The Challenge: Ensure access to affordable health care for all Tennesseans, reduce costs, eliminate health care disparities, and foster healthy lifestyles.
At the end of 2008, the United Health Foundation named Tennessee the 47th Unhealthiest State in the nation. It seems we eat too much, we smoke too much, and we don’t exercise enough. Whether you agree with this assessment or not, most of us are aware that obesity, lung cancer, and stroke are just a few of the serious and costly health problems that result from these overindulgences and inactivity. The cost of medical care could soon throw Tennessee’s healthcare system into a financial crisis. If the state does not establish some preventive measures for catastrophic illness, then all of us could end up with financial problems that far outweigh the current economic crisis. Those of us who are employed, who have good health insurance, who eat right, who exercise and regularly visit a physician have little concern about this crisis because we feel that we are not directly affected.
America is one of the wealthiest countries in the world, spending 16% of the GNP on health care. For fiscal year 2008-09, healthcare and social services made up approximately 28% of the Tennessee state budget. With these kinds of resources in the federal and state systems, no person in Tennessee should be without adequate healthcare. Yet 683,000 Tennesseans remain uninsured. These individuals often go without medical care because they lack insurance and cannot afford to take part in the system. Many others are underinsured or have recently lost jobs. Unless the federal government bails more industries out, some predict that Tennessee could see even more job losses, and along with those jobs, more employees and families without health insurance for employees and their families. Homes, cars, savings accounts, and other assets could easily be lost by individuals who have to pay enormous medical bills.
What happens to families without insurance? Usually, the first line of treatment for individuals with no regular physician is a hospital emergency room. Even if the emergency room does not admit the patient to the hospital, the patient will at least be stabilized or treated before being released. Emergency room treatment is the most expensive level of care.
Who ultimately pays for the cost for service to the uninsured? This expense is borne by everyone else who pays money into the system. In Tennessee, health care is paid for through a combination of sources: private insurance, federal and state government, local hospitals, and other neighborhood clinics that offer care to the poor and the uninsured. The large number of individuals seeking charity care is already a real burden on existing systems and could become an even larger burden if the state reduces the TennCare budget. A reduction in TennCare’s budget would require reducing the number of people enrolled, reducing enrollees’ benefits, reducing payments to providers, or some combination of all three. Reducing benefits or payments to providers simply shifts the burden of care to hospitals and private clinics, both of which will ultimately be unable to bear the burden of these unreimbursed costs. When these resources are exhausted, many Tennesseans could simply be left without medical care.
The quality of healthcare Americans receive is another significant consideration in the healthcare crisis. Quality greatly depends on an individual’s economic status, race, and ethnic origin. And whether people have insurance determines where and how often they receive care. The uninsured tend to make fewer visits to the doctor and receive very little preventive care. Many illnesses that could have been avoided or managed go untreated and often result in severe illnesses that are much more costly to treat.
Infant mortality and poor birth outcomes are two examples of preventable increased health care costs...According to the Kaiser Family Foundation “. . . the infant mortality rate for college-educated black women is higher than the rate for white women with similar education.” A study by Kimberlee Wyche-Etheridge, MD, MPH, MPHD, confirms that Nashville (Davidson County) clearly reflects this national statistic. Of 19,375 births studied, 14.1% of black births were low-birth-weight babies; Black mothers were 1.8 times more likely to give birth to a low-birth-weight baby. A low-birth-weight baby is likely to have more health problems than a normal-birth-weight child. These increased health problems are more costly at the time of birth and more costly later during childhood. And they could likely have been prevented had there been appropriate early intervention and prenatal care for the mother. Tennessee must ensure that all citizens have access to affordable healthcare regardless of ethnicity, race, or socioeconomic factors.
Increasing health costs also affect Tennessee businesses. Rising health insurance premiums present a problem. Statistics show that in 2006, only 37% of employers with 50 or fewer employees offered health insurance to their employees. And higher insurance premiums are not the only increased costs that an employer faces. An employee out on sick leave for an extended period can easily increase employer costs for an employer. There could be additional costs to hire and train a temporary employee, and if the employer has a large pool of sick employees, then the cost of health insurance for the entire group could be driven up. Increased costs could lead to lower quality insurance for all employees if the employer simply cannot keep up with rising costs.
