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Healthcare: Facing Barriers
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Who has a right to healthcare?

What are the challenges?

Who is meeting them?

Seven years ago, Yvonne King of Salt Lake City was diagnosed with colon cancer.   She hopes she’s beaten it, but she doesn’t know for sure because she hasn’t been tested since her surgery.   A mother and grandmother who works full time without benefits, she struggles to afford health care.  Every place she called, every place she tried to go, she was told “if you don’t have medical insurance, you just don’t bother.”

For Yvonne King, for every Utahn, for every American, there is a stark question:  "Do I have a right to healthcare?"  In the United States, there are an estimated 47 million people just like Yvonne King.  More startling, every year 18,000 people die from diseases that could be prevented or cured, simply because they do not have access to health care.  The numbers paint a dismal picture.

In Utah, an estimated 300,000 to 400,000 people are uninsured.  That’s roughly twice the population of Salt Lake City.  Nationally, the number of uninsured equals the populations of Utah, New Mexico, Wyoming, Montana, Idaho, Nevada and California – combined.  A 2001 Harvard study shows that among 1.4 million bankruptcies declared each year, 700,000 are due to medical debt.    

As Yvonne King found, without insurance, finding a physician is a difficult task.  “I really need some form of insurance to be able to get into the doctor,” she says.  “But I was so sick that I couldn't hold down a fulltime job. I was just working part-time. There were no medical benefits and I thought,  ‘Boy this is Catch 22.’”  She spent a year looking for a surgeon who would take her on as a patient.  While she was looking, her cancer progressed from stage one to stage three.  The doctor removed the tumor, but he recommended chemotherapy to increase her chances of survival. Already worried about how she would pay the $87,000 she owed for her surgery, she declined chemotherapy.   She couldn’t afford it and if she didn’t survive, she didn’t want to burden her children with her debts. 

Most of us know a neighbor, friend, or family member grappling with this very issue.  The biggest barrier is financial.  Either they can’t afford health insurance, or they can’t afford the $60 or more for an office or clinic visit.  Some are forced to choose between housing, food, and health care.  Health often comes in last.  Says Dr. Brent James, “Consider a typical family of four. It means that a health-insurance premium today is almost the same as the mortgage payment on the median American home. Well if you had to choose, would you rather have a home to live in, or would you rather have health insurance -- because that’s the choice we are coming to.” 

Even if everyone were insured, barriers would still exist.  Language, culture, geography and a shortage of health care providers all keep people from getting the care they need. Says John Nelson, former president of the American Medical Association, “Isn't it an interesting paradox?  We have more care available in the United States of America, more technology available -- new innovations that were unheard of when I was a medical student -- and yet sitting within the shadows of the walls where that technology is given, people can't get in the door.” 

As health care costs rise, more people are being left behind. In Utah, dozens of clinics are trying to help them. While clinics provide an important safety net, Dr. David Sundwall, executive director of the Utah Department of Health, says that net is not big enough and “is pretty porous.”  “We catch a lot of people, we help them but a lot of people still fall through the holes in the net,” says Dr. Mark Babitz.  

Many of those who are uninsured or underinsured find themselves forced to delay receiving care until they’re in crisis.  Preventive or early care is simply not within their reach.  For too many of the uninsured, the Emergency Room becomes a health-care solution  -- one that is the most expensive and inefficient. And one that offers no follow-up or continuity of care.

One quarter to one half of all Utahns lack a primary-care physician. “It’s common for us to see many non-urgent problems in the ER because the patients are either unable to get care, unable to get into care, unable to afford care or have not planned for care,” says ER nurse Jane Powers at Cottonwood Hospital.  From their days of working in an Emergency Room, Powers and Dr. Mansoor  Emam knew too well what can happen when chronic illnesses go untreated. 

That’s why, in 2004, Dr. Emam founded the Maliheh Free Clinic in Salt Lake City that offers care to the working poor with chronic illnesses.  The clinic, whose name means comfort and beauty in Farsi, is the realization of a lifelong dream. 

As a young boy in Southern Iran, the suffering he saw motivated his desire to become a physician and provide basic health care to patients who otherwise don't have that privilege.  His clinic in Salt Lake, which supplies $20,000 a week in donated medicine, takes 600 to 800 calls a day from those needing care.  Only about 60 to 80 of them can become patients.

“What happens to the other, you know 600 to 700 patients?” asks Dr. Emam.  “Where do they go?  Where do they get their care?  It's obvious that, you know, we could have four of these clinics in this valley, seven days a week and we still would not meet the need.”  Also trying to fill in the medical gap are local, non-profit community-owned health centers that focus on family and preventative medicine in underserved neighborhoods where language, culture, geography or poverty create barriers.

Cobbled together through state, federal and private funds, these centers see a mix of patients – both insured and uninsured -- who pay a sliding scale fee based on income. But the clinics often face financial crunches that put their services in jeopardy.  In rural towns, problems are compounded by geographic isolation.  More than dollars, distance is the problem.

“We actually know when we look at physicians, the vast majority of them choose to practice in urban or suburban communities, and only a very small proportion, I believe it's about 5% of the total, is practicing in rural America, and yet 20% of our population lives in rural America,” says Dr. Marc Babitz.  

