Category Archives: Uninsured Individuals
Vanessa Grubbs, MD, MPH, is an assistant professor at the University of California, San Francisco, School of Medicine, and a scholar with the RWJF Harold Amos Medical Faculty Development Program. She is writing a book about what she calls the “sometimes irrational use of dialysis in America,” which will include a version of this narrative essay.
It is a Monday afternoon like any other and time to make my weekly rounds at the San Francisco General Hospital outpatient dialysis center. I push my cart of medical charts down the long aisle of our L-shaped dialysis unit and see Mr. Rojas, my dialysis patient for over a year now. He is in his mid-40s and slender, sitting in the burgundy-colored vinyl recliner. His blue-jeaned legs and sneakered feet are propped up on the extended leg rest. The top of his head shines through thinning salt and pepper hair. White earbud headphones peek through gray sideburns. He is looking intently at his Kindle, rarely glancing up at the activity around him.
I roll my cart up to his recliner, catching his eye. His right hand removes the earbuds as the left pauses his movie. He looks up at me, smiling. “Hola, Doctora. How are you?” he says with emphasis on the “are.”
“I am good. How are you doing?” I smile back at him as I grab his chart from the rack. I write down his blood pressure and pulse—both normal—and the excellent blood flow displayed on the dialysis machine. My eyes shift to his fistula, the surgically thickened vein robustly coursing halfway up his left forearm like a slithering garden snake. It is beautiful to me. Through it, Mr. Rojas is connected to the dialysis machine.
“I am good, Doctora. No problems. I feel healthy. Strong.” His brown eyes glint.
Enrollment in registered nurse (RN) programs has increased for the 13th consecutive year, according to preliminary data from the fall 2013 nursing school enrollment survey conducted by the American Association of Colleges of Nursing (AACN). But with a 2.6 percent enrollment increase from 2012 to 2013, entry-level baccalaureate nursing programs saw their lowest growth rate in five years.
Though interest in nursing careers remains strong, AACN said in a news release, many qualified individuals seeking to enter the profession can’t be accommodated in nursing programs. The preliminary data show that 53,667 qualified applications were turned away from 610 entry-level baccalaureate programs in 2013, and AACN expects that number to increase when final data are released in March.
The primary barriers to accepting all qualified nursing school applicants continue to be a shortage of faculty, clinical placement sites, and funding, AACN reports.
The 2013 survey shows stronger growth rates for RN-to-BSN programs, at 12.4 percent, as well as master’s programs (4.4 percent) and doctor of nursing practice programs (21.6 percent).
Two Robert Wood Johnson Foundation (RWJF) grantees will join with George Washington University and the Wake Forest University School of Law next month to present a health policy forum on safety net programs that serve low-income and uninsured patients.
The Washington, D.C. event will feature Mark A. Hall, JD, and Sara Rosenbaum, JD—both recipients of RWJF Investigator Awards in Health Policy Research and co-editors of a new book, The Health Care Safety Net in a Post-Reform World.
The forum, which will take place October 17 from 10 am to 12:30 pm at George Washington University, will also feature experts from the Commonwealth Fund, the Hastings Center and elsewhere.
In many communities it is challenging to provide care for patients without insurance or with Medicaid, especially if they have complex or urgent health care needs. Getting approval for a diagnostic test or a timely appointment with a specialist - if it’s to happen at all - often requires several phone calls to empathic colleagues, cashing in on favors, and extensive coordination to make it all happen.
With a small pool of specialty physicians providing care for uninsured and underinsured adults, there is a limited capacity to provide timely care. Wait-times for appointments are long, and this often results in fragmented care plans, disease advancement and overuse of emergency departments and hospitals.
The supply-demand mismatch may get worse as strapped states cut Medicaid reimbursement levels to physicians and as the Patient Protection and Affordable Care Act takes effect, expanding Medicaid eligibility to an additional 15 million adults. In a recent New York Times guest editorial, Killing Medicaid the California Way, Bruce C. Vladeck, PhD, former assistant vice president of the Robert Wood Johnson Foundation (RWJF) and administrator of Medicare and Medicaid from 1993 to 1997, and Stephen I. Vladeck, JD, a professor of law at American University, give a grim account of the legal and political forces that may perpetuate provider shortages and ultimately threaten the equal access mandate.
But the problem of limited access for the uninsured and underinsured may not be so bleak. In 2008, six RWJF Scholars from Yale University (Erica S. Spatz, MD, MHS; Michael S. Phipps, MD, MHS; Katherine Goodrich, MD, MHS; Danil V. Makarov, MD, MHS; Kate V. Viola, MD, MHS; and Oliver J. Wang, MD, MBA, MHS) joined a local effort to bring a program called Project Access to New Haven, CT. Project Access expands the pool of providers for the uninsured by encouraging local specialty physicians and area hospitals to donate care; Project Access employs patients navigators to coordinate care and to address patient-level barriers to care delivery.
Amy N. Finkelstein, Ph.D., M.Phil., is a 2003 Robert Wood Johnson Foundation Investigator Award in Health Policy Research recipient and a professor of economics at the Massachusetts Institute of Technology (MIT). Finkelstein gave the following interview to the Human Capital Blog as part of our ongoing Voices from the Field series. Read more about her research.
Human Capital Blog: How did you come up with the idea for this study?
Amy Finkelstein: In early 2008 I heard a story on the radio about how the state of Oregon was conducting a lottery for access to Medicaid. It was one of those once-in-a-lifetime moments in which I thought "I must drop everything and look into this right away!" and so that's what I did. This was, literally, the chance of a lifetime: the opportunity to bring the gold standard of medical and scientific research—a randomized controlled trial—to an important social science and policy question.
HCB: Why hasn’t this kind of randomized control trial study of Medicaid been done before?
Finkelstein: There have been two major impediments to doing a randomized control trial of the effects of being uninsured relative to having insurance. The first is ethical concerns regarding doing such a randomization for research purposes. In our case this wasn't an issue because the state of Oregon had decided that a lottery was the fairest way to allocate a limited number of Medicaid slots. It was doing it for policy, not research purposes. Fortunately however the state also saw the enormous potential to learn from this opportunity and generously collaborated with researchers at Harvard, MIT, Providence Health & Services, and the National Bureau of Economic Research to make this possible.
The second major impediment of course was funding. Here we were extremely fortunate to have such generous funders, including of course the Robert Wood Johnson Foundation!
HCB: What were some of the most surprising findings?