Lights! Camera! Access! (to healthcare, that is)

22 05 2010

Hi there! I’m Kelly Hu, and welcome to my blog! I’m a rising senior at Duke University, majoring in the Environmental Sciences and pursuing a Global Health Certificate.

I’ll be spending the summer interning with the non-profit organization Project Access of Durham County (PADC), which links low-income, uninsured Durham residents to specialty health care clinics, pharmacies, and laboratories in the area. PADC aims to address the inequities of our current healthcare system and reduce some of the barriers that prevent economically-disadvantaged people from accessing adequate, affordable care.

Let me first stress that inadequate access to healthcare is not just a problem in Durham: 45.7 million Americans under age 65 lacked insurance in 2008, a number that continues to rise with increasing unemployment rates and the protracted economic recession.  And while 60% of people in that age bracket receive coverage as an employer benefit, and while Medicare covers virtually all those who are 65 and older, non-elderly individuals who cannot afford insurance nor qualify for Medicaid are left without coverage—these people form the vast majority of uninsured Americans. In that vein, those with the lowest income, in any age bracket and of any race and ethnicity, are most likely to lack insurance. In fact, almost 70% of the uninsured population earns less than the federal poverty line ($22,025 for a family of four) or are near poor (have incomes between one and two times the federal poverty level).

Without insurance, people are less likely to receive preventative care, are more likely to be hospitalized for conditions that were preventable, and are more likely to die in hospitals than those with insurance. Part of the explanation for this is that slightly more than half of uninsured adults do not have a regular place to go when they are sick or need medical advice; this causes conditions to worsen and continue for longer periods of time, degrading the health and functional conditions of a large part of the American population. And without routine check-ups, silent health problems may grow into more severe conditions requiring more complicated and more expensive treatment. With regard to the latter, uninsured families are three times as likely to struggle with monthly expenses such as rent, food, and utilities (1), and the addition of medical bills—particularly in light of rising healthcare costs—exacerbates the financial problems these families face.

Medical insurance acts as a safeguard against medical debt. For a fixed monthly payment, it frees patients from paying the full cost of care and keeps household savings and assets intact. Uninsured patients, however, lack this service and are frequently charged the full cost of care, which may be two to four times what hospitals and other public programs actually pay for hospital services. Overall, uninsured patients pay for 35% of their healthcare costs out-of-pocket and are frequently at risk for amassing unaffordable medical bills.

Worsening medical conditions not only levy high financial costs for patients and their families, but on the health system as well. The inability of patients to pay for their care leads hospitals to absorb the cost, which taxpayers ultimately support; if we want to reduce the amount of money taxpayers must spend on expensive emergency and last-resort care, the key is to prevent serious conditions from developing in the first place.

So how exactly does PADC help this population? The organization acts as a safety-net provider for those who are uninsured and do not qualify for public funding, working with various physicians and other medical care providers to offer patients the specialty healthcare they need at no cost. Patients are enrolled into the program based on referrals from Lincoln Community Health Center (LHC) and must be at least 200% below the federal poverty line to qualify. Based on the information provided in enrollment interviews, qualified patients are then referred to specific clinics, to which PADC provides transportation to ensure that appointments are kept.

PADC is based on the original Project Access model developed in Buncombe County in 1995. Related work done to address inequalities in healthcare access has taken place in thirteen other North Carolina counties where additional Project Access systems have been implemented, as well as several other states: Kansas, Washington, Texas, and Michigan. The work is primarily centered on urban populations that have larger provider bases and existing safety net providers, but rural models have been developed as well. Urban and rural projects alike, however, have generated millions of dollars in donated care provided by physicians and hospitals, and have allowed the medical community to document the volume of donated care for patients who would otherwise be unable to afford it. On a national level, more than 70% of physicians report donating medical care to the uninsured, but such services continue to be overlooked as a component to the nation’s safety net services to the uninsured (Baker et al., 2005). Overall, studies have shown that Project Access and other forms of donated care have:

  • Created accountable safety net systems that improve the health of the uninsured and demonstrate significant returns on investment through reduced community costs and improved business productivity from healthier workforces.
  • Built and sustained physician-led administrative support that better organizes and celebrates physician charity care.
  • Implemented strategic planning that creates a healthcare safety net providing the full continuum of needed services to uninsured patients.
  • Established outcomes measurement systems that document the return on community investment. (Baker et al., 2005)

This summer, my work with PADC will primarily consist of enrolling patients into the program while learning how a safety net healthcare provider functions. Along those lines, I would like to examine the impact of the health care reform bill on safety-net providers, specifically in light of the expansion of Medicaid and the implementation of the American Health Benefit Exchange. Will healthcare reform adequately address the disparities in health coverage in low-income populations? If so, will healthcare reform reduce/eliminate the need for safety-net providers and donated care?

I am also hoping to work on a possible collaboration project between PADC and the Children’s Environmental Health Initiative (CEHI). CEHI is part of the Nicholas School of the Environment and is a research, education, and outreach program committed to fostering environments where all children can prosper. The project would entail mapping patients’ home addresses and clinic locations to help PADC more quickly determine to which clinics patients should be referred. To do this, I would use CEHI’s GIS (geographic information systems) software to place patients and medical clinics on a map of Durham County; PADC could then determine the proximity of patients’ homes to those clinics that address their specific medical needs, and choose the appropriate clinic.

Overall, however, I simply hope to learn more about the uninsured population. Understanding the social and economic conditions that prevent them from accessing insurance, as well as the disease patterns within this population and how they differ from those of the insured, are instrumental in building a health system that benefits the entire population. On a personal level, the project is the first opportunity that I have had to truly interact with low-income residents. From speaking with them and learning about their personal situations, I am hoping that this summer will expand my awareness of the world around me and give me a greater sense of social justice and how best to achieve it.

*all statistics taken from:

– Kelly Hu



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