Aug. 16, 2005 – The absence of health insurance for a growing number of families may not be as glamorous an issue as the war on terrorism, but by most estimates it is a more deadly issue. And, as usual when it comes to social ills, if the mainland United States is catching a cold, the Virgin Islands is getting pneumonia.
According to a 2003 study by the V.I. Bureau of Economic Research, 24 percent of Virgin Islanders — or 26,500 residents — are without health insurance. That is far higher than the approximately 15 percent of people nationwide who are uninsured.
Delegate Donna Christensen says the lack of affordable health care is one of the top 10 causes of early death. She cites Families USA Web site, which has a study reporting that the uninsured often don't seek health care for chronic medical conditions. (See "Families USA").
Christensen and some other leaders and researchers in the territory spoke with the Source recently about the impact a lack of adequate health insurance is having on the territory. They suggested some of the causes, and pointed to a few ways to address what they see as one of the most pressing problems facing Virgin Islanders.
Their concerns are backed up by a July analysis completed for Congress' Center on Policy and Budget Priorities by Leighton Ko, a senior fellow in health policy at the center. He wrote that infant mortality rate for births to insured mothers was 8.5 percent lower than it was for uninsured mothers, and that insured children were 5.1 percent less likely to die an early death than uninsured children.
The lack of health insurance for V.I. residents also has an impact that probably goes beyond health issues. Ko cited a California study that showed education suffers when children are uninsured. Uninsured students miss more school and their grades are lower.
Rodney E. Miller Sr., president and CEO of Roy Lester Schneider Hospital, agreed that access to health care, or lack of it, extends into issues across society.
"Access to health care is not just a health care issue –– it is an economic development issue because areas with high rates of uninsurance, like the Virgin Islands, have slower economic growth than areas with low rates of uninsurance."
Miller is quick to point to a recent V.I. study that showed 60 percent of those without health insurance are working people.
The problem of the working uninsured extends across the United States. New York Times columnist Paul Krugman wrote last year, "In most advanced countries, the government provides everyone with health insurance. In America, however, the government offers insurance only if you're elderly (Medicare) or poor (Medicaid)." Krugman noted that insurance premiums are exploding, and that he believes the system of employment-linked insurance is falling apart.
Miller is focusing his concerns on what effect the uninsured have on hospitals' ability to provide quality health care. He called the St. Thomas hospital a safety-net hospital, which he defined in a column published in the Source last year: "Unlike a private health care facility or office, a safety net hospital is mandated by law to treat anyone who comes through its doors. Notwithstanding some creative efforts at attempting to collect money from the uninsured and underinsured, our safety net hospitals realistically collect only a tiny amount of money from treating these patients."
Safety-net hospitals bear an increasing burden of providing care as the numbers of uninsured patients rise, he wrote.
Michael Burton, spokesman for Roy Lester Schneider Hospital, put a different perspective on in. "No matter what you think, we are all paying for the costs of the uninsured," he said.
This raises the point of whether health care is being rationed – more for the wealthy, less for the uninsured.
"There are numerous statistics that show that people who lack health insurance coverage are significantly less likely than people with insurance to get timely and routine care, are less likely to have a regular doctor, and more likely to forego medical treatment even when it is needed," Christensen said.
On the flip side, those who can afford good insurance may be getting too much health care. Author Don Peck wrote in The Atlantic last year: "Because neither patients nor physicians pay for them directly, expensive tests, treatments, and procedures of only marginal value are routinely ordered, and expensive new technologies that barely improve the ability to detect or treat a disease are widely and rapidly adopted. … The result is a system in which patients with insurance can order up an expensive test that is one percent more effective than a test costing one third as much — indirectly pushing health-care premiums beyond the reach of many others."
One of the reasons the health care problem is exacerbated in the Virgin Islands is that the federal government has put a cap on Medicaid funds available to residents of the territory.
Christensen has said in earlier interviews that the territory receives about $436 for each of the approximately 15,000 people eligible for federal Medicaid assistance. The national average is about $3,800 per eligible person. (See "Territories Push for More Money For Medicaid").
In June of last year, Christensen and others requested the General Accounting Office to study how the ceiling on Medicaid payments was affecting health care in the Virgin Islands. The GAO agreed to do the study, and it is expected to be completed by next month.
At the end of July, Christensen threw her support behind the Healthcare Equality and Accountability Act of 2005. She said this bill would address the disparities in health care that continue to disproportionately affect people of color. One of its key objectives is to expand health coverage to minorities.
Christensen cited these statistics concerning minorities and health care:
— On average, Hispanics, African Americans and American Indians have higher mortality rates than whites, and these death rates are particularly disparate during the most productive life years.
— Latina women who were newly diagnosed with breast or lung cancer were diagnosed in later stages and had lower survival rates than white women with the same conditions.
— African Americans are three times more likely than whites to be hospitalized for asthma and about 2 ½ times more likely to visit an emergency room with an asthma attack. This is significant because hospitalization for asthma is an avoidable admission if the condition is adequately managed.
