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The Honolulu Advertiser
Posted on: Tuesday, May 23, 2006

Working poor often face Hobson's choice

By Laurel Johnston


To learn more about the Hawai'i Uninsured Project and efforts in developing solutions to this important concern, please visit www.healthcoveragehawaii.org.

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The faces of the uninsured here in Hawai'i are often the working poor who are one paycheck and one health condition away from disaster.

Another real-life example was brought to our attention during Cover the Uninsured Week, May 1-8, a national initiative to bring community awareness to this issue. The following story is but one of many that we hear about when the uninsured seek help from the Hawai'i Uninsured Project.

A 30-year-old college graduate working full-time is forced to leave her job due to a newly diagnosed mental health condition requiring medication and ongoing monitoring. As a result, the employer-sponsored health insurance she enjoyed while working becomes her own responsibility under a federal law called COBRA. COBRA allows an individual to pay the insurance premium out-of-pocket after leaving employment. Now dependent on a pre-tax unemployment benefit of $900 a month, she can't afford the $300 monthly cost to keep her insurance. She does not qualify for Medicaid/Quest, nor is there a cheaper insurance plan available to her.

The woman subsequently develops an unrelated medical condition that, if treated early, responds well to antibiotics. She seeks and receives primary care at a community health center and is referred to a specialist available twice a month at the community health center but who is booked for months. She keeps waiting until her appointment is a week away, but the pain from the condition has become unbearable, and now she is faced with deciding to seek treatment at a hospital emergency room or waiting, with the risk of developing a more serious chronic condition. Ultimately, she incurs a bill at the E.R. that she cannot afford to pay.

This story underscores the fact that almost anyone may become uninsured, and it illustrates that while there is a safety net that helps those without health insurance, it is insufficient to meet the myriad needs faced by uninsured people. Thirteen private nonprofit community health centers across the state annually serve 26,000 uninsured people. While some may believe this safety net is of adequate size and scope to meet all the needs of the uninsured, they are mistaken.

Public subsidies that support community health centers are inadequate to meet the needs of even the patients currently served. Meanwhile, there are about 90,000 more uninsured Hawai'i residents who remain unserved.

Further, community health centers provide a comprehensive array of primary outpatient care, but they can't begin to cover all the specialty, emergency or in-patient care that uninsured people may need.

What about charity care? Growing needs and expectations for healthcare coupled with stagnant or even decreasing reimbursement rates have left Hawai'i's acute-care hospitals with more than $500 million in uncompensated care over the past five years. This jeopardizes their ability to provide care for the insured and uninsured alike.

Additionally, private physicians also are unable to offer as much charity care as they used to because they, too, are having a difficult time making ends meet.

Throughout the month of May and until the end of this year, the Hawai'i Uninsured Project will continue to provide awareness about this issue and offer proposals to address the problem of the uninsured in Hawai'i. While government insurance programs have been recently expanded to insure more children, programs for adults target the very poor, disabled and aged, leaving the gap group of the working poor who must choose between healthcare insurance and other basic needs, like paying rent. However, as we have heard from countless individuals who face being uninsured, government and private insurance programs are only effective if we can get everyone enrolled in some type of affordable plan.

Until then, as a state and as a community, what do we want to do about Hawai'i's uninsured population? We have some immediate recommendations on how to achieve affordable health care coverage for all:

  • We need to encourage and support adequate and stable funding for our safety net providers community health centers, Native Hawaiian healthcare systems, rural health clinics, community mental health centers and acute-care hospitals.

  • We need to share our stories about the uninsured. Whether it is your personal story or that of friends and family, talk with local, state and national government officials. They need to hear from you about how this issue affects many different people and that it needs urgent attention.

  • We need to participate in wellness programs focused on increasing exercise, improving nutrition and eliminating substance abuse and tobacco use. We not only benefit as individuals; our collective action will result in reducing unnecessary costs for health insurers and healthcare providers, along with building a healthier community.

    Our ultimate wish is that when Cover the Uninsured Week comes around in May 2007, we can report that in Hawai'i we have achieved coverage for all.

    Laurel Johnston is executive director of the Hawaii Institute for Public Affairs. Also contributing to this report were Beth Giesting, executive director of the Hawaii Primary Care Association; David Peters, executive director of Hoola Lahui Kauai; and Rich Meiers, president & CEO, Healthcare Association of Hawaii. They wrote this commentary for The Advertiser.