More Than Volunteering: A Story & Analysis of the Uninsured Working Poor

Christopher nauser

Abstract—In the face of the rising cost of health care in the United States, especially the cost of health insurance premiums, fewer employers are offering health insurance as a benefit of employment.  This trend is primarily being seen in lower paying, non-professional positions.  However, this portion of the population, often referred to as the working poor, earns too much to qualify for government health insurance for the poor (Medicaid).  Despite the staggering increase in the number of uninsured, little is being accomplished on the federal level to provide health insurance for these people.  And the cost of treating the uninsured free of charge not only has an impact on the health care industry, but they also have an impact on society, such as reduced productivity at work.  This paper seeks to give a first hand account of working with some of the uninsured working poor.  Additionally, this paper seeks to give an analysis of this group’s position within the health care field as well as what some states are doing to ensure that this group becomes insured and what some people are doing for them until they are insured.

It was another hot, humid mid-July Tuesday in Kansas City.  While the temperature outside was nearing 100 and would not drop below 80 until about 9 pm that night, the temperature in the operating room was right around 60, with no humidity.
“Yeah, I’m going to volunteer at the free health clinic tonight.” 
“I bet you see a lot of drug addicts and AIDS patients,” Kyle said as we were standing outside of Operating Room 5, waiting for the nurses and medical students to wheel the patient out.
I stood there, my mouth hanging open for a minute while I pinched myself wondering if he really just said that.  Kyle was one of my co-workers this past summer.  As he was a senior in college and in the midst of applying to medical school, I thought that of all people a future doctor would not be as ignorant as to make that kind of statement.  Yet when I stopped to truly reflect on what he said, I have to admit that I was just as unknowing about what to expect when I went to volunteer at the Jackson County Free Health Clinic from 6 – 9 pm for the first time in late May.

From 2005 to 2006, in the United States, the number and percentage of people without health insurance increased from 44.8 million (15.3%) to 47 million (15.8%).  Also, the percentage of people without employment-based health insurance decreased from 60.2% to 59.7%.  Additionally, in 2006, 38.3 million (12.9%) people were covered by Medicaid (health insurance for the poor), which was statistically unchanged from 2005 (DeNavas-Wait 2007).

For most people in the United States, health insurance is through one’s employer, in which the employee pays a certain amount of the premium while the employer pays the rest.  On average, in 2007, an employer paid approximately $8,900 (73%) of the $12,000 health insurance premium for a family of four (Cook, Allison 2007).  However, as seen in the statistic above, the percentage of people with employment-based health insurance is decreasing.  And this decrease is primarily occurring in lower paying, nonprofessional positions.  Yet, people in these positions do not qualify for the U.S. government’s safety net health insurance like Medicaid, because they earn too much money.  Yet they are unable to afford health insurance on their own.

It is this group of people, the working poor of America, that experience some of the most challenging obstacles in obtaining medical care (Shi, Leiyu 2005).  The working poor are unable to afford health insurance on their own not only because of the instability of their jobs and the decreased likelihood of these jobs offering employee benefits, but the income for these individuals, which is tied to the minimum wage, is shrinking.  “Adjusting for inflation, the minimum wage has decreased steadily over the past thirty years, dropping from $7.10 per hour in 1970 to $6.48 in 1980 to only $5.15 per hour in 2000.” (Shi, Leiyu 2005).

In the face of the steeply rising cost of healthcare the federal government will need to take the lead soon to provide universal coverage for the uninsured.  In a 2003 report entitled Covering The Uninsured, published in Health Affairs, it was estimated that if all of the uninsured became fully insured the cost of additional care would be between $34 and $69 billion (in 2001 dollars).  However, this would only be expected to increase total health care spending three to six percent or increase health care’s share of the gross domestic product by about one percentage point.

About 5:45 pm on the last Tuesday of May, I opened the door of the Jackson County Free Health Clinic.  The clinic was located on the third floor of the vacant doctors building next to the recently moved hospital.  Immediately, I was decked with the smell of a musty, old, and overused waiting room accompanied by the odor of stale cigarettes and sweat.
“What am I doing here?” I thought. 
However, this thought was immediately replaced by a curious wondering about the people I saw.  Most were Caucasian.  Some were skinny, others overweight.  And still some were obese, on oxygen, and used a cane to assist in the laborious walk to the connecting room for Pharmacy Assist.

I was not expecting this.

