What does a health crisis look like? See Houston

What does a health crisis look like? See Houston

By Richard Wolf, USA TODAY
June 18, 2007

HOUSTON — Ijeoma Onye awoke one day last month short of breath, her head pounding. Her daughter, Ebere Hawkins, drove her 45 minutes from Katy, Texas, to Ben Taub General Hospital, where people without health insurance pay little or nothing for treatment.

Onye, 62, waited four hours to be seen. Still, going to the emergency room was faster than getting an appointment. For that, "you have to wait months," Hawkins says.

Ben Taub is the hub of the Harris County Hospital District, a network of hospitals and care centers serving the Houston area's 1.1 million uninsured residents and hundreds of thousands more with little coverage. Here, the national statistic of 45 million uninsured people is more than a number. It's a crisis.

Nationally, more than 15% are uninsured. In Texas it's nearly 24%, the Census Bureau says, the highest percentage among the states. Here in Harris County, it's 30%, according to state figures, the highest rate among the nation's top 10 metropolitan areas.

As the Houston area struggles to deal with a rising tide of uninsured, it offers a lesson for the nation: Let the problem get out of hand — to a point where nearly 1 in 3 people have no coverage — and you won't just have a less healthy population. You'll have an overwhelmed health care system.

"Texas is the case study for system implosion," says neurosurgeon Guy Clifton, founder of the Houston-area group Save Our ERs.

The problems here, as elsewhere, are many. Small employers are dropping health coverage. Federal and state subsidies don't make up the difference. Illegal immigrants represent 21% of the county's public caseload, even though they represent only about 6% of the area's population.

Compounding the problem, insurers are slashing hospitals' reimbursement rates, often leading the hospitals to reduce unprofitable services such as emergency rooms.

The huge number of uninsured residents here means that health officials must make tough decisions every day about who gets treated and when. "Does this mean rationing? You bet it does," says Kenneth Mattox, chief of staff at Ben Taub, the Houston area's pre-eminent trauma care facility.

Some states are trying to tackle the problem. The broadest solutions have been advanced in Massachusetts, Vermont and Maine. California, Illinois and Pennsylvania may not be far behind. Still more states are trying to insure all children as a first step toward insuring all residents. In most of those states, proposals range from increasing government subsidies to mandating that either employers offer or consumers buy coverage.

Then there's Texas, where the insurance crisis has multiple causes:

•Small businesses dominate the economy, but only 31% of those with 50 or fewer employees offer insurance in Texas, compared with 43% nationally. As a result, 48% of Texans are covered by employers, compared with 53% nationally.

•Income limits to qualify for Medicaid, the federal-state health insurance program for the poor and disabled, are among the lowest in the nation here. Texas has set a limit of $4,822 per year for a family of three, compared with nearly $10,000 in Florida, $18,000 in California and $25,000 in New York. Texas has no subsidized health insurance program for childless adults; 19 states and the District of Columbia offer some coverage.

•The state has forfeited more than $900 million in federal money under the Children's Health Insurance Program (CHIP) during the past six years because it wouldn't put up 28 cents for each 72 cents in federal aid. Restrictions put in place in 2003 cut about 200,000 children from the program in a state with the highest percentage of uninsured children, nearly twice the national average. "It's a horrible scandal," says Jeffrey Starke, chief of pediatrics at Ben Taub.

State officials say the biggest problem in Texas is a surging population: about 23.5 million in 2006, up 12.7% from 2000, about twice the national growth rate. Texas' increase has continued to be fueled by immigrants who cross the nation's longest border with Mexico.

"We have tremendous population growth, and we have to try to keep up with that," says Nora Belcher, senior health adviser to Gov. Rick Perry.

The state's Medicaid program has doubled in cost in 10 years despite its low income limits, Belcher says. CHIP money was left on the table because the program started late and could not be fully funded during a 2003 budget shortfall.

"Others would call us cheap," she says. "We think we're prudent."

'This system is broken'

The growth of the nation's uninsured population has stretched hospital emergency departments to the breaking point.

Nationally, ER visits rose from 93 million to 110 million from 1994 to 2004, an 18% jump, according to the Centers for Disease Control and Prevention. Texas experienced a 33% increase; in the Houston area, it was more than 50%, according to the Texas Hospital Association. The number of hospital emergency departments dropped by more than 12% in the USA in the same period.

Emergency rooms here are routinely overcrowded. "When I came in this morning, there were people waiting from yesterday," says Kellie Manger, a triage nurse at Ben Taub, on a recent weekday.

About half of the people going to emergency rooms here just need primary care, a percentage that's similar elsewhere. "We see lots of patients here who haven't seen a doctor in years," says Katherine King-Casas, an emergency room physician at Ben Taub.

Packed emergency rooms also are caused by overcrowded hospitals in general. At Ben Taub, Mattox gets calls from area business leaders and politicians seeking to "sneak in the back door a maid, a nanny." Doctors, frustrated by long delays for surgeries, try getting patients admitted to the hospital to move them ahead in line.

