Baby Coming - No Insurance
Shortly after being laid off last October, Chris Jackson learned his wife was pregnant with their first child.
"It was good news, but the timing couldn't have been worse," the 27-year-old Manchester resident said.
Jackson and his wife, Jacinda, a full-time graduate student, have been without health insurance since November 2007. They elected to discontinue coverage after Jackson's employer changed to a plan that would cost the couple more.
"Health insurance was taking so much out of my check each week, I just couldn't afford it," Chris Jackson said.
As the U.S. recession persists, circumstances like the Jacksons' are becoming more common. With joblessness on the rise -- New Hampshire's unemployment rate hit 5.1 percent in January, the highest level since March 1994 -- New Hampshire health-care providers are serving more uninsured patients.
Although the recently enacted federal stimulus package provides a temporary private health-insurance subsidy for laid-off workers, more Granite Staters are seeking care through public programs. Others are not paying their bills or are putting off treatment altogether.
While President Obama prepares to host a bipartisan summit on health-care reform this week, the recession is testing families such as the Jacksons.
After undergoing hernia-repair surgery last April, Chris incurred a bill of close to $10,000. "We worked out a payment plan with the hospital, but when I got laid off from my job, I couldn't pay those bills," he said. "It's had a pretty profound effect on my credit as well."
Jacinda is receiving prenatal care at the federally qualified Manchester Community Health Center, which offers free and discount care to many uninsured patients, Chris said. She is also receiving nutritional assistance through the federal WIC program, he added.
Meanwhile, Chris is substitute teaching and looking for full-time work while Jacinda finishes her master's degree in psychology.
"Hopefully she's able to land a job right out of school," Chris said. "The reality is we may have to move to a state where there are more opportunities."
Unpaid hospital bills
Because of its expense, the couple opted not to buy COBRA, which enables employees who leave a job to purchase the health insurance offered by their previous employer. The average monthly cost of COBRA for New Hampshire families is $1,191 -- or nearly equal to the average Granite State family unemployment insurance benefit of $1,210 per month -- according to a report the New Hampshire Health Care for America Now Coalition released last week.
Under a temporary COBRA subsidy included in the economic stimulus package, former workers involuntarily terminated between Sept. 1, 2008, and Dec. 31, 2009, can purchase nine months of coverage by paying only 35 percent of the premium. (The remaining 65 percent is paid by the employer, who will receive the money back in a payroll tax credit.)
For the Jacksons, the subsidy reduces COBRA's price into the realm of consideration. "It probably brings it closer to a reasonable mark," Chris said. "If things were to continue as they are right now, I probably could afford it."
Although the COBRA subsidy is intended to help laid-off workers, many might not be aware of it. While treating a patient last week whose husband had recently lost his job, Nashua ophthalmologist John Dagianis informed her of the subsidy.
"She had no clue," said Dagianis, a partner at Nashua Eye Associates. "Whatever message [policymakers] are putting out there, I'm not sure it's gotten out to the people who need it."
Uninsured patients are increasingly turning to health-care programs supported by state and federal dollars and therefore charging lower fees. The Manchester Community Health Center, which receives public and private funding, has seen its uninsured patient population increase, said its president and CEO, Ed George. From last July 1 to Jan. 31, 63 percent of the center's new patients were uninsured, George said. For the comparable year-earlier period, 40 percent were uninsured.
The center, which provides primary care and other health services to 7,000 patients, charges fees based on patient income, with many receiving free or discount fare. Patients whose incomes do not qualify them for discount care, however, account for much of the growth in the center's uninsured population, George said.
"They may have a full- or part-time job, but don't have provisions for health insurance or don't make enough to buy it," he said.
Amid the growing uninsured population, New Hampshire hospitals are seeing increases in charity care and bad debts. In the last six months of 2008, Elliot Hospital in Manchester provided $21.7 million in uncompensated care, nearly 20 percent more than it provided in the last six months of 2007, said the hospital's chief financial officer, Rick Elwell. Uncompensated care includes charity care given to income-eligible patients and unpaid patient debts.
At Upper Connecticut Valley Hospital in Colebrook, charity care accounted for 4.7 percent of gross revenues during the last three months of 2008, CEO Louise McCleery said. By comparison, charity care accounted for 2.6 percent of revenues in fiscal year 2008, which ended last Sept. 30. The hospital's bad debts in the last three months of 2008 represented 9.3 percent of revenues compared with 4.8 percent in fiscal year 2008, McCleery added.
"As I talk to CEOs across the state, every one has seen an increase in charity care, bad debt and the number of patients coming in without insurance," said Steve Ahnen, president of the New Hampshire Hospital Association. "It clearly creates a challenge for hospitals and providers."
Drop in reimbursement
That challenge is compounded by falling endowments and, for larger hospitals, decreases in state Medicaid reimbursement rates that took effect last fall.
Elliot Hospital's endowment has lost about 25 percent of its value since last June, Elwell said. And because of state budget cuts, the hospital anticipates it will receive $3.5 million to $4 million less in Medicaid reimbursements this year, he added.
Although an increase in federal Medicaid assistance under the stimulus bill is expected to yield an additional $250 million for New Hampshire in 2009-10, Gov. John Lynch is under no obligation to use those funds for Medicaid, so long as state Medicaid eligibility is not reduced, Ahnen said.
Given the financial squeeze hospitals face, the New Hampshire Hospital Association in a letter last week urged the governor to use the stimulus money for Medicaid, which helps pay for low-income residents' health care.
"When (hospitals) lose money every time they treat patients, their ability to continue to serve communities will be challenged even more," Ahnen said.
While hospitals strive to maintain quality care with diminished means, outpatient and specialty practitioners are noticing patients putting off treatment because of financial concerns.
"We're beginning to see people postponing elective procedures," said Steven Paris, medical director for the Dartmouth-Hitchcock outpatient practice in Manchester. And at Nashua Eye Associates, routine eye exams were down 10 percent in January, Dagianis said.
"My greatest concern is (patients) are going to put off needed testing and exams that could catch disease processes earlier and prevent longer-term issues," he said.