My volunteer assignment consisted of working in the Pharmacy Assist portion of the clinic.  In this part of the clinic Dr. Lindsey, the director of Pharmacy Assist, and volunteers help patients fill out the necessary paperwork to receive prescription medications from drug companies free of charge.  Additionally, generic medications which the drug companies no longer provide free of charge are dispensed.  My first night at the clinic, I shadowed an experienced volunteer, Julie, who was a third year pharmacy student of Dr. Lindsey’s at the University of Missouri-Kansas City School of Pharmacy.
The first patient, Mr. Crowler was a man about 45 and a self-employed landscaper.  After the turtle-paced walk to the Pharmacy Assist waiting room, he plunged into the chair with a long exhale.  He had been working outside all day in the heat and he looked as worn as the old jeans and gray shirt that he had on.  Coming to the clinic was the first time he was really able to sit and relax.
“What can we do for you this evening Mr. Crowler?” Julie asked.
“All I need is to pick up some medicine,” he said.
Mr. Crowler came to the clinic this evening because he was called earlier in the afternoon when his medicine, which was ordered two to three weeks previously, came in.  I was unaware that some of the pharmacy students arrived around 4:30 with Dr. Lindsey to sort, record, label, check patient charts for correct dosage and call the patients to inform them that their medicine had arrived. 
“All we need is for you to sign right here so we know you got your medicine.”
“Do you have any questions?  Is there anything else I can do for you?” Julie asked while reviewing the dosage once again.
“I think that’s it,” Mr. Crowler said.
He was off with his prescriptions for the next three months, at least from that drug company. 
Talking with Dr. Lindsey and Dr. McCandless, the director of the clinic, I found that the patients at the clinic were taking, on average in 2005, nearly 6 medications that had to be ordered through the Prescription Assistance Programs offered by most major drug companies.  The most common medications were for high blood pressure (hypertension), hyperlipidemia (such as high cholesterol), depression, diabetes, GERD (acid reflux disease), and arthritis.

A correlation is often found between one’s Socioeconomic Status (SES) and one’s health status.  “In general, SES is defined by income, education, and occupation, but the same concept is often referred to as social class in other countries.” (Shi, Leiyu 2005).  Even though there are different ways to measure one’s SES, the SES of an individual is probably one of the most used explanations for the “linkage between vulnerable populations and poor health care access and health status” (Shi, Leiyu 2005).  This generalization can be made because, according to the Kaiser Commission on Medicaid and the Uninsured, approximately two thirds of uninsured are low-income families and 61% of the uninsured are over the age of 30.  Thus, this large of majority of the uninsured working poor can be classified as having low-SES.  Indeed, in 2007 all 350 patients at the clinic were below the 200% Federal Poverty Level (FPL) (Lindsey, Cameron).   The 200% FPL is approximately $19,000 for an individual and $32,000 for a family of three.  According to the Kaiser Commission on Medicaid and the Uninsured this group of people under the 200% level run the greatest risk of being uninsured and therefore have a decreased likelihood of receiving preventative care and being hospitalized for avoidable conditions.

Because of low-SES these individuals “have fewer financial resources to maintain and promote personal health adequately” (Shi, Leiyu 2005).  For the 350 chronically ill patients at the clinic 80% had three or more chronic conditions with two-thirds having either Type I or Type II diabetes, or pre-diabetes (Lindsey, Cameron).  Indeed this was shown in an analysis of eight years of data completed by Dr. Jack Hadley, in The Journal of the American Medical Association in 2007, which found that the uninsured were less likely to receive care and more likely to have worse outcomes than their insured counterparts (Hadley 2007).

The next patient, Mrs. Williams, who was about 55, with shoulder length brunette hair and deep green eyes worked as a cashier at the nearby K-Mart.  She was not so easy to help or at least I thought so at the time. 
“What can we help you with this evening?” Julie began as usual.
“Ohh I was just needing to order some medicine,” Mrs. Williams said as she was opening the plastic grocery bag with empty medication bottles.
“Let’s see what we have here,” Julie said as she started sorting through the bottles.  Some of the bottles were small and white while others were the tall and orange with white caps. 
“The white bottles mean that we order the prescriptions for them while the orange ones mean that the we tell the dispensary that this prescription needs to be filled.” Julie explained.
After recording what needed to be ordered and what needed to be filled through the dispensary on the sheet on top of the patient file, we went back to the little office area and sat down at the computer to enter the necessary information to order the prescriptions. Before we printed the applications, however, we checked the most recent doctor’s visit dictation to ensure that the prescription had not changed.  Then, we checked for a letter from the drug company we were ordering from saying that this patient was able to receive prescription assistance for the next year.  If not, or if the letter was dated over a year, it meant that we had to see if the patient’s most recent tax return was on file so we could print a “New Patient/Renewal Application” and add a copy of tax information so we could order the prescription.
Luckily, Mrs. Williams had this letter and it was not dated over a year.  Therefore we just had to print out a reorder form.  In this case, all of the medications were from Pfizer, which did not require a signature from her for a reorder.  However, some applications/prescription requests, required patient signatures, and even tax information, or pay stubs, every time the prescription was ordered.

