Thursday, September 24, 2009

Health Care and Indigents

Health care for the indigent is a major problem in the United States. According to the National Institutes for Health, a very large pool of individuals under age 65 are at risk of being medically indigent. A myriad of health programs for some economically disadvantaged individuals do exist, but their level of funding has fluctuated over time--and many poor individuals must rely entirely on the generosity of a relatively small number of hospitals and other providers for their care. Economic pressures on these providers as well as structural changes in the health care sector can only adversely affect the amount of charity care that they offer. It is clear that a well-planned solution to indigent care in the United States, rather than a piecemeal approach, is needed.

According to, although the provision of health care for this population is often characterized as indigent care, the population is extremely heterogeneous with only a portion of the population truly living in poverty. As well described in a recent series of six reports from the Institute of Medicine, the population includes a large proportion of working individuals who can support themselves quite satisfactorily but cannot afford the rapidly rising cost of health insurance. In this society in which health insurance is most commonly employer-based, those who work for organizations with few employees or who move from employer to employer often cannot maintain health insurance coverage. A significant portion of the population receives coverage through Medicaid or through the state Children's Health Insurance Program (SCHIP). These individuals often have limited access to care. Limited access is available to migratory farm workers, undocumented aliens, individuals between jobs and certain ethnic and racial groups.

Institute of Medicine studies have clearly documented the negative impact of the uninsured on the health of individuals and families; the negative economic consequences of inadequate healthcare for medically indigent patients on their communities; the extraordinary stresses imposed upon health providers, particularly hospitals who are providing increasing amounts of uncompensated care; and the overall cost to society of a system which focuses on providing emergency care rather than primary care for the medically indigent. A combination of demographic changes and continued rise in healthcare costs suggest that these challenges will progressively increase for the foreseeable future, according to

States have criteria in place to handle indigent health care. For example, Colorado has information on the official state website that provides instructions on qualifying for this type of health care, and it is not insurance. See more at about it at this website portal: . The State of Georgia established an Indigent Health Trust Fund in 1990 to handle those who qualify as a resident in that state:,2094,31446711_31959660,00.html. And in Texas, individual counties are responsible for indigent care.

Providing care to the medically indigent is draining the financial resources of many hospitals, according to While a unified plan has yet to emerge from Congress, several proposals are being considered. These range from expanding Medicaid to requiring that employers provide a minimum level of healthcare benefits to employees. Meanwhile, states have begun to cope with the problem on their own. Special taxes, lotteries, supplements, and universal insurance plans are among the solutions being tested. Despite these efforts, the question of who will pay for those who cannot remains largely unanswered. Historically, hospitals shifted the cost of indigent care to private payers through increased charges. But a growing number of payers that use negotiated price contracts and preferred provider arrangements are refusing to recognize and pay for hospitals' costs of providing indigent care. Payment shortfalls, caused by inadequate third-party payments, challenge hospitals to find other sources to finance uncompensated services. Three major factors have added to this burden:
--Fewer payers are willing to share in the cost of providing indigent care.
--The cost of providing care has increased significantly.
--The volume of uninsured services has grown.

According to the Savannah Business Journal, state laws vary widely as to what is defined as a community benefit that a hospital provides. Some hospitals include bad debt, un-reimbursed cost of Medicare, charity care, cash and in-kind contributions, community health improvement services, health professionals education, medical research, economic development projects and housing programs. Also, many physicians will not accept patients who are on Medicaid in those years between 18 and 65, because they “lose money on those patients. They’re not welcome there. And they refer them over to the ER of the local hospital, which compounds the situation in the ER. With Medicaid, the reimbursement to physicians is very low. Some hospitals have had no choice but to pay physicians to care for patients that have presented themselves to the hospitals in order to fulfill their responsibility as a community hospital. Patients that are indigent or “self-pay" typically have little to no funds to pay for health care, where the odds of collecting any money for services is a relatively low percentage. And, according to the Sarasota County Beat, the profile of the typical indigent care recipient is someone who has a job, but does not have insurance.

According to, there are many approaches for developing and managing healthcare programs aimed at serving the indigent population. Common problems all of these programs face are:
--Not enough funding to cover the entire indigent population.
--Limited time and staff.
--Reporting requirements.
--Administrative challenges.

Counties pay medical claims for the poor at a reduced, or Medicaid rate, but health providers are not required to bill patients, indigent or otherwise, at the lower rate, according to the Rapid City Journal. And, it's logical that an uninsured person who receives health services should not receive a discounted billing rate. If Medicaid rates or less are paid for reimbursement, then hospitals are going to have to get that money from somewhere. If a person had a catastrophic illness and could have afforded health insurance, why should everyone else have to pay for that? On balance, there should be no problem helping those who are truly poor. Everybody's got access to health care. It's just a question of who pays for it. The indigent-care system could benefit from some transparency as it could give greater opportunity for public accountability. Rising costs for indigent care place unfair burdens on those taxpayers who pay their own health costs. Large health care bills create a conflict between individual privacy and the public's right to know. Taxpayers should be able to know precisely where their money is being spent.

In the Bible, Jesus is quoted as saying that "the poor you will have with you always." Until modern times in the U.S., families and charities took care of the indigent. In many parts of the world, this is still how it works. However, now Americans feel they are more sophisticated, and mandate that the government should take care of paying for indigent health care needs. Yet, these costs still are paid for by taxes collected from American taxpayers. So, in effect, those who receive the care have it paid for by those who pay the bill and don't receive the services. The pending legislation in Congress may offer a solution, but it will be an expensive one and have long lasting detrimental economic ramifications. Unfortunately, if you get sick, you need to see a doctor or go to an emergency room. There is no way around that. Even poor people need to get and stay healthy. The solutions are tough, but necessary. Government run health care? No. A better way to help the poor? Yes. Let's figure it out before the country goes bankrupt.

Until next time. Let me know what you think.

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