Category Archives: Underinsured
Michael K. Gusmano is a research scholar at the Hastings Center in Garrison, New York and former president of the American Political Science Association’s Organized Section on Health Politics and Policy. After completing his PhD in political science at the University of Maryland at College Park, Gusmano was a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research at Yale University from 1995 to 1997.
The nation’s 11 million undocumented immigrants constitute a “medical underclass” in American society. [1,2] Apart from their eligibility for emergency Medicaid, undocumented immigrants as a population are ineligible for public health insurance programs, including Medicare, Medicaid, the Child Health Insurance Program (CHIP), and subsidies available to purchase private health insurance under the Patient Protection and Affordable Care Act (ACA) of 2010, because they are not “lawfully present” in the United States.  Federal health policy does provide undocumented immigrants with access to safety-net settings, such as an acute-care hospital’s emergency department (ED), or a community health center (CHC). Since 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) has required that all patients who present in an ED receive an appropriate medical screening and, if found to be in need of emergency medical treatment (or in active labor), to be treated until their condition stabilizes. CHCs such as Federally Qualified Health Centers and other nonprofit or public primary care clinics serving low-income and other vulnerable populations trace their origins to health policy that includes the Migrant Health Act of 1962. 
Linnea Windel, MSN, RN, president and CEO of VNA Health Care in Aurora, Ill., received the Illinois Primary Health Care Association’s Danny K. Davis Award last fall for her leadership of and service to the community health center movement. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2008-2011).
Human Capital Blog: Congratulations on your award! What does this mean for you and for your organization’s work?
Linnea Windel: The community health center movement (and the work that we do) reaches thousands of uninsured and underinsured people who, in most cases, wouldn’t have access to primary health care services otherwise. The award highlights the purpose of our work and the work of many.
HCB: The award is named for Danny K. Davis, a member of the U.S. House of Representatives and a champion of the community health center movement. How is VNA Health Care carrying out his mission?
Windel: When we became a federally qualified health center (FQHC) 12 years ago, we were serving 6,000 patients; this year we are on track to serve 60,000 patients. In the space of 12 years, we’ve expanded our service area and now have nine health centers in suburban Chicago. We live out the purpose of the community health center movement and the purpose of the award through the provision of care in communities with significant need.
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.
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.