After shadowing for a few patients it was my turn to take the lead and have Julie follow me to ensure I was doing everything satisfactorily.  Even though I knew I had help, I was still very nervous and wanted to do everything right. 
“Mr. Walsh” I announced, in the waiting room, with a slight crack in my voice.
With a little spring, he raised up out of his chair and followed Julie and I to the Pharmacy Assist waiting room.
“How are you doing this evening?” I asked.
“Oh I’m doing pretty good, just have to get to work after I take this medicine home to my wife.” He said with a smile. Mr. Walsh was about 38, slightly overweight, with short brown hair and working as a janitor on the night shift.
“I need to order a couple of things and pick some medicine up.” He told me.
Picking up the medicine was again the easy part.  And following the normal procedure of ordering medications, I went to the computer and inputted all of the information needed and printed the application/re-order forms.  It seemed to be pretty easy and I thought I had done everything correctly and so did Julie.
      About an hour later, as Dr. Lindsey was going through the prescription requests to sign the prescriptions she stopped. “Who helped, Mr. Walsh?”.
“I did” I replied nervously, worried that she might be upset if I did something wrong. 
“Everyone makes mistakes, don’t worry it can be fixed.” She said in her very kind and gentle demeanor with a smile on her face, sensing my nervousness.  “First, this order for Advair 10/25 needs to printed again because Mr. Walsh’s patient assistance has gone over the year limit because this letter is outdated.  So you need to print a New Patient Application/Re-Enrollment form and attach the updated tax information.  Also, this prescription for the Vytorin 10/12.5 needs to be filled out on one of the order forms that is in the “shorty” file cabinet in the waiting room.” 
The prescription form that I found in the file cabinet took ten minutes to fill out because it had to be hand written and include the shipping information, the patient information, and the doctor information.  The drug company only accepted the prescription requests on these special forms, which had to be mailed in.
Because of these mistakes, I had to call Mr. Walsh and let him know that the next time he was coming to the clinic that he should bring his most recent tax return because we did not have an up to date copy.  Also, the renewal application and the special form both required his signature.  It was fortunate that he was returning the following week for a doctor’s appointment, because otherwise he would have had to make a special trip out just to sign two papers.

After making this mistake, I was adamant not to make another one, to keep everything straight.  However, even by the end of the summer there were still times that I had to stop and ask Dr. Lindsey for help, because it felt as if there were always exceptions to the rule.
Sometimes a different prescription had to be ordered because the drug company stopped providing that specific drug in their Pharmacy Assistance Program or only people who had been receiving a certain drug through PAP before a certain date could continue to order it.  This was why the wall behind the computer in the back room of the clinic was filled with typed notes, or post-it notes about the little things that each drug company did differently, and what we subsequently had to do to get the prescription order right.

I began to wonder why each drug company had their own form, paperwork, and different requirements.  It took me nearly the entire summer to start remembering all of the little things that had to be done for each drug company.  And when each patient receives prescription assistance from multiple drug companies there is too much for the patients to do and information to keep straight, especially if they are working two jobs.  I then started to wonder why the drug companies did not create a universal form for the patients to use especially since these patients did have a genuine need and this need was commonly for medications for chronic conditions like diabetes, high blood pressure, and asthma, which were seen frequently at the clinic. 

Because many of the patients who go to free health clinics are working poor and have few resources for medical care, many try to get through illnesses on their own and not seek medical assistance.  This results in decreased early detection of such diseases as diabetes and cancer (Weiss, Gregory 2006).  However, in the face of this genuine need of the working poor little is being done on a national scale or even business scale to help care for this vulnerable population.  Right now the most help being provided is on a community scale. “By far, the largest number of free health clinics today have a mission of providing care for the working poor and for the uninsured.  In many communities, these patients have been identified as being those in greatest need of medical care for acute illnesses and for chronic conditions” (Weiss, Gregory 2006).

