If area hospitals become overrun with people suffering from COVID-19, medical professionals will begin to triage patients to assess how to allocate potentially scarce resources like ventilators.
But a kind of triage – originating from the French “trier” or “to sort” – already happens outside the hospital as the uninsured and underinsured often elect to avoid medical care, fearful of huge debts.
During an outbreak of contagious disease, that can have significant consequences for those individuals as well as on the community as a whole.
The U.S. Census Bureau found that in 2014-2018, about five percent of East Lansing residents did not have health insurance, leaving them medically and economically very vulnerable.
But a much larger percentage may be left vulnerable by the problem of being underinsured. While many people in East Lansing have insurance, not everyone has good or quality insurance that adequately covers emergency room visits, imaging, and expensive medications.
Insurance Gaps Become Vivid Public Health Problems During Epidemics
What leaves some people uninsured? Many without insurance make slightly above the cutoff limit for Medicaid – 133 percent of the federal poverty line – and struggle to afford insurance. Low health literacy and low educational achievement also correlate with difficulties in procuring insurance.
Residency status can also limit options. Those protected under DACA, for example, are ineligible for insurance through Medicaid or the Marketplace established by the Affordable Care Act. Refugees can receive Medicaid for only a limited time following their arrival in the U.S.
Dr. Farhan Bhatti is a physician and the CEO of Care Free Clinic, which provides “quality and compassionate medical, dental, optometry, and behavioral health care to people with limited access to the healthcare system.” In Lansing, Bhatti treats uninsured and underinsured patients from the Greater Lansing area, including patients from East Lansing.
According to Bhatti, “people in East Lansing are still victim to the industry-wide practice of high deductible plans and rising copays that put health care out of reach for all but the wealthiest among us.”
Insurance companies sometimes deny covering tests, imaging, and medication – even when a physician sees these treatments as essential to a patient’s wellbeing – in order to reduce costs.
Says Bhatti, “The shifting of costs to the consumer and the denial of care that physicians deem necessary but that insurances don’t want to pay for is something that affects all people, including residents of East Lansing.”
Underlying conditions such as high blood pressure, heart disease, and diabetes can lead to a worse prognosis for those who contract COVID-19. Things become even worse when these conditions are left untreated.
Bhatti points out that those with quality insurance face better outcomes, explaining, “Their disease hasn’t advanced as far as my patients because they’ve had access to medications that they’ve been able to afford.”
Medicaid Expansion Still Leaves Gaps
In the last decade, the Affordable Care Act allowed for the expansion of Medicaid and provided subsidies for others who purchase their insurance on the Marketplace.
Today, approximately 2,500,000 people in Michigan use Medicaid. Bhatti believes that the state of Michigan did a good job of enrolling people.
But the system is confusing, to say the least. Locally, Care Free Clinic had a cadre of volunteers “whose only job was to sit with our patients at a computer, see if they were eligible, and help them enroll,” says Bhatti.
And Medicaid has not been a golden ticket to receiving health care. Unlike Care Free Clinic, most healthcare providers give preference to patients with commercial insurance and limit the number of Medicaid patients they see.
Bhatti explains, “The state government reimburses Medicaid at such a low rate that doctors lose money on every Medicaid patient they see. Doctors have to pay their staff, their rent, their utilities, etc., and they can’t do that if they accept high volumes of Medicaid patients.” Care Free Clinic relies on philanthropic donations to make up the financial gap.
Medicaid recipients often wait months to establish care with a primary care provider, and not all are easily assessable by public transportation. Dr. Aron Sousa, the interim Dean of the MSU’s College of Human Medicine explained that the university’s health clinics accept various forms of Medicaid, but the clinics’ locations on Hagadorn and Service Roads are difficult to reach for those dependent on public transportation.
If Medicaid recipients need to see a specialist, the problem is even worse. For example, no board-certified physicians in the Greater Lansing area who specialize in dermatology and neurosurgery accept Medicaid outside of emergency care. Alliance Obstetrics and Gynecology, one of East Lansing’s largest women’s health centers, recently stopped accepting new patients who use Medicaid.
Ingham County residents can opt to use a plan sponsored by Molina Healthcare, but no doctors in the area accept the insurance. Some Molina-insured patients are traveling for care to Southeast Michigan – now the epicenter of the state’s health emergency.
Insuring Students Isn’t So Simple
Students, post-doctoral researchers, and contingent faculty at MSU can face many challenges to obtaining insurance, posing public health risks unique to a university town.
Those under the age of 26 are able to remain on a parent’s insurance through the provisions in the Affordable Care Act, and other MSU students can purchase the Student Health Insurance Plan (SHIP), which provides Blue Care Network Insurance, but that currently costs $1,896 per year.
MSU automatically enrolls international students, medical students, and veterinary students in insurance, however, international students are currently able to opt out and purchase their own insurance privately, and this exception has led to international students being underinsured.
According to MSU Human Resources, “international students with private coverage have experienced financial hardship and barriers to health care access, resulting in threats to academic success and student wellbeing.”
MSU will no longer permit international students to purchase insurance privately beginning with the Fall 2020 semester, but some are currently relying on private insurance that may not cover all COVID-19 related treatments.
Moreover, international students may be unsure of how to navigate the U.S. health care system, particularly if they hail from a country that has universal health care.
Graduate students at MSU employed as teaching assistants receive Blue Care Network insurance as part of their contracts. While many research assistants receive the same insurance, they are not guaranteed the same benefits promised in the contract negotiated by the Graduate Employees Union.
Graduate students not employed by the university can face major insurance gaps. They can purchase the Student Health Insurance Plan (SHIP), but, again, it currently costs almost $2,000 a year.
One former MSU graduate student recalled to ELi how she was able to find hourly work on campus after her department stopped providing funding. For her – as is the case with many grad students – it was tough to come up with that nearly $2,000 lump sum.
She turned to the ACA Marketplace for insurance, and she believes that the insurance she found was quality, but, she notes, she “had no pre-existing conditions nor did I need to see any specialists at that time.”
Some post-doctoral researchers and contingent (adjunct) faculty receive medical insurance from the university, but many don’t. They can buy into SHIP, but many seem unaware that they are eligible or can’t afford it.
All these gaps in insurance mean gaps in care. And that creates health risk not only for those un- and under-insured, but also for those around them during this extraordinary health emergency.