The new Medicare Prescription Drug Coverage plan that starts at the beginning of next year may give some people some relief, but there is uncertainty of how beneficial it will be for V.I. residents.
Dr. Jacqueline Hoop-Sinicrope, a consultant of the Office of the Governor who conducted a study on the uninsured in the territory, and Kitichia C. Weekes, coordinator/director of the V.I. State Health Insurance Assistance Program, discussed these questions with the Source.
"Yes, it will benefit persons with Medicare in the territory," they said, speaking of the prescription drug plan. "Prior to this new benefit, Medicare did not pay for most prescription medications. … With the Medicare Prescription Drug Coverage, all persons with Medicare will have the opportunity to receive prescription assistance by enrolling in a Prescription Drug Plan that offers insurance coverage for prescription drugs (both generic and brand name) for a monthly premium of about $32.20 per month and a share of the costs of prescription drugs."
However, it is this monthly premium and cost sharing that has Christensen concerned.
"The cost sharing will likely be too high for many senior residents of the V.I., and the rules about qualifying for extra help will likely be too complicated and complex to figure out," she wrote. "Because the new law urges seniors to enroll online, I am concerned that the digital divide and other issues that affect computer access will serve as a barrier."
Christensen added that, although she opposed the prescription drug plan, she would work with AARP and others to assist beneficiaries as they navigate the complex system.
Hoop-Sinicrope and Weekes noted that there will be help for people in specific income categories. "Medicare will also cover 95 percent of the prescription drug costs for persons with high out-of-pocket costs (after $3,600 is spent out of pocket)," they said. Others on Medicare with lower prescription drug costs could also see significant savings, they said.
Hoop-Sinicrope has been involved in the V.I. government's effort to alleviate the problem of too few people having access to health insurance. She is working with researchers who have been looking for two years at options to expand insurance coverage here. (See "Insurance Pools Might Help V.I. Uninsured". A final report with recommendations is expected to be submitted by the end of this year.
Even with the various government efforts being made, Miller said he believes the situation will probably get worse before it gets better. The federal government is phasing in cuts in Medicaid funds over the next five years, he noted. About 4 percent of the Roy Lester Schneider Hospital budget comes from Medicaid. Miller expects that to drop instead of rising to closer parity to stateside hospitals.
The Gov. Juan Luis Hospital, also a safety-net hospital, has a Financial Investigation Unit that assists self-pay patients in finding ways to pay the hospital, including offering help in applying for Medicaid. This is part of the hospital's commitment to provide care to people regardless of their ability to pay, said Aishé Nisbett of the hospital on St. Croix.
Another way the V.I. suffers from the way present health insurance is set up is through insurance plans that are cheaper but don't cover health care on the islands, Miller said. The patient is forced to leave island to get the care.
Miller said residents of the Virgin Islands spend millions of dollars on health care outside the territory that they could just as easily receive here.
Hoop-Sinicrope cites two tacks toward making health insurance affordable to all residents — having Congress raise the Medicaid ceiling, and improving the local infrastructure for providing care with lower administrative costs.
Christensen acknowledges that all the government efforts presently being made are piece-meal efforts affecting only certain portions of the population.
"We really need to do something about getting everyone covered," she said. Hillary Clinton tried to get universal health care passed in the early 1990s when she was first lady. Of that effort, Christensen said, "People are still making fun of what she was trying to do, and she was trying to do the right thing."
Christensen said it seems unrealistic to think there will be a dramatic change in the U.S health care system, given the current balance of power in Washington.
However, more people are becoming aware that something is wrong.
Nicholas D. Kristof, another columnist for The New York Times, wrote at the beginning of this year: "If the U.S. had an infant mortality rate as good as Cuba's, we would save an additional 2,212 American babies a year."
According to the CIA Fact Book, there are 41 countries with lower infant mortality rates than the United States, and the infant mortality rate is actually going up in the United States. Infant mortality rates appear to be tied directly to how many people are insured and how they receive, in Christensen's words, "preventative and regular health care."
Dr. Beverly Banks Randall, a neonatologist at Schneider Hospital, has noted that the territory's infant mortality rate between 1999 and 2001 was about nine deaths per thousand live births. That was higher than the national average of seven deaths per thousand, but well below the rate for African Americans of more than 14 deaths per thousand. The Virgin Islands' infant mortality rate also appears to be falling.
Christensen can bring her focus from statistics to experience. She maintained a private medical practice on St. Croix from 1975 to 1996. "We would piece together medication programs using samples," she said. "We helped with medications. Sometimes, we did not accept pay." She added that sometimes patients still did not get what they needed.
People with Medicare and their family members can contact the VI SHIP offices on St. Croix at 772-7368 and on St. Thomas at 714-4354 or 340-776-8311, ext. 1005 for information and personalized counseling on the Medicare Prescription Drug Coverage. VI SHIP is federally funded by the Centers for Medicare and Medicaid and locally administered by the lieutenant governor.
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