online list at www.needymeds.com and a printed manual with information similar to PhRMA’s list. On its Web site, there is also information on state programs, and it is building a list to explain the various discount drug cards certain programs give to eligible patients.

Rx Outreach is a patient assistance program developed by Express Scripts Inc., a pharmaceutical benefit manager. Patients can apply online at www.rxassist.org to receive prescriptions for free but with an administrative fee, according to the Web site. PhRMA, NeedyMeds and Rx Outreach are also found on the Cover the Uninsured Web site at covertheuninsuredweek.org.

Beyond Medicare, Medicaid

In addition to Medicare and Medicaid, the Health Resources and Services Administration, under the U.S. Department of Health and Human Services, offers the Consolidated Health Center Program, which provides comprehensive primary care to patients regardless of income, according to its Web site. The majority of the participants, 64%, are minorities; 40% are uninsured, and 36% have Medicaid coverage, according to the Web site.

Pending legislation

Organizations such as the American Medical Association and Cover the Uninsured have made headway in Washington in raising awareness of the issue of the uninsured. There are numerous bills related to the uninsured pending in House and Senate committees, according to the Cover the Uninsured Web site.

Several bills currently in House or Senate subcommittees aim to expand health benefits or access for the uninsured. In the House, these include bills targeted to increase health insurance for children in Medicaid or state health insurance programs, proposals to expand availability of health insurance coverage, bills to increase coverage through Medicare and bills to expand access to individuals by offering tax credits.

Bills in the Senate include provisions that provide tax incentives for employers who expand their health benefits and bills that would create expert groups to work toward affordable health care coverage.

For Your Information:

• Kathleen Stoll, director of health policy, can be reached at Families USA, 1334 G St. NW, Washington, DC 20005; 202-628-3030; fax: 202-347-2417; e-mail: info@familiesusa.org; Web site: www.familiesusa.org.
• Cover the Uninsured can be reached at 1825 Connecticut Ave. NW, Suite 300, Washington, DC 20009; 202-572-2928; fax: 202-745-5109; Web site: covertheuninsuredweek.org.
• Allison Neves can be reached at EyeCare America, 655 Beach St., San Fransisco, CA 94109; 415-561-8518; fax: 415-561-8567; e-mail: aneves@aao.org; Web site: www.eyecareamerica.org.
• Betsy van Die, media relations director, can be reached at Prevent Blindness America, 500 East Remington Road, Schaumburg, IL 60173; 888-331-2020 ext. 322; fax: 847-843-8458; e-mail: info@preventblindness.org; Web site: www.preventblindness.org.

• Pharmaceutical Research and Manufacturers of America can be reached at 1100 Fifteenth St. NW, Washington, DC 20005; 202-835-3400; fax: 202-835-3414; patient assistance Web site: www.helpingpatients.org.
• NeedyMeds can be reached at P.O. Box 63716, Philadelphia, PA 19147; 215-625-9609; Web site: www.needymeds.com.
• Rx Outreach can be reached at Express Scripts Specialty Distribution Services Inc., P.O. Box 66536, St. Louis, MO 63166-6536; 800-769-3880; Web site: www.rxassist.org.
• The Health Resources and Services Administration can be reached at U.S. Department of Health and Human Services, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857; 301-443-3376; Web site: www.hrsa.gov.

References:

• Gottlieb JL. Helping low-income patients obtain prescription medications. Arch Ophthalmol. 2002;120(11): 1575-1576.
• Center for Studying Health System Change news release. Medical debt a problem for almost 20 million American families. June 30, 2004.
• HRSA’s Fiscal Year 2004 Budget – Foundation of America’s Health Care Safety Net. U.S. Department of Health & Human Services; 2004.

• OSN Staff Writer Jeanne Michelle Gonzalez specializes in practice management, regulatory and legislative topics in addition to cataract and refractive surgery.