"Safety-net facilities were never designed to handle one-third of a population," says George Masi, Ben Taub's chief operating officer. "I don't think this is unique to Texas. Something's got to be done. This system is broken."

Crowding leads hospitals to send patients elsewhere.

In the Houston area, hospitals divert patients about 20% of the time, says Charles Begley of the University of Texas School of Public Health. Ambulances pile up outside emergency rooms, often waiting an hour or two to get their patients in for treatment. David Persse, the Houston Fire Department's medical director, says the area record is six hours. The situation is so bad that patients have called 911 from one ER to get to another.

Doctors here cite horror stories, such as the patient who died after being diverted by helicopter from a Houston hospital to one in Austin. "Diversion kills you," Clifton says.

Long waits, packed corridors

The greatest demand for health care isn't in emergency rooms. It's at the clinics and health centers designed to relieve them.

Maria Gutierrez came to Ben Taub's orthopedics clinic one day last month to have her ankle checked after surgery and to fill some prescriptions. The visit took 8½ hours. A week later she was back, in a corridor where as many as 350 people with specialty clinic appointments wait for hours. "Sometimes you don't want to be in the hospital all day," she says.

Bartolome Martinez arrived at the Strawberry Health Center in Pasadena, just outside Houston, at 4 one recent morning to be first in line for the few walk-in slots allotted. The 70-year-old native of Cuba waited outside until the center opened at 7:30 and was still waiting inside at 9 to have the pain in his side analyzed. Still, he says, that was better than waiting three months for an appointment.

Joyce Heifner, 54, discovered the San Jose Clinic, the nation's oldest charity care clinic, five years ago after struggling for about 15 years with the effects of polio she contracted as a child. The clinic, booked like all the others, is a 70-mile drive for her from Livingston, Texas, which has no public hospitals or clinics for the uninsured.

San Jose tries to fill the gap between primary and hospital care with its own specialists, but the wait can take months. "We have one rheumatologist who comes here," says Rosanne Popp, a primary care physician. "There's not an appointment until next year."

For the working poor, waiting for treatment means less time on the job. Angel Martinez, 20, broke his ankle last month and was taken to a private hospital, which put on a cast and billed him $4,500. "That's money that I don't have," he says. He had surgery at Ben Taub and is eager to get his stitches out so he can go back to work as a driver. "This is the foot I use for the gas and the brakes," he says.

The large numbers of uninsured and overburdened health care system have consequences: Studies done during the past 25 years indicate that being uninsured is hazardous to your health.

The uninsured are more likely to have high infant mortality rates. They are more likely to develop high blood pressure and hypertension. They are less likely to get treatment for trauma. They are less likely to receive timely cancer diagnoses. They are more likely to die from heart attacks.

'They die sooner'

Among the states, Texas has the highest percentage of uninsured adults — 27.6% — who say they are in poor or fair health, rather than good or excellent health, the American Hospital Association says.

Even when the uninsured see doctors, they often can't afford drugs. "You prescribe, you send them home, they don't get well," says Efrain Garcia, a cardiologist who volunteers at San Jose. "They die sooner. They have more complications. They are more disabled."

Cora Sylvester, 50, of La Porte, about 25 miles east of Houston, waited about a year after noticing a lump on her breast because she was poor, uninsured — and busy. Eventually she came to The Rose, a women's diagnostic center. She has since had chemotherapy, surgery and radiation, but her long-term prognosis is questionable.

"It's always an issue to not have any type of insurance," she says. "You feel like you just fell in a hole."

Faced with the onslaught of uninsured patients, Texas is taking steps to rework some of its policies.

Late last month, the Legislature changed its rules to add more than 127,000 children to the 300,000 now covered by the Children's Health Insurance Program. Asset tests were eased, enrollment periods extended and waiting periods eliminated for many clients. The Legislature also paved the way for a new program that will subsidize insurance for 200,000 adults.

'We make a little dent'

Still, there is nothing being proposed on the scale of Massachusetts' fledgling program to insure all residents. "There is not going to be a Massachusetts-mandate, one-size-fits-all solution for Texas. We're just too big," Belcher says. To do that here, says Camille Miller, president of the Texas Health Institute, would cost $6 billion.

In the meantime, Houston's health care system is doing what it can. The Harris County Hospital District is educating patients about when to use clinics, not emergency rooms. The Harris County health care Alliance is trying to develop less costly insurance products, especially for small employers.

"Gateway to Care" navigators help uninsured people find primary or specialty care at area clinics. "We're touching thousands of people, but there are a million people without insurance," says Sandy Steigerwald, patient care coordination manager for Gateway to Care.

An "Ask Your Nurse" program offers phone advice to ease the burden on emergency rooms. "We make a little dent," says the nursing program's Titiana Grossley-Brown.

For all their efforts, Houston-area health officials have been unable to reduce the numbers of uninsured.

"Our problems are horrible and embarrassing, but everybody's aware of them," Begley says. "What we're struggling with is what can we do about them."

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