When a health policy causes harm

When a health policy causes harm
© Greg Nash

Policies, whether they are federal, local, state, administrative, or at an individual institution’s level, sometimes fail to address the deeper issues that created the problem or ignore the issues that may arise as a result.

Social problems and social determinants of health affecting everyone, from youth to elders, can’t be addressed with a simple checkbox system or a straightforward policy.

Conditions that affect health and access to health care include factors such as housing, nutrition, and transportation.

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For example, I know from working with patients with disabilities as a pediatric rehabilitation physician, that many factors contribute to whether a patient will make an appointment.

Families with young children are often balancing childcare, work schedules, school drop-offs, and transportation issues every time they attend a doctor’s appointment. Many patients avoid visiting an office when they have an outstanding balance on their account.

A hospital or clinic policy meant to improve attendance may indeed deter people from receiving valuable medical care due to financial restraints.

Policies, whether they are on the federal, state, local, or administrative level of institutions, can often allocate resources toward an organization’s most important goal. Unfortunately, an organization’s most important goal is not always in the best interest of the population they serve.

Policies on every level often reflect the thoughts and beliefs of the policymakers. If those who are enacting the policies are not from diverse backgrounds, essential aspects of the policy that may disproportionately affect those who are already disadvantaged may be overlooked.

While I am not an expert in policymaking and evaluation, I have seen first-hand what policies can do to people — whether it is a federal, state, local, or individual institution policy.

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To adequately address patient needs, health-care providers must identify patients who need assistance and also have support and funding in place from their health-care organizations to provide case management, patient resources, and support for the community-based programs that will help provide interventions for the patients.

Addressing the need starts with policy change but cannot be completed effectively without collaboration from all parties involved.

For instance, the federal policy for the Affordable Care Act expanded insurance coverage for the uninsured and improved access to preventative care. Increased insurance coverage for many Americans has been beneficial for some, but for others, the cost of medical care continues to impede access to care and create financial hardships.

Working families with employer-sponsored insurance, as well as those who purchase insurance through Healthcare.gov, are still spending significant amounts of money on their healthcare due to out of pocket costs.

ProPublica does a recent examination, and MLK 50 revealed that Methodist Le Bonheur Healthcare was not publicizing the financial assistance and charity care services that were available and then suing patients with unpaid medical debts who would have qualified for the services.

These debts have now been erased, but the emotional impact on the families will not soon be forgotten.

The Affordable Care Act was helpful to many because of the increased access to preventative healthcare it created. However, without partnership and policies in place from healthcare organizations to help manage cost, those with more limited resources and complex medical needs continue to experience significant financial burdens.

For many insured families, out of pocket costs create barriers to care, including delayed or skipped care, increased medical debt due to the rising costs of medicines and treatments, and even wage garnishments if their unsettled debts are sent to collections.

Despite the benefits that the Affordable Care Act does provide, this policy is in jeopardy. In December 2019, a federal appeals court determined that mandating health insurance for everyone was unconstitutional, and the law continues to be in courts to evaluate whether it is still viable without the universal insurance requirement.

The future of the Affordable Care Act continues to be uncertain, leaving instability in the health-care landscape and doubt in those who have pre-existing conditions or rely on healthcare exchanges for their insurance needs as they wait to see how the prolonged court battles unfold. 

History has shown that federal, state, and local policies can improve lives. But often there are greater costs that erupt as a result.

For example, in the 1930s, thousands of families were moving to Chicago for better opportunities, but housing options were limited. The Chicago Housing Authority was founded in 1937 to operate the public housing developments built by the federal government to meet the housing needs of working-class families with low incomes.

The “neighborhood composition rule” required that public housing tenants be of the same race as the other residents in the area, which increased segregation of minorities to the South and West sides of the city.

In 1966, a group of residents sued the CHA, stating that they engaged in racial discrimination by building public housing solely in areas with poor minorities. Despite the landmark court decision in the Supreme Court case of Hills vs. Gautreaux, public housing continued to be relegated to the South and West sides.

Those who chose not to live in public housing found getting a mortgage loan almost impossible due to redlining policies that still affect homeownership and the opportunity to build generational wealth for minorities today.

The Brown v. Board of Education Supreme Court ruling taught us that separate is not equal, but there is more work to do.

As a result of decades of segregation and disinvestment, the communities on the South and West sides of Chicago continue to be disadvantaged.

Decreased access to economic opportunities and quality education have ushered in violence, health-care disparities, and increased rates of incarceration.

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In healthcare, there are similar policies to improve patient access and experience that have caused new and different problems to arise.

The policy at an office where I receive medical care states that a no-show or a cancellation less than 24 hours before the appointment will result in a $25 fee. The purpose of the policy was to improve attendance and encourage early rescheduling to make room for other patients who are waiting to be seen.

While the intentions were well-meaning, a policy like this may have an impact on whether a person can attend their doctor’s appointment.

For those who hold power to make such policy on any level, it is urgent to involve the community affected by bringing diverse thinking to the table of policymakers and to look into the future and weigh the possible impact of the policies.

And hopefully, that way, there is no harm done.  

Laura Deon, M.D., is an assistant professor in the Department of Physical Medicine and Rehabilitation at Rush University Medical Center, where she specializes in Pediatric Rehabilitation. She teaches the Health Equity and Social Justice Course at Rush Medical College and is a Public Voices Fellow through The OpEd Project.