What Happens If You Are Both Too Rich And Too Poor For Health Insurance?

After being kept up all night responding to pages, I was still half-asleep walking into Mr. Jenkins’ room for what I thought would be a routine early morning admission for new-onset seizures. From scanning through the electronic medical record, I was not expecting to encounter the unfortunate and complex array of social factors underlying his condition.

Mr. Jenkins was in his late 20s and had three children to take care of. He worked in construction as a pipefitter, a job that required him to climb and work on tall structures with minimal protective equipment. He had been doing this job to support his family since dropping out of high school at the age of 16. Upon further inquiry regarding the symptoms he was experiencing, he disclosed to me that these were not actually new-onset seizures. At the age of 19, the patient had gotten into an altercation with a neighbor and was hit in the head with a brick. Following this incident, he had suffered from recurrent seizures and was diagnosed with epilepsy. In the past, he had seen numerous doctors for his condition and had been prescribed Keppra, an antiepileptic medication which he had been taking to prevent these seizures from occurring. However, he had been experiencing side effects and stopped taking his antiepileptic medication. Subsequently, he began to experience more frequent seizure episodes, including on the job while working on an elevated platform.

When it came time to renew his contract with the construction company, he found himself out of a job due to the nature of his work. Consequently, he lost his employer-provided health insurance, and, as a result, he lost access to his medical home and access to his antiepileptic medications. To support his family, he started working odd jobs, and his income exceeded the maximal cutoff to be eligible for government-sponsored health care. Despite being above this threshold, he did not make enough money to afford private health insurance either. For some time, his only form of health care came from trips to the emergency room to receive temporary prescriptions for his seizure medication. Mr. Jenkins relayed to me that his goal from this hospital admission was to again obtain medications to control his seizures and to receive a doctor’s clearance that would allow him to return to his previous line of work so that he could have job security and receive employer-sponsored health insurance.

This patient falls into what has been referred to in health care as “the donut hole.” It is essentially the health care system’s version of a catch-22; he could not receive regular access to health care without working, and he could not get back to work without first controlling his seizure disorder with the help of the health care system and medical professionals. Understanding the gravity of this patient’s unfortunate situation led me to wonder how the health care system in a modernized nation could leave so many people without access to basic affordable health care. How has a system become so complex, convoluted, and corrupt that a person who was perfectly capable of being cured by modern medicines was denied access to a simple cure that would allow him to function as a productive member of society? This is not a problem that I can begin to fix myself or even begin to answer, but I do not feel that it is okay to dismiss these issues as “too bad so sad.” I hope to bring attention to the people who suffer from little or no access to health care, and I can only hope that moving forward, we, as a society, find solutions to these issues and make decisions that are not just based on monetary incentives.

Thankfully, I am fortunate enough to train in Austin, Texas, where residents and local government officials have elected to create a safety-net health care system to care for people such as Mr. Jenkins. The Medical Access Program (MAP), established in 2004 by Central Health, is a program that allows socioeconomically disadvantaged people who would otherwise be unable to afford health insurance a way to access health care and obtain necessary medicines via a network of CommUnityCare clinics. This program is funded by Travis County residents taxpayer dollars and serves as health insurance for residents of Travis county at or below the poverty line. In 2019, Mike Geeslin, president and CEO of Central Health, reported, “Last year Central Health funded care for 1 in 7 Travis County residents, or about 184,000 people, and we’re planning to care for more people in the years to come.”

Despite efforts via the Affordable Care Act to expand health care coverage to a larger percentage of Americans by making health insurance more affordable to the socioeconomically disadvantaged, it is estimated that 8.5 percent of Americans were still without health insurance in 2018. Local programs such as MAP are essential in supplying health care to this otherwise underserved population. However, such programs still have their limitations. Access to specialist care can be very limited, and non-emergent or elective surgeries cost-prohibitive. Continued health care reform is vital to ensure everyone has access to necessary health care so they can continue to thrive and be productive members of our society.

Vincent Fussell is a family medicine resident.

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