There are also other areas that have to do with health care, but don’t look like health care even though they indirectly contribute to the healthcare crisis: Education, the lack of access to proper nutrition resulting in obesity, and the environment in which people live. Education indirectly contributes to the health care crisis because uneducated children cannot possibly be expected to take care of themselves properly let alone become healthy adults who contribute to society. For example, a pregnant teen who has dropped out of school has not received enough education to raise a baby properly. If she visits a health care professional, she may be unable to understand from the instruction she receives from that healthcare professional about medication or baby formula. Many uneducated adults face similar problems. They may not understand why they have been instructed to perform or not perform certain tasks, and this can effect long term management of diseases such as high blood pressure and diabetes.
Similarly, despite the prosperity that the most Tennessee citizens experience, many poor and underserved adults and children lack proper nutrition. Many people are unaware that the food they eat directly contributes to their bodies’ health. Easily accessible fast foods usually do not list the ingredients or calorie content in a way that the average consumer can understand. These citizens have not been taught how to properly nourish their bodies and simply do not have access to the fresh fruits and vegetables that they need in their diets. They live in the midst of poor communities where there are no grocery stores that sell fresh foods and vegetables, and many have no way to travel outside of their own communities to find them.
One prominent Middle Tennessee physician shared his story of caring for a 36-year-old female patient who presented with high blood pressure and bleeding. The patient weighed over 300 pounds and was a single mother with 10 children ranging in age from 11 months to 19 years. The family was poor and lived in government housing. The physician indicated that he could treat the high blood pressure and the bleeding, but patient compliance remained a major issue because the she had great difficulty getting around and little motivation to care for her own health. She does not have good food choices, and her lack of appropriate choices will clearly impact the lives of her children. This single mother needs more than medical treatment to deal with her overall life issues. She needs additional education, and she needs support from all sectors of the community.
Public and private schools discontinued nutrition and home economics classes years ago. Physical education classes were also discontinued, thus putting very little importance on feeding and exercising the body. The modern society in which many people now live does not encourage physical activity. There are very few inner city parks where children and parents can exercise safely, and most shopping must currently be accessed by automobile or bus. Urban planners need to be cognizant of health considerations as cities of the future are developed and constructed.
A recent study by the Centers for Disease Control listed Tennessee as one of the three most obese states in the nation. Obesity itself is not a disease covered by medical insurance but can lead to other medical problems that are covered by insurance and are very costly to treat. Insurance companies need to pay for preventive care and wellness programs so that they, the insurance companies, could save money by not having to pay for as many costly procedures on the backend. People cannot be forced to do the right thing, but participation in wellness programs could be encouraged through the use of appropriate reward systems. In the long run, refocusing on wellness rather than on sickness would benefit everyone. Without some kind of intervention, Tennessee is setting itself up for even more difficult problems down the road.
Any solution that provides adequate medical care for every citizen would have to include larger numbers of medical professionals. Will there be enough physicians and other healthcare professionals around in future years to take care of the aging population? High costs are also driving up the cost of medical education and thus reducing the number of individuals seeking careers in the health care professions. Once they are out of school, physicians are faced with a number of challenges such as long work hours, large numbers of sick people, and too few nurses. High-cost malpractice insurance and loan repayments force physicians to select areas of specialization that will yield high enough salaries to cover their accumulated debts. The profession is left with very few physicians where they are really needed, in primary care. Primary care physicians are part of the solution and are essential to overall patient care because they provide early treatment and prevention and because they coordinate treatment with needed specialists.
Why is health an important issue for Tennessee citizens? It is important because every individual wants to live a fruitful, happy, and productive life. Poor health robs people of their lives because so much time and energy is spent on their illnesses rather than on productive pursuits. Illness comes at great economic cost to individuals, to families, and to society. Time to enjoy the beauty of the life that each individual was given is lost. Time that could be spent with children and family members is lost. Time to invent that one thing that could change the course of life as we know it today, completely vanishes.
In America, actions that are necessary to resolve an issue are generally delayed until a situation becomes a major problem. It is important that people not panic and react to the health care crisis in the same manner that people reacted to the gasoline shortage after Hurricane Gustav. Health care is already in big trouble and everyone—big business, small business, state government, local government and private citizens—needs to recognize that small changes made today will truly make a difference for the future of health care in Tennessee.