Yet, some progress is being made on a state scale.  As of November 2007 twelve states were working on reform proposals and three states had enacted and are implementing reforms that seek to achieve near universal coverage for all state residents.  The three states were Maine, Vermont, and Massachusetts. (Kaiser Commission 2007)

The Massachusetts health reform law, passed in April 2006, required all state residents to have health insurance by July 1, 2007.  This will then be verified through a database of insurance coverage when an individual files his/her state income tax forms in 2008.  The individuals without insurance are expected to help defray the cost of the insurance by paying premiums.  However, those who earn under 300% FPL are eligible for the Commonwealth Care Health Insurance, a subsidized insurance program.  The premiums for this program are set on sliding scale dependent on household income and no deductibles, such a co-pay, will need to be paid.  And for those individuals under the 100% FPL ($9,600/year) they will be provided with subsidized comprehensive health coverage and any premiums waived.

Massachusetts is subsidizing this law through several means.  First, there are the premiums that every individual, if able to, must pay.  Second, employers who do not provide insurance for their employees are required to make a Fair Share Contribution to the state for the employees subsidized insurance.  The current estimate for a fair share contribution is approximately $295 for each employee.  Additionally, a Free Rider Surcharge will be imposed on employers who do not offer insurance and whose employees use free care.  The surcharge can range from 10% - 100% of the state’s costs of services.  Lastly, Massachusetts will be redirecting some of the public funds currently spent on “free care” through the hospitals, which is the largest source of uncompensated care in the U.S. 

According to an American College of Physicians report, in 2001 hospitals shouldered about $24 billion of the approximately $98.9 billion of total medical care received by the uninsured.  It should also be mentioned that community/free health clinics provided about $7.1 billion of uncompensated care in 2001 with the government (federal, state, and local) spending approximately $30 billion.

When considering the costs of the uninsured the direct costs, just discussed, cannot be the only ones considered.  Indeed the indirect costs due to lack of insurance are harder to estimate and calculate.  The consideration of indirect costs of the uninsured should include the societal costs reduced life expectancy, lower workforce productivity, and decreased amounts of education.  In the report from the American College of Physicians a study was cited that estimated that employers lost $61.2 billion annually in 2001 because of lost productivity or employees being absent.

Looking at the clock as I turned my car on I saw that it was 10:05 pm. This first night at the clinic was so different than what I had expected.
“So much for things finishing at nine,” I thought, turning off the loud radio and sitting there letting out a sigh while staring out the windshield at the empty parking lot.
For the additional hour that we were there, while Dr. Lindsey finished checking and signing prescriptions, I helped stuff envelopes, fax the signed prescriptions, make corrections to order forms, and file patient charts.
There was so much to keep straight and check on while taking time to sit and talk with patients and correctly order the needed medications.  Yet in the midst of the busyness of helping over 20 patients that night, everyone in Pharmacy Assist did it with a smile on their face and a willing, open heart.  The most important thing though was that they never forgot that what they were doing was for the patients, and that it needed to be right, even though no one was getting paid.

Despite a lack of exact figures, more than 50,000 individuals (Weiss, Gregory 2006) in the U.S. volunteer each year in almost 1,100 free health clinics (Lamoureux, Nicole).  “In almost all clinics, however, all volunteers work side by side without attention to the usual status gradations.  When clinics are busy, they tend to be very busy, and attention is focused on patients and patient care.” (Weiss, Gregory 2006).  A reason that I found many volunteered in the clinic was because they believe that healthcare should be provided to all people, not just those fortunate enough to have insurance.  And in the midst of the federal government failing to address this issue directly volunteers, whether physicians, nurses, pharmacists, or lay seek to address it the best way they can: volunteering their time, effort, and talents.

While I was unsure why I even began to volunteer at the Jackson County Free Health Clinic I found a passion in the work I did with the other dedicated volunteers.  Maybe this work was not important on a grand scale such as national policy change, but it was important on an individual scale. To be able to have a smile for a person like Mr. Crowler who just got off of work and came straight to the clinic to get his medicine. To be that person who shows a patient that they are not forgotten and that they are important is unforgettable.

One Tuesday night, at the beginning of August I was invited to see a musical.  Dr. Lindsey had no problem with me taking a night off from the clinic to go to this musical with friends. 
“Why do you keep checking your watch?  You checked just a minute ago.” Gina asked me. 
“I’m just thinking.” I replied, while thoughts of Mr. Crowler, Dr. Lindsey, Elaine, Julie, Eli, Lindsey and many other people filled my head.

Dr. Lindsey was right when she told me on that first apprehensive night I was there, through a slight bend of her lips: “The clinic is addicting”.

Works cited