Table Of ContentThe Care of the Uninsured in America
Nancy J. Johnson Lane P. Johnson
●
Editors
The Care of the Uninsured
in America
Editors
Nancy J. Johnson Lane P. Johnson
El Rio Community Health Center Arizona Health Science Center
Tucson, AZ Tucson, AZ
USA USA
[email protected] [email protected]
ISBN 978-0-387-78307-9 e-ISBN 978-0-387-78309-3
DOI 10.1007/978-0-387-78309-3
Springer New York Dordrecht Heidelberg London
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To Our Patients
Preface
As the director of a Faith Based Community Health Center, I daily find myself
interacting with medically uninsured patients and their families. At our clinic, we
are blessed with wonderful staff and volunteers. We make a significant difference
in the lives of the people we serve, and I have learned that the effort also makes a
significant difference in the lives of our staff and volunteers.
As I interact each day with our patients and their families, I come away recog-
nizing that there is no individual face of poverty. Having lived my adult life rela-
tively well off financially, I am struck with how many of our patients look like my
friends and neighbors; that there is no particular ethnicity or age. Our patients look
pretty much like the rest of us.
The sobering fact is how close to the truth that may be. The difficulty of being
medically uninsured is only the tip of the iceberg. Many Americans are only a few
paychecks away from homelessness, and less than that to lose (if they ever had) their
medical insurance. For most of our patients, it is not about choice, it is about circum-
stance. Joblessness, homelessness, accident or illness, advancing age, disability, and
mental illness are all merely predisposing factors. Every day at our clinic, we count
our blessings and realize how fortunate we are to be able to provide health services,
and that it is a fine line to cross and find one’s self in need of health services.
The least we can provide is respect and caring, and we strive for that with every
interaction. It is not always easy, but respect and compassion are the real foundation
of a medical home.
As we have come to work with other organizations in our communities to address
the larger problems of the medically uninsured, we recognized that there were few
resources to help us figure out what the issues are, and how we might go about trying
to resolve them. Practically every community in the United States has to address these
issues. Rather than continuing to reinvent the wheel, we have compiled this book as
a collection of thoughts and ideas that may help get you started.
Bless you for your compassion and caring. Let us all move forward together.
Nancy J. Johnson, RN, PhD(c)
Executive Director
El Rio Community Health Center
Tucson, AZ, USA
vii
Preface
As a physician, I have been trained to take care of each person’s medical issues as
I see them, and consider the ethnic, cultural, economic, and demographic issues
primarily as they relate to the medical concerns. Even though my career has been
focused on the medically underserved. Even though I have a degree in public
health, and despite what I teach my students.
What the editing of this book has reminded me is how important it is to consider
our patients collectively if we are going to be effective in the long run. We can take
care of patients through our days, our years, our entire careers, and still not affect
the system that helps to perpetuate the conditions in which our patients find
themselves.
As a physician, one learns to compartmentalize, and at times this is a useful
strategy in taking care of patients. But it allows us to too easily separate ourselves
from our patients and their conditions, to think of them and us.
There are very few of us in the United States who are far away from the possibil-
ity of no medical coverage. That we are the only developed country that is in this
position, and over 25% of our residents are without any medical coverage insur-
ance, is shameful. It is about us, and we all must do more to correct these inequities.
There are sufficient resources in this country to accomplish the goal of health care
for everyone. What we lack as a country is sufficient political will.
Some other lessons I have learned or been reminded of in this editing process:
What we have written is a snapshot in time. The past influences the future, but
we cannot dwell on it. We have to consider what the most effective means are to
provide care to the medically uninsured, and move forward.
Among medically uninsured populations, the diversity is as significant as the
commonalities. There is no single fix.
Regardless of a patient’s background, the single most important tool we have in
taking care of the medically uninsured is the development of a medical “home”
which patients can identify as the place they can come to get care. What is a medi-
cal home? Nancy said it best. Where you are respected and cared for as the person
you are, not the circumstances that have placed you in the position you are in. I am
convinced it is from this concept that a viable system can be developed.
ix
x Preface
As Dr. Cullen’s chapter on information technology points out, what is required
is not just a new electronic system that follows the patients, but a new language that
creates and defines a system that can appropriately care for the patient. What we
design for the complexities of caring for the medically underserved can serve as
model for caring for everyone in this country.
Many innovative, bold, and wonderful solutions have been developed as local/
regional models. As communities and states we can learn from, and support, each
other. But the local models are not, by and large, self-sustaining. Ultimately, solu-
tions to the lack of medical insurance in this country will require a national perspec-
tive, and federal funding. That is part of the work we all must do, and Dr. Dalen’s
chapter points out some of the possibilities and pitfalls other countries have
experienced.
When I wonder how the system we have hasn’t already collapsed from its own
weight, I just need to look at the people working within it. Healthcare is a service
industry, and we have been blessed with professionals who understand and live the
concept of service in their daily lives, who go the extra mile for the patient despite
the vagaries, the barriers, and the sometimes mean spiritedness of the organiza-
tional infrastructure. At times I look at the ascending generation and wonder if they
have the heart, the vision, the courage, the resolve, and the tenacity to even continue
to try to weave new thread in this patchwork quilt of a healthcare system. But then
I look at the young workers at Nancy’s clinic, or my own students, and my heart is
filled again with hope.
Lane P. Johnson, MD, MPH
Associate Professor, Clinical Family and Community Medicine
Associate Clinical, Professor, Mel and Enid Zuckerman
Arizona College of Public Health
Arizona Health Sciences Center
Tucson, AZ, USA
Contents
Who Are the Uninsured? ................................................................................. 1
Howard Eng
Why Are People Uninsured? ........................................................................... 21
Nancy J. Johnson
The Culture of Poverty and the Uninsured ................................................... 35
Nancy Johnson
Health Disparities and the Uninsured ............................................................ 45
Nancy J. Johnson
Providers of Care for the Uninsured .............................................................. 63
Nancy J. Johnson
Chronic Disease and the Uninsured ............................................................... 87
Nancy J. Johnson
Medical Homes ( preferably “Health Home”) and the Uninsured ................ 109
Nancy J. Johnson
Medication Assistance for the Uninsured ...................................................... 129
Nancy J. Johnson and Janet S. Smith
Medically Uninsured Refugees and Immigrants ........................................... 145
Lane P. Johnson
Medically Uninsured and the Homeless ......................................................... 153
Jennifer Vanderleest
Care of Underserved People with Mental Illness .......................................... 161
Francisco A. Moreno and Sarah Heron
xi
xii Contents
Medically Uninsured Older Americans ......................................................... 171
Lynne Tomasa
Direct Caregivers Association: An Option for a Rapidly
Growing Aging Population? ............................................................................ 187
Judith B. Clinco
The Rural Uninsured ....................................................................................... 195
Lane P. Johnson
Dental Care for the Uninsured ........................................................................ 205
Lane P. Johnson
Uninsured Children at School ......................................................................... 217
Fran Bartholomeaux and Nancy J. Johnson
Building Community Collaborations Around Care for the Uninsured ...... 231
Nancy J. Johnson
Information Technology and Medically Uninsured ...................................... 243
Theresa Cullen
The Role of Government in Providing Health Care to the Uninsured ........ 259
James E. Dalen
Think Nationally, Act Locally ......................................................................... 271
Lane P. Johnson
Index .................................................................................................................. 279
