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Looking Beyond Our Health Care Myth

"A lack of health insurance or 'good' health insurance means a lack of health care," writes Nancy Short

Not long ago, when I was working as a registered nurse in a large emergency department, a young man arrived from a highway construction site with his thumb severed below the joint. His co-workers brought the thumb along with him to our department. The man's supervisor spoke with the physician, who then proceeded to sew a flap over the stump.

The man was not insured and I found myself wondering whether his thumb would have been attached if he had insurance. I wondered because that's how it goes in our country: A lack of health insurance or "good" health insurance means a lack of health care.

Americans don't like to hear that. Many believe health insurance really isn't essential because there's a health care "safety net." I recently heard someone say on public radio that "Although there are 45 million uninsured people in America, no one is going without health care.  It is the law of the land and they can get health care."

Those of us who've seen the reality up close know that statement to be astoundingly untrue. It reflects a widespread misperception that some network exists to "take care" of the uninsured and the underinsured. 

Yes, federal law requires an emergency department to treat and stabilize you.  However, if you have diabetes, heart disease or some other chronic illness that requires regular "fine tuning," the ED is unavailable until you are in crisis. Nor will it provide you preventive care such as a physical or a Pap smear, or regular care such as chemotherapy.

County public health departments might seem like a less costly alternative, but their main purpose is to provide community services such as water safety, restaurant inspections and screening for infectious diseases.

Some Americans are lucky enough to have access to a local, federally qualified community health center -- assuming they can get an appointment with a clinician and then find a pharmacy and pay the bill for prescriptions. Similarly, some churches and other nonprofits provide "free clinics," which can be a good option but serve too few communities.

However, even for people with public insurance, notably Medicaid, our system is cracking. Last year, Tennessee enacted a cost-cutting change that allows Medicaid beneficiaries only five prescriptions per year. When I visited several rural and free clinics in east Tennessee last summer, patients requiring up to 12 medications asked me how they were supposed to pay for the "extra seven." Many ended up picking the medications that seemed most likely to keep them alive. In North Carolina, eligible persons face a waiting list to receive life-saving drugs for HIV and AIDS. So it goes across the country.

I recently left full-time nursing to help train future nurses and, this past year, to work on health care issues in Washington, D.C., for a leading U.S. senator. I learned in detail about good ideas such as "pay for performance measures" to help monitor quality, and electronic health records to improve efficiency. But I also followed with interest the contentious debate over proposed health savings accounts for individuals.

Proponents say these accounts will harness market forces to expand care for millions of people. Based on research and what I've seen personally, however, I don't see how the accounts will provide much help for countless patients with chronic illness. Patients who lack health care are likely to forego the accounts and spend their money on other needs. Or, if they do purchase basic coverage, the deductibles will be so high they'll avoid getting routine care.

This may sound like an acceptable trade-off to policy makers, particularly those who believe in market forces and avoiding "handouts" that discourage hard work. But grand policies can look very different when you're the person worrying about an asthmatic child or a spouse battling schizophrenia. As an ED nurse, I witnessed far too many uninsured patients leaving with prescriptions for critical medications when they could barely afford their bus fare home.

Health care is difficult, both in the field and in the policy arena, but the least we owe people who are struggling is to stop fooling ourselves that we are a compassionate nation where only lazy and immoral people go without health care. That is a myth we are telling ourselves to feel better. It certainly is not the "law of the land" -- unless, of course, we choose to make it so.