Over half a million people live in rural Utah, where health professionals are a scarce commodity.  Some 90,000 of them are uninsured. Many work dangerous jobs.  The Wayne Community Health Center in Bicknell is where some turn for their basic needs.  With a population of 335, Bicknell is classified as one of Utah’s remaining frontier towns. The closest hospital is three hours away.  “You see and at least treat initially every infirmity known to man -- truly,” says  Dr. Jeffrey Chappell at the Health Center. “I think we're very good in this clinic to providing primary care and urgent care.  Specialty care is a challenge for these people.”  A major problem in small rural clinics like his, he says, is finding physicians who will stay. 

Language and culture can be as cruel as miles of separation from services.  The Stephen D. Ratcliffe Community Health Center in Salt Lake City’s Rose Park area deals with patients who, although predominantly Hispanic, come from diverse cultures and speak a variety of languages. 

The primary-care physicians there are more like town doctors from a bygone era. Says Luz Sanamiego, “When you work in this type of clinic, of course you develop a relationship with them.  You see them at church, you see them outside of the grocery store, you go shopping and you find some of them.”   

The health-care crisis comes back to a very basic question, “Who has the right to healthcare?”  It’s a question that Utah’s state legislature took up in 2007, a question driven by State Senator Scott McCoy’s proposed amendment to the Utah Constitution.  “We know what the issues are, we know what the models are,” says McCoy.  “Let's put one together that will work for Utah, work for Utah citizens, so that  the healthcare system will work for everyone.” 

McCoy’s amendment was never put to a vote.  The legislative session ended without further action.  While several states are experimenting with ways to provide Universal Coverage, the question of how to find a health care system that is accessible for all Utahns remains.  And people like Yvonne King will continue to ask, how we  -- as a just and compassionate society  -- can continue limiting care to the people who most need it.  

Nancy Green’s hour-long documentary, “Healthcare: Facing Barriers,” airs on KUED October 22 at 8 p.m.  A free screening and public discussion on this program will be held Thursday, October 18, at 7 p.m. at The City Library Auditorium,  210 East 400 South, Salt Lake City.  Panel members will include producer Nancy Green and panel guests: Dr. Keith Horwood, medical director, Community Health Centers, Inc., Dr. Marc Babitz, director, Utah Department of Health -- Division of Health Systems Improvement, Lorna Koci, director, Utah Food Bank and 211, and Alan Pruhs, associate director, Association for Community Health.   

What do you hope to accomplish with the film?
It’s important for us to understand the barriers people face in accessing healthcare, because it affects each of us on a personal, financial, and societal level.  If you’re having a hard time finding care, know that you’re not alone.  Most of us know a neighbor, friend, or family member grappling with this issue.  Financially, we all pay increased healthcare costs to cover the uninsured or people who delay receiving care until they’re in a crisis. And then there’s the human cost when anyone suffers and feels lost.  We found people who are trying to provide care, to fill in the healthcare gaps, but the need is too great and resources too limited.  They often ask, how can we as a just and compassionate society continue limiting care to the people who most need it?  It’s a tough question.

In a developed nation, should medical care be a social responsibility?
On some level we already acknowledge that medical care is a social responsibility. We have government programs such as Medicaid and Medicare. We require that we give life-saving treatment.  But all other major industrialized nations, except for the United States, have universal coverage for their citizens. Some in the form of socialized medicine, some in private sector medicine, most in a combination of both. At some point, you need to limit or ration care. In the United States we do that by rationing who has access to care.  We ration people instead of services.  But we are heading towards reform.  Right now several states are experimenting with ways to provide Universal Coverage and the discussion is also playing out on a national level. 

What ethical issues did you find as you explored this question in Utah?

As soon as you start to look at healthcare issues lots of questions arise.  Do we believe that healthcare is a right or a shared social benefit?  How much care should we provide? What is our social contract or social responsibility to each other?  Do we make sure everyone has care, whether they’re in this country legally or not?  What is the role of government, healthcare providers, and patients? 

Why don’t people have access to health care?

People are struggling to find healthcare.  They are either too poor, or unable to find care due to geographic, cultural or language barriers. The biggest barrier is financial—people don’t have the money to get care.  Either they don’t have the money to afford health insurance, or they can’t afford the $60 or more for an office or clinic visit.  People are forced to choose between housing, food, and healthcare, and health often comes in last.  Even if we could wave a magic wand and insure everyone tomorrow, there would still be barriers to care.  Language, culture, geography and the lack of providers all keep people from getting care.

What is the private non-profit sector doing to fill the gaps in our health care system?

There are non-profit organizations throughout the state that are dedicated to filling the gaps in our healthcare safety net.  We have a free clinic that runs on an all-volunteer staff.  We have groups that get donated care from specialists.  And there are the Community Health Centers that exist in underserved neighborhoods. There are people working hard both on a State level and a private level to provide care.  The problem is that the need is far greater then their resources.

Do we as a society have the will to care for our sick?

There is reason to hope that we will find a way to address the problems of rising medical costs and the growing number of uninsured.  Nearly everyone is recognizing the need for reform—local and national government, big and small business owners, doctors and providers, hospitals and insurers. Locally, the United Way of Salt Lake created a working group to find solutions and they’re coming out with a proposal this fall.  But any reform will require each of us to look inside and ask where do I stand on this issue?  What is my responsibility?

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