Insurance Doesn’t Guarantee Health Care Access

angela-mossBy Angela Moss, PhD, RN, APRN-BC

Health insurance is a common proxy measurement for access to health care services. That is, if a person has health insurance, they also have access to health care services and time to seek regular visits. Unfortunately this isn’t always the case.

A new Gallup-Sharecare Well-Being Index shows the number of adults without health insurance is up 3.5 million this year. But those with health insurance also may not have access to doctors, nurses or clinics.

One of those Americans is my patient; I’ll call him Joe. He has worked two full-time jobs for all of his adult life. Joe is 57 years old and regularly works the evening shift six or seven days a week from 2 to 11 p.m. in a distribution factory operating heavy machinery. He then clocks in for his night shift warehouse job at another factory from midnight to 7 a.m.

For nearly 30 years, Joe has had about four hours of sleep a day between 9 a.m. and 1 p.m. He smiles proudly and says he supported his family with his tough schedule. He put three kids through college and now all three are independent, successful professionals who are free from college loan debt. He and his wife own their home and two vehicles outright.

No time for checkups

But what cost has this been to his health?

The health consequences of insufficient sleep can be catastrophic. Studies consistently show that bad sleep habits, otherwise known as poor sleep hygiene, contribute to poor perception and judgement, irritability, reduced efficiency and productivity at work, increased work errors, and in cases of drowsy driving, serious injury and fatalities.

Lack of sleep on a regular basis is associated with long-term health consequences such as obesity, diabetes, high blood pressure, heart disease, mood disorders, decreased immune function, alcohol misuse and decreased life expectancy.

When I first met Joe five years ago in my primary care clinic, he said he had not seen a health care provider in “maybe 20 years.” Joe said he had no idea his sleep schedule might be causing negative health effects.

Yes, he was enrolled in one of his employer’s health insurance plan, but said he has never had time for regular health checkups and in general felt his health was “pretty good.” Also, the out-of-pocket deductibles were “pretty high” and he wanted to spare the expense. It was not worth it to him to lose his daily sleep to some to an appointment if he did not feel sick.

Health care at work

As a nurse practitioner, in 2009 I designed and developed a worksite primary care and wellness program for low-income workers in an industrial facility near Chicago. The mission of the Healthy Living Program is to provide quality, comprehensive and cost-effective primary care and wellness services at the worksite in order to meet the health care needs of the diverse employee population. Today, the Healthy Living program supports over 8,000 annual clinic visits, dozens of wellness programs each year, staffs three nurse practitioners, and hosts over 2,000 annual nursing student clinical hours and projects.

Prior to the development of this program, those employees had limited access to health care. Even though they had the company-sponsored health insurance, due to personal financial limitations, transportation barriers, and time constraints related to their work-life schedules and family responsibilities, access was limited.

But because of the worksite program, workers like Joe don’t have to take a day off work or miss the only four hours of sleep that day for an appointment. A worker could drop in as the night shift ended before heading home. There is no cost to the worker  —  no deductible, co-pay or laboratory fees  —  because his employer company pays directly for the worksite clinic operational costs.

Catching problems early

The Healthy Living Program removed barriers to access for workers, enabling them to utilize health care services. And because workers like Joe had worksite access to health care services, we were able to address his health concerns before they became catastrophic.

During that first visit we discovered Joe’s blood pressure and blood sugar numbers were both high. Over the next year Joe and I met twice weekly at the worksite clinic to manage his high blood pressure and diabetes, and to address significant memory and mood concerns, as well as his sleep hygiene. We worked together to identify key lifestyle changes such as increased daily exercise and better eating habits to get his blood sugar under control. These lifestyle changes helped improve his blood pressure as well along with a blood pressure medication.

Today Joe says the worksite clinic saved his life; his blood pressure and blood sugar are both normal, his memory has improved, and he’s working on improving sleep hygiene. 

Joe has been able to cut back his work schedule to allow for more sