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Health care system is sick, but no one treatment will cure it

This article first appeared in the St. Louis Beacon, July 2, 2009 - You've seen the problem too many times in too many ways already.

Maybe you've encountered it in the doctor's office where you found yourself digging deeper into your wallet because the co-pay has doubled since your last visit. Perhaps it hit you when a catastrophic illness, such as cancer, made you lose your job and your employer-paid health insurance. Or maybe your eyes were opened after a divorce when you realized you not only had parted company with a spouse but with health benefits.

This problem may have even followed you into an auto showroom where the sticker price of a General Motors vehicle could easily read without a hint of sarcasm: "This product includes an extra $1,525 to recoup the price of health care for our workers. By the way, health benefits cost more than the steel." 

These and other experiences have made the health-care crisis real and inescapable to everyone, including President Barack Obama. The president favors universal coverage for Americans as well as giving consumers a choice between private insurers and a government-sponsored program. Already lawmakers and interest groups are lining up for or against these ideas. Obama hopes Congress will pass a bill acceptable to him before the end of the year.

The UnInsured -- no safety net in sight

The health-care crisis is really a constellation of crises, one being the growing number of uninsured. Nationwide, an estimated 47 million Americans lack health insurance.

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Cynthia Bauer, 55, of Florissant, is one of the 750,000 Missourians in that category. She learned the hard way after  a divorce a couple of years ago left her with no health insurance. She doesn't qualify for Medicaid, the federal-state health insurance for the needy, and she hasn't yet bought a policy from a private insurance company. Bauer is mostly hoping she isn't hit with a major illness before she finds a job that provides health benefits.

For now, she's a substitute teacher in the Ferguson-Florissant District, and she picks up extra money during the summer as a flutist with the Alton Municipal Band. She also relies on investment income to tide her over during the summer when school is out.

Bauer says, "Divorce made me lose my health care. I'm completely lost. I need all of my earnings to cover bills, and I don't have enough left for health insurance."

She thinks state and federal lawmakers could help in the short term by allowing people to do volunteer work in exchange for credits they could use to access the health system as needed.

The Unemployed -- No Job, no insurance

Darryl Moore, 53, of north St. Louis, doesn't know Bauer, but he might think she's lucky: At least she's able to work and decide whether to pay for health care. In 2007, doctors found a cancerous tumor lodged near Moore's liver. He eventually had to quit work and so lost his health insurance. He now collects disability and relies on Medicaid. That's not a good solution, he says, because he has to pay $400 out of pocket before the health insurance assistance kicks in.

"My disability payments aren't enough, so it's a real struggle," Moore says. As a vocational counselor, he used to help people who had left their jobs due to a disability and were trying to get back into the workforce.

"A lot of people like myself," he says with a chuckle. "I still have side effects. But I'm blessed that I have been cancer-free."

Life-saving drugs -- at a higher and higher cost

Moore didn't talk about the cost of drugs to treat his cancer, but the cost of prescription medicine is a central part of the debate over health care. Dr. Steve Miller, chief medical officer at St. Louis-based Express Scripts, sees generic medicines as one solution to lowering costs and producing better medical outcomes.

Plenty of short-term measures are available that could reduce costs and improve outcomes immediately, says Miller. These include shifting to generic drugs where appropriate; relying more on a mail-order pharmacy delivery; and shifting to electronic prescriptions, which involves sending prescriptions directly to pharmacies to cut down on prescription errors blamed for the 7,000 deaths a year.

He wants the Food and Drug Administration to clear the way for doctors to use generic equivalents for some biologic drugs, such as insulin. Shifting to generic versions of just four biologic drugs would save Americans about $71 billion over the next 10 years, Miller says.

Along with many lawmakers, including Rep. JoAnn Emerson, R-Cape Girardeau, Miller supports a measure by Rep. Henry Waxman, D-Calif., to give the Food and Drug Administration authority to approve generic versions of costly biologic drugs. The Federal Trade Commission said last month that that authority would offer a way to bring lower-priced biotechnology drugs to the market.

In addition, Miller argues that $42 billion could be saved each year if consumers had access to generic versions of traditional drugs or pills taken by mouth.

Of course, Miller's recommendations aren't going to appeal to everyone with a stake in the health-care debate. Drug companies might protest a more widespread use of generics, and drug stores might have something to say about a reliance on mail-order delivery.

Still, Miller believes time is on the side of Express Scripts, which he says is growing because it shows companies how to save money and produce better medical outcomes, partly through the use of generic drugs.

Miller says Express Scripts focuses not only on preventing bad outcomes but helping patients cope with illnesses. He mentions a hepatitis C medication that makes patients feel as though they have a bad flu. The drug must be taken for six to nine months to rid the body of the virus, but only about 20 percent of patients complete the treatment because of the side effects. Express Scripts has raised the level to almost 80 percent by helping patients through the side effects. Because the drug can cost about $1,500 a month, the success rate of Express Scripts has boosted its reputation for helping clients make a difference on the bottom line.

"It's becoming clear over time that the current (health-care delivery) system is not sustainable," Miller said. "But we're very upbeat. We believe Express Scripts is well-positioned to be a solution for the health-care crisis."

Insurance companies -- looking to change

One of the biggest questions in the health-care debate is the role of government. Steve Walli, CEO of United Healthcare of the Midwest, isn't sure whether a government-funded system will be part of the mix, but he personally doubts it's the answer. He says United Healthcare continues to support universal coverage, but he says a lack of competition isn't the issue.

"Competition is what we deal with every day in the current system," he says, adding that's why 165 million Americans get their health care through employers. He says physicians' groups and hospital groups constantly tell him that they can't make money under government-run programs -- Medicare and Medicaid -- and would be concerned about the reimbursement levels if the federal government competes with private insurers.

Still, Walli says some things do need to change, and he's particularly concerned with affordability. Equally important are finding and using treatments proven to work. Walli says that about half of medical practitioners don't follow evidence-based guidelines to produce the best medical outcomes possible. He's struck by studies suggesting "you're likely to have the treatment decided by your ZIP code than by the seriousness or your illness or condition."

He says, "We find 10-fold rates of variance in certain procedures being done in one market to another, but there's no 10-fold variance in the health status of the population. You ask why and I think it's just the training and the accepted practices in a community."

The Obama administration wants to end such variances by financing several studies to give doctors quick and easy access to data on treatments that work best. That system won't be up and running for a decade.

Meanwhile, Walli points to a decline in the quality of care in this state. The latest United Healthcare foundation report ranks Missouri 38th in quality of care -- a substantial drop from 26th in 1990 and 33rd in 2003. The report cited health disparities, such as tobacco use by nearly a quarter of the state's residents, a child poverty rate of 22 percent, a low public-health funding rate of $42 a person, and a high rate of preventable hospital care as factors affecting the state's ranking.

Sharing information -- finding out what works

Louise Probst, executive director of the St. Louis Area Business Health Coalition, is releasing a study on health care in Missouri later this month. There's some excitement about the work the coalition is doing because it holds the promise of bringing down the costs and improving the quality of care -- ahead of what's happening in Washington.

Probst wants to help both practitioners and consumers make better informed decisions about health by making information more transparent and accessible. Her assistant, Mary Jo Feldstein, says the study's data will be useful for health-care providers, public-health researchers and consumers. For example, a doctor wanting to refer a patient with diabetes to a specialist could use the data to determine how many times the available specialists have followed the recommended guidelines for treatment.

Public-health researchers could find out how well treatments are working, and whether physicians are managing certain medical conditions. Consumers could use the data to help them make quality and affordability decisions about health care.

"That leads to a healthier population and leads to controlling costs over time," Feldstein says.

Probst welcomes Obama's message about the urgent need for health reforms. She says many people don't realize the amount of cost shifting already taking place for health care.

"We pay for health care through premiums, through dollars we spend when we go to the doctors," she says. "We also pay for it in lower wages. We pay for it in every good or service that we purchase. All of our goods and services are more expensive because of the health-care costs embedded in the cost."

Bankruptcy -- for some, the last resort

Nathan H. Goldberg sees their faces all too often, the couples and individuals who visit his office on Lami Street to inquire about bankruptcy because they are overwhelmed by medical bills. Bankruptcies always have been common, says Goldberg, citing Thomas Jefferson, Abraham Lincoln and Walt Disney among those who took this route. But in modern times, bankruptcy stemming from medical bills is a growing phenomenon.

Goldberg talked about one case this week. The husband is an administrator at the Department of Veteran Affairs and the wife has been coping since childhood with medical problems. He earns about $40,000, Goldberg says, but adds medical bills have put the couple in a hole.

"People may have some money but not the kind that's required to cover major medical procedures," he says. "They feel embarrassed, devastated, depressed, and wonder if things are going to change because they don't see any light at the end of the tunnel. If they're sick, they really need medical help."

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.

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