Healthcare Insights: As Millions Lose Health Coverage, Those Who Provide Care Suffer

On May 1st, the New York Times reported that as many as 24 million people will lose coverage under the Affordable Care Act due to the expiration of subsidies that Congress did not extend.  People simply cannot afford the increased costs. For example: “When Joyce Rena Bumbray-Graves, a 63-year-old home care worker from Woodbridge, Va., saw premiums for her husband and herself more than double, from $544 a month to over $1,300, she had to give up her insurance”.

As premiums rise to unaffordable rates, some people who don’t drop coverage altogether switch to lower priced plans which have higher deductibles, higher co-pays, and less coverage.  

In this issue of Healthcare Insights, I want to return to the subject of physician and healthcare worker well-being in relation to the intensifying vulnerability of the population they serve.  

A recent National Academy of Medicine article notes that:

“Much has been written about the likely consequences of cuts to federal health programs for patients—and rightly so, given that they are significant in scale. Importantly, attention must be paid to understand the interlinked consequences for members of the health workforce. The authors of this commentary believe there is a real risk that widespread un- and underinsurance could cause significant care challenges and moral distress for clinicians—and thereby contribute to difficulties in providing care as well as a crisis of burnout that is already straining the care system.”

Put succinctly: “Health care access and clinician well-being are two sides of the same coin.” 

It is important to understand what happens when people are uninsured or lose coverage.

The above data illustrates a major theme: people who are uninsured live their lives at great and unnecessary risk! When people lose access to the albeit fragmented but essential role and purpose of primary care, they are more likely to develop chronic, unexpected, and in many cases deadly conditions.

From the National Academy of Medicine, here are some typical vignettes of  how clinicians experience the consequence of people losing their health coverage:

• A patient with heart disease loses Medicaid coverage and can no longer afford to see her cardiologist. The cardiologist, who has a years-long relationship with the patient and her family, knows the likely consequences of an interruption in care, but can do little to help her.
• A low-income working mother brings her child to the pediatrician for a wellness visit and immunizations. However, she learns after the visit that she has failed to keep up with a new state requirement for Medicaid re-enrollment. She must choose between forgoing the essential care or receiving the care along with a bill that she and the pediatrician know she cannot pay.
• A patient with type 2 diabetes cannot afford the increased copay for Medicaid-covered services in her state. She informs her physician that she is unable to keep up with the recommended exams and testing. The patient, a mother who is the primary caretaker of her young children, is worried. She asks the physician if she will be okay if she can no longer keep up with her diabetes management.
• A community clinic that provides care for low-income families is no longer reimbursed for seeing Medicaid patients at a rate that can sustain the practice. The owner is forced to close her doors, knowing that there are few remaining options for care in the area.

Today’s crisis of the uninsured and the impact on healthcare providers has changed.  A few years ago, the common term for healthcare provider demoralization was “burnout”. Contributing factors to burnout were typically defined as working understaffed or working without the right information systems and available equipment, and working in the general environment of having to treat more and more complex patients.  As a result, providers experienced moral distress from not being able to go home after a shift knowing that one was not able to provide enough of the right care that the practitioner has spent his/her life learning to provide.

COVID-19 exposed these conditions as never before.

Today, more and more clinicians experience deeper demoralization as exemplified in the graphic below:

Many are unaware of the Dr. Lorna Breen Health Care Provider Protection Act, passed into law by the 117th Congress in March, 2022.  

The content of the law is:

“This bill establishes grants and requires other activities to improve mental and behavioral health among health care providers.

Specifically, the Department of Health and Human Services (HHS) must award grants to hospitals, medical professional associations, and other health care entities for programs to promote mental health and resiliency among health care providers. In addition, HHS may award grants for relevant mental and behavioral health training for health care students, residents, or professionals.

Additionally, HHS must conduct a campaign to (1) encourage health care providers to seek support and treatment for mental and behavioral health concerns, and (2) disseminate best practices to prevent suicide and improve mental health and resiliency among health care providers.

HHS must also study and develop policy recommendations on

• improving mental and behavioral health among health care providers,
• removing barriers to accessing care and treatment, and
• identifying strategies to promote resiliency.

Furthermore, the Government Accountability Office must report on the extent to which relevant federal grant programs address the prevalence and severity of mental health conditions and substance use disorders among health care providers.”

This is Dr. Lorna Breen for whom the federal law was named.  She was an Emergency Room physician at New York Presbyterian Hospital in New York City. She tragically took her own life on April 26, 2020.

We must recall that New York City was the epicenter of the COVID-19 pandemic at that moment.  The health system was unprepared. There were no known cures. There was no vaccine. Emergency rooms filled up. Intensive Care Units filled up, and thousands died every day.  

The population was in fear and panic.

Healthcare providers feared their own exposure to the virus and bringing the highly contagious disease home to their families.

In previous articles in Healthcare Insights, I have reported on the high suicide rates among doctors and the increasing levels of moral distress and burnout that cause doctors and other healthcare professionals to leave hospitals or leave healthcare as a profession altogether.

I have also reported on the many support systems that have developed since the pandemic to alleviate many of the stressors that doctors and their colleagues face, many of which have had success.

The pandemic accelerated levels of burnout and moral injury that health providers had faced for some time.

