It’s not the kind of report card that would make your parents proud: Despite spending more than twice as much per capita on health care as other wealthy nations, the United States ranked last of six major industrialized countries in measures of efficiency, access, equity, quality and outcomes, according a recent report by the Commonwealth Fund.¹

As the nation gears up for the next presidential election, and moviegoers take in Michael Moore’s documentary “Sicko,” health insurance has once again risen to the top of the domestic agenda. Addressing the needs of the nation’s 43.6 million uninsured—almost 15 percent of the population—has become a challenge simply too urgent to ignore.² “The uninsured person is not just the person who doesn’t have a job and lives under a bridge. It’s also the single mom who is making $22,000 a year and commuting to work and needing day care. And that’s a surprisingly large group,” said Ivan R. Schwab, MD, professor of ophthalmology and director of the cornea and external disease service at the University of California, Davis.

One answer, or many? Possible solutions to improve access to health care are jockeying for attention, and they range from single-payer with universal coverage, to market-managed with health savings accounts and income tax deductions, to state-mandated with employer-provided basic care.

“How do we cover these people?” asked Ravi D. Goel, MD, a comprehensive ophthalmologist in Cherry Hill, N.J., and instructor at the Wills Eye Institute. “What is the most efficient way to utilize precious health care resources to create the maximum benefit for all patients?” Dr. Goel was elected this year to the governing council of the Young Physician Section of the American Medical Association, which hopes to make the uninsured a major topic for next year’s elections. (For more information, visit www.ama-assn.org and click “Coverage for the Uninsured.”)

Dr. Schwab raised a basic philosophical question haunting the insurance debate: “Is health care a right or a privilege?” Until questions like that are resolved, physicians must grapple with how best to manage patients who don’t have the resources to pay for health care.

Dollars Down, Morbidity Up

In terms of sheer numbers, ophthalmologists may be missing access to 88 million uninsured eyes in this country. In many cases, however, physicians feel a moral obligation to provide care to those without insurance, said Dr. Schwab, the cost of which they then write off. According to the AMA, the average physician provides $2,000 in uncompensated care each week.³ “If you’re going to deliver this care anyway, wouldn’t it be better to have some funding for it?” Dr. Schwab asked. Dr. Goel noted that ophthalmologists also provide on-call care in emergency rooms, which are the last resort for many uninsured people, but are the most expensive use of the health care system.

Poor health is not cheap. From low-tech to high-tech services, a dearth of insurance is creating a major barrier to care. Despite the relatively low costs of eyeglasses, for example, approximately 5 million adults in 2002 could not afford them when needed.⁴

A 2003 Health Affairs article reported the underuse of medical care by the uninsured population aged 55 to 64. This group is caught between employer-sponsored care and Medicare, and is faced with soaring individual premiums. The report showed that this group’s lack of health care access cost $1.1 billion in excess morbidity and mortality for just three conditions—cataracts, heart attack and depression. Eighty percent of the loss was related to cataracts alone.⁵

This age group was also the target of a recent study in The New England Journal of Medicine, which found that previously uninsured patients used up to 51 percent more medical resources upon entering Medicare than those who had had private health insurance. Highest utilization was among patients with cardiovascular disease and diabetes.⁶

Recipes for Difficult Care

Caring for both the uninsured and underinsured brings a special set of challenges for ophthalmologists:

• Threat to medication adherence. For people with bare-bones insurance, premiums, copays and deductibles can empty pockets fast, particularly when medication is prescribed. “Even generics are expensive if your monthly check goes to pay for rent or food,” said Dr. Schwab. “Even a few dollars a month becomes too expensive.” He added that the underinsured are a “misplaced, forgotten part of the health care problem.”
• Uninsured and undocumented. Lack of health care compounds the fear of ill health, and for those lacking legal residence, worries about deportation add to the troubling mix. According to a RAND report, undocumented immigrants accounted for about a third of the total increase in the number of uninsured adults nationally from 1980 to 2000.⁷ They are much less likely than other groups to be covered by public insurance.
• Transportation woes. For any patient with severe vision problems, transportation may be a barrier to care. For those also lacking financial resources, transportation can be a nonstarter. Dr. Schwab recounted the example of a homeless patient he treated for an infected cornea. Although a friend brought him in more than once for follow-up, the patient was not completely healed when last seen by Dr. Schwab, who suspected that transportation troubles prevented his return.
• Advanced conditions. Dr. Schwab’s patient also faced a more dismal prognosis due to his delay in care. “Had he come in earlier, I probably could have kept him from losing sight in the eye,” said Dr. Schwab, who never learned of the outcome. “Patients we see with no insurance or limited insurance have more advanced conditions that are harder to treat. It’s not because they’re a different kind of person. It’s because they come in later in their disease course.” Dr. Goel described an uninsured patient he treated a few years ago who also sought care late. “On clinical exam, he had classic features of optic neuritis,” including decreased vision and pain with eye movements. Although Dr. Goel recommended further follow-up, the patient declined, taking a wait-and-see approach. He ultimately ended up in the emergency room, where his evaluation cost thousands more than it might have otherwise.
• First stop, eye doc. Ophthalmologists are often the unwitting first point of care for the uninsured. A failed driver’s test will bring them to care in a hurry, said Dr. Schwab, making the ophthalmologist’s office their port of entry into the health care system. “Patients might come in with mild visual symptoms, thinking they simply need a change in glasses,” said Dr. Goel, “when, in fact, they have something more significant. For the uninsured, this becomes a big issue. The challenge for the ophthalmologist is to coordinate care beyond that initial visit.” Patients with diabetes or hypertension, for example, often require not only referral to physician specialists but also coordination with social workers, nutritionists and visiting nurses.

The Mission of Medicine

Establishing relationships with colleagues can help provide care to these patients. “Introduce yourself to the hospital social worker,” said Dr. Schwab, “so the next time you have an uninsured patient, you can call and ask, ‘Can you help me with resources?’” Dr. Goel added that it’s useful to connect with nonophthalmologist physicians. “To keep lines of communication open, every day I try to pick an internist to talk to about a mutual patient,” said Dr. Goel, who explained that this aids collaboration when an uninsured patient needs services outside his realm of expertise.

But regardless of insurance status, said Dr. Goel, the standard of care needs to be the same for all patients. “We have a responsibility to our patients to make sure they get the best care possible.”

The Patchwork Pocketbook

For the uninsured eye patient and the physician willing to uncover every option for financial support, there is a patchwork world of resources. “Explore the patients’ resources,” said Dr. Schwab. “They may have some they don’t realize.” Several million uninsured people are eligible for Medicaid, for example, but are not enrolled in the system. Everyone in a clinic or practice—from physicians to technicians and office managers—should know what’s available, said Dr. Goel. The National Association for the Visually Handicapped (www.navh.org) can help clients locate or activate many resources, including:

• Dependent insurance
• Medicaid or Medicare
• Federally qualified community health centers (www.bphc.hrsa.gov)
• Veterans Affairs Health Benefits Service Center (www.va.gov/health)
• State pharmacy assistance programs
• County health services
• Homeless service agencies
• Social service clubs such as the Lions Clubs
• Indigent transportation services
• Ophthalmology residency programs in teaching hospitals
• Ophthalmic pharmaceutical companies, which may offer free or discounted products for indigent patients (Pfizer Helpful Answers www.pfizerhelpfulanswers.com and Merck Patient Assistance and Prescription Discount Programs www.merckhelps.com are two examples.)
• Prevent Blindness America, a volunteer eye health and safety organization, which provides vision screening, education and advocacy
• EyeCare America, a public service program of the Foundation of the Academy, provides access to eye care through volunteer ophthalmologists and hosts a Web site that provides the latest in eye health information. The site includes resources for patients who need ophthalmic drug assistance.

Founded in 1985, EyeCare America merits special mention. It is the largest program of its kind in American medicine. With the help of more than 7,000 volunteer ophthalmologists, EyeCare America provides eye care services to the medically underserved and those at increased risk for eye diseases. More than 90 percent of these services are made available at no cost to patients. Last year, the program referred almost 15,000 people to volunteer ophthalmologists. Nearly a third of these were uninsured, according to Allison Neves, director of communications for EyeCare America. Ophthalmologists who would like to volunteer can enroll online at www.eyecareamerica.org (under the “How to Help” tab), or send an e-mail to pubserv@aao.org .

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