By Simrun K. Bal, M.D.
New Hampshire Union Leader, June 15, 2020
As an internal medicine resident (a doctor undergoing advanced training and working under supervision), the current medical and economic crisis related to COVID-19 has weighed heavily on my mind. Even before the pandemic, we residents often cared for patients experiencing the systemic inequities of our current health care system.
We serve uninsured and under-insured patients who may not be able to afford, for example, the $200 out-of-pocket cost for a vial of much-needed insulin for diabetes management.
In our primary care clinics, some patients save up over months to afford a needed diagnostic test. Now, with COVID-19, we serve patients who face even greater obstacles. Losing a job, losing health insurance, and getting sick is a deadly combination that reveals underlying vulnerabilities in our health care system.
Can we utilize the current crisis as an opportunity to focus on achieving access for everyone to health care that is affordable, universal, and equitable?
In the United States, our health care system is based on employer-based coverage, for up to half of all Americans. The main origins of this practice began around World War II when wages were frozen temporarily due to inflation. Individual companies were not allowed to raise pay, so they instead attempted to distinguish themselves from other businesses by offering health insurance as a key benefit to workers.
Although it may seem that employer-based coverage was functioning well prior to the pandemic, there are clear signs that it was not. Research in 2019 demonstrated that even with employer-based health coverage, more than half of Americans still delayed or postponed suggested treatments due to cost. Furthermore, as noted in the American Journal of Public Health in 2019, the majority of Americans who file for bankruptcy due to medical debt actually have health insurance.
Now, in another historic crisis, the COVID-19 pandemic has caused millions of individuals to lose their jobs. As of early May, at least 170,000 individuals in New Hampshire — about 12% of the state’s population — have filed for unemployment. This meant that many were suddenly and shockingly removed from their health insurance plan, finding themselves without coverage or being unable to afford coverage. Our patients describe feeling as though “someone has pulled the rug out from under [their] feet.”
Congress has taken temporary measures that appear reassuring, such as providing assistance through the CARES Act as well as the Families First Coronavirus Response Act. In New Hampshire, workers who have lost their jobs in the past 60 days or who anticipate job loss over the next 60 days can apply to enroll in the ACA marketplace. Unfortunately, those unemployed workers can often only afford the least expensive “Bronze” plans, with high deductibles. Fortunately, telemedicine services are also expanding, allowing providers to reach patients in rural areas of New Hampshire who might be unable to be present for in-person care.
Although I am grateful for these tentative signs of progress, I feel concerned that the vulnerabilities of our current health care system limit the possibilities of what we can achieve with these temporary measures. Access to health care coverage shouldn’t be a benefit given by an employer only during times of prosperity.
The health of all of us depends on the health of each of us. The public good depends on protecting individuals, particularly those who are most at risk. It is for this reason that we must carefully investigate alternatives to our current health care system. This choice will be a key component of the 2020 election. Different options include a public-option healthcare plan or single-payer health care (Medicare-for-All).
With a public-option plan, Americans would have a choice between private coverage and a public option (which could be purchased by employers). Unfortunately, people would still be at risk for changes in coverage due to job loss. About 10 million Americans would also still remain uninsured, and the same complexity in payments would still be present. In contrast, Medicare-for-All would provide universal, streamlined coverage. By eliminating private insurers and lowering the cost of prescription drugs, it would actually reduce spending on health care and allow us to begin improving the quality of care. These two options represent ways in which we can challenge the health care status quo and respond to the inequalities revealed by this pandemic.
Within each challenge is an opportunity. With the challenges posed by the current pandemic, we are learning many painful lessons about the vulnerabilities in our health care system.
I encourage citizens in New Hampshire to continue to educate themselves about the U.S. health care system and proposed reforms, to pay attention to temporary policy changes, to participate in making these changes permanent, and to consider involvement in groups advocating for change.
These opinions are my own and do not necessarily reflect those of my employer.
Dr. Simrun K. Bal is an internal medicine resident physician at Dartmouth-Hitchcock Medical Center in New Hampshire. She lives in Hanover.