Yet, burnout rates, moral injury, and conditions for an increasingly demoralized workforce are increasing.

The Crisis Is Deepening

I think it is important to consider the enormity of the challenges we are facing as a nation when it comes to the burdens on our population, our healthcare practitioners, our governments, and our communities given what we know about systems failures that result in fewer people having access to high quality healthcare.

I am reminded of the commentary by Dr. Stephen Hahn, an internal medicine doctor at Jacobi Medical Center in Bronx, NY. I asked him about his personal and professional feelings about growing vaccine hesitancy, and the current promotion of vaccine hesitancy by state and federal officials. Dr. Hahn:

“He shared his vision of the destruction of vaccine availability and how public confidence in vaccines represents the destruction of the Town Square, which for him leads to a challenge to his personal conscience to act in the political and governmental space, to be responsible for speaking out. He explained: “If I am walking past the town square, the center of civic life in my community, and I see someone throwing a rock through the window of one of the churches or other houses of worship, do I stand by and do nothing because the rock was not thrown at my house of worship? Or do I act because all of the churches are in the Town Square as representations of the community and the values that we all share? And if I don’t act, how have I in my own way contributed to the destruction of the Town Square?”

“Today, what is being done to vaccines by my government is like a rock thrown through the window of a building in the Town Square. Vaccines are so close and deep to what we have been trained in. As such, I must ask: are we shirking our responsibilities as physicians when we see that the Town Square is being vandalized and we do nothing?”

“Treating one patient at a time and taking them through the steps to accept vaccines is just hard work, work we are trained to do. Taking collective action now to protect vaccine availability and to encourage vaccine acceptance is required to protect us from the next pandemic. To step into a role in collective action is a new challenge, one that we are not trained for.”  

“Acting Our Way into New Ways of Thinking” (as opposed to thinking our way into new ways of acting)

I learned the above phrase from Swedish healthcare improvement leaders.  Fundamental to successful improvement is a consciousness built on learning through action.

Dr. Hahn recognizes that he is not trained or equipped to enter the work of public discourse to influence policy. In essence, his honest self-critique suggests that by thinking or even training alone, he will not possess the skills necessary to impact the enormous world of how public policy is changed.

I am pleased to share the work of Dr. Alistair Martin, the recently appointed Health Commissioner of the City of New York.

He writes: “Since the third century AD, physician Yi He has been considered a founder of traditional Chinese medicine. In one of the most famous passages regarding Yi He, the third century BC Discourses of the States, he was asked a question that physicians still grapple with over 2000 years later: do healers have a role to play in state affairs? He responded, “The superior physician rescues the state, whereas the inferior one merely attends to the sick.” His response underscored the ancient Chinese belief that physicians and public servants shared the same purpose. In fact, the terms “physician” and “state minister” were essentially interchangeable in ancient Chinese society. Both terms described healers. Just as physicians were healers of the human body, they were also seen as healers of the body politic”. 

In the article cited here from the International Journal of Emergency Medicine, Dr. Martin discusses the great success of voter registration projects undertaken in hospitals and other healthcare settings. From the VOTE-ER project which he helped expand in Boston, we learn that:

“62% of unregistered voters haven’t registered simply because no one has ever asked them. With 83% of people in the U.S. visiting a medical facility each year, healthcare settings present a unique opportunity to change this. By integrating voter registration into patient interactions, we not only help eligible people register but also build deeper trust between providers and patients. When asked about voter registration during a visit, patients have reported feeling more deeply cared about and supported in more ways than just their health.” 

On the all-important topic of keeping people eligible for healthcare, “Dr, Martin has plans to confront this crisis: Keeping as many New Yorkers insured as possible could prove to be the main challenge of Dr. Martin’s tenure.

“This is why I’m here,” he said in a recent interview, after meeting with colleagues at a city health department clinic in Downtown Brooklyn.

For those who did not otherwise qualify for exemptions from the work requirements, Dr. Martin said he planned to partner with city officials to offer options for community service — which can satisfy the requirements, even if unpaid.

Dr. Martin has also begun thinking about how to mobilize underemployed New Yorkers to volunteer with the health department or public hospital system, as a way to keep their health insurance.

“What if the volunteering that they were doing was helping other New Yorkers stay covered on Medicaid?” he said.  

A Time To Organize

The dual crisis of Americans losing access to healthcare and the impact on healthcare providers is, as cited earlier “two sides of the same coin.”

There is always a place for important personal and localized efforts to mitigate the impact on individual patients and providers.  From these acts, we learn and expand what is successful and we spread the practices more broadly.

At the same time, it also seems clear that the systemic and growing dual crisis of loss of access to care and increasing demoralization of the workforce must be confronted at the political and policy levels.  

Dr. Alistair Martin is just one voice who is doing so much to engage the health system politically through civic engagement and challenging norms. It is an important example of what can motivate doctors to organize, tying their own personal challenges to those of their patients. Traditional union activity can help with organizing collective voice.

It must also be considered that traditional collective voices may not address the root causes of the problems doctors face.

The American healthcare crisis is at the core of healthcare workers day-to-day challenges.  

Civic engagement can define a new era of organization and learning to act our way into new ways of thinking.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.