Imagine going to a community health fair and getting a free mammogram or prostate cancer screening--and then not being able to follow up with a doctor if the test reveals a potential problem. For the nearly 46 million uninsured people living in the United States, most of them people of color, the likelihood of receiving medical advice that they cannot afford to follow is not fantasy but a daily reality.
According to The Commonwealth Fund, a private foundation that works to improve health care quality and insurance coverage, national health care spending is growing at a rate of 7% per year--faster than the U.S. economy. Many people who are unable to afford these rising rates will become one of the 16 million Americans who are considered “underinsured” because they can’t afford their co-pays and other out-of-pocket expenses.
Or, they will join the ranks of the uninsured. The Kaiser Family Foundation reports that 40% of uninsured adults do not have a regular doctor or other primary health care provider to go to for routine visits. That means no pap smears, no mammograms, no annual physicals or other preventive care. As a result, many uninsured patients are unaware that they have a medical problem until they visit the emergency room.
Racial and ethnic minorities are disproportionately affected by this absence of health care coverage. Income, Poverty and Health Insurance Coverage in the United States: 2004, a report by the U.S. Census Bureau, reveals that nearly one third of Hispanics, 20% of African Americans, 29% of American Indians/Alaska Natives and 17% of Asians lack health insurance, compared to only 11% of non-Hispanic whites.
The good news in this otherwise grim scenario is that there are many national, state and community programs that can help bridge the gap between uninsured patients and the medical care they need. Minority nurses can play a key role in helping uninsured or underinsured patients of color learn about and take advantage of these options.
“We expect our nurses and other health care staff to provide exceptional quality care,” says Sandra Haldane, BSN, RN, chief nurse for the Indian Health Service (IHS) in Rockville, Maryland. “I think it is incumbent upon nurses to know how to access other services [for patients] when need be.”
One way nurses can help close the insurance gap is to participate in local health events that target the uninsured. “Being active in the community is very important. Our chapter volunteers a lot,” says Sylvia Pelroy, RN, president of Angeles del Desierto, which is the Yuma, Ariz., chapter of the National Association of Hispanic Nurses (NAHN). Whenever Pelroy hears of an event that needs nurses--like a flu vaccination drive for the uninsured--she and her chapter members prepare to serve.
Nurses can also help uninsured patients and families locate nearby sources of free or low-cost medical care, such as free clinics and hospitals that offer charity care. According to the Association of American Medical Colleges (AAMC), major teaching hospitals provide more than half of all hospital charity care, even though they make up only 6% of hospitals nationwide. Many of these medical schools and teaching hospitals offer programs such as student-run community clinics that provide free care to low-income and uninsured patients.
As part of its Protecting America’s Uninsured program, AAMC maintains a national database, searchable by region, of teaching hospitals that provide services to the uninsured. One example is Local Access to Coordinated Healthcare (LATCH), a Durham, N.C.-based collaborative effort between Duke University Medical Center and local health agencies. LATCH’s goal is to reach uninsured Durham residents--primarily Latino families--in their homes to educate them about their health conditions and
match them to available health services.
The LATCH program has a multi-agency team of bilingual, culturally competent staff. And indeed, culturally sensitive minority nurses who work in or near a teaching hospital or low-cost clinic can do much to help bridge communication barriers and establish trust when referring uninsured minority patients to these programs. Having a nurse of color share this information could help an apprehensive minority patient be more accepting of an unfamiliar doctor or medical facility.
“While being technically competent [and] having expert critical thinking skills is important, one big component [of nursing is] always being mindful and in tune with the culture and traditions of the people you work with,” says Haldane, who is an Alaska Native and a past president of the National Alaska Native American Indian Nurses Association (NANAINA).
In addition, there are grassroots organizations and public awareness campaigns that nurses can get involved with to work toward solutions for the uninsured. For example, the Robert Wood Johnson Foundation sponsors an annual Cover the Uninsured Week in May to raise awareness of the plight of the uninsured and mobilize the nation to do something about it.
The campaign encourages the health care community to plan events to assist the uninsured--e.g., helping eligible children and adults enroll in available public health programs such as Medicaid--and to contact their members of Congress urging them to make this issue a higher priority. For Cover the Uninsured Week 2006, the foundation reports, more than 3,000 events were held coast to coast.
Sometimes, however, lack of insurance is not the only problem. In some cases, uninsured minority patients may be eligible to receive free medical care but lack access to the facilities that provide it.
The Indian Health Service, which is a federal agency, operates 48 hospitals and several hundred freestanding ambulatory care centers that will treat any patient who is a member of a federally recognized American Indian and Alaska Native (AI/AN) tribe, regardless of whether the patient has health insurance or not. “However, out of the over three million AI/AN people who live in the United States, we only provide service to about 1.8 million of them because the rest do not live near any of our facilities,” says Haldane.
Nurses in the private sector can help by making sure their AI/AN patients, particularly those who have no other insurance, know where the closest IHS facilities are, and helping them find sources of transportation to the facility, if necessary. Haldane advises nurses to be savvy about knowing which programs their own facility can and cannot provide to uninsured patients and to become familiar with their own processes for helping patients move between providers.
For example, she says, her agency sometimes contracts with non-IHS facilities to offer major care for its patients. “If one of our patients needs services that we do not provide, they are referred to the private sector if that particular service is a priority.” The IHS Contract Health Service, a program in which funds are set aside to pay for these situations, would cover those medical visits for uninsured patients.
Because advocacy by nurses on behalf of uninsured patients can only be effective if there are enough nurses to do it, the nursing shortage is another factor that is exacerbating the problem. The shortage has especially impacted uninsured minority populations who live in outlying and rural communities.
“A rural location is the only place where you have people most in need of health care services with the fewest options available to receive those services,” says Alan Morgan, chief executive officer of the National Rural Health Association (NRHA). “Recruitment and retention of rural nurses is vitally important to maintain the level of care we need in rural America.”
Morgan urges minority nurses to consider living and working in rural environments to help increase access to care and coverage for these patients. He has seen improvement in communities where nurses and other health care professionals come together to share ideas. “I would strongly encourage nurses to link up with their peers in other rural communities for education, peer support and to find good examples of what is working elsewhere,” he says.
There are more than eight million uninsured children in the United States, according to the Census Bureau. It is estimated that nearly five million of these children are eligible to be covered under an existing federal or state assistance program, but they are simply not enrolled. Here again, nurses can help close the gap by educating parents about available programs and helping them enroll their kids.
The two major federally funded programs that provide free or reduced-cost health care for children from low-income families are Medicaid and the State Children’s Health Insurance Program (SCHIP), both administered by the Centers for Medicare & Medicaid Services (CMS). Different eligibility rules apply in each state, so nurses who are knowledgeable about the regulations in their area are in the best position to help their youngest patients get signed up for coverage.
Valerie Akong, RNC, a labor and delivery nurse at Gwinnett Medical Center in Lawrenceville, Ga., estimates that over one fourth of the patients she serves are uninsured. “When we receive pregnant patients who are in labor, they are considered to be in an emergency situation, so usually Medicaid will cover the mother and child during delivery,” she says.
Because the facility where she works is not a charity hospital, Akong believes it is even more important for her to be the link that connects her uninsured minority patients and their newborns to professionals who can provide appropriate care after the patients are discharged.
“We make sure patients know the names of the clinics that are nearby and we put them in touch with social workers who can help them with their individual situations,” explains Akong, who is African American. “We also have Hispanic patients who need interpreters and I help locate them.” Her biggest challenge, she adds, is helping patients find good prenatal care. She also shares information with patients about insurance assistance programs for their children.
The Health Resources and Services Administration (HRSA) helps build public awareness of SCHIP programs by administering the Insure Kids Now campaign. Insure Kids Now provides information and resources to help nurses and other volunteers get the word out about specific programs in each state. The campaign offers posters, brochures and other educational materials in both English and Spanish for nurses to share with patients, including information for families with concerns about immigration status.
Government-funded Medicare insurance covers nearly all individuals over age 65. But before they reach that age, several million older Americans have no access to health coverage. According to the Census Bureau, about one in eight uninsured adults are the “nearly elderly”--those who are age 55 to 64.
This population requires more health care on average than younger age groups. To make matters worse, many people in this group experience being uninsured for the first time in their lives when they retire from their careers. According to the Robert Wood Johnson Foundation, the percentage of large-company retirees who continue to receive health benefits from their employers has decreased 40% over the last decade.
Nurses can help by starting or volunteering for community outreach programs that address the needs of the uninsured nearly elderly. Another option is to educate older individuals about state and national programs that are available to serve them.
For example, the Centers for Disease Control and Prevention (CDC), through its Division for Heart Disease and Stroke Prevention, funds a program that promotes heart health in low-income, uninsured and underinsured women age 40-64. Cardiovascular disease is the number one killer of American women across all races. The program, called WISEWOMAN (Well–Integrated Screening and Evaluation for Women Across the Nation), offers risk factor screening, blood pressure testing, cholesterol testing and education on nutrition and exercise.
Even after receiving medical care, uninsured patients still need to be able to afford their prescriptions, but they may not know where to go for help. This lack of awareness about prescription assistance options is not a new problem, according to Elaine Gansz Bobo, deputy vice president of the Pharmaceutical Research and Manufacturers of America (PhRMA), an industry association representing pharmaceutical and biotechnology companies. “Patient prescription assistance programs have been around for over 50 years, but people did not know these programs were out there or they did not know how to access them,” she says.
To close this knowledge gap, in April 2005 PhRMA created the Partnership for Prescription Assistance (PPA), which serves as a national clearinghouse for programs that help patients who lack prescription drug coverage. “The PPA represents over 475 public and private patient assistance programs,” Gansz Bobo says.
Since its inception, the PPA has helped match more than two million people to programs that can provide them with free or nearly free medications, PhRMA reports. They’ve built awareness in part by using bright orange “Help Is Here Express” tour buses that travel around the country and link uninsured individuals with drug benefit programs on the spot. To spread the word in communities of color, the PPA tapped popular African American talk show host and author Montel Williams to be the national spokesman for the program and launched a major advertising campaign targeted to Hispanic health consumers.
Gansz Bobo asks nurses to encourage their uninsured patients to call the PPA to see if they qualify for a program. “Language is no barrier,” she adds. “Our call center accepts calls in English, Spanish and approximately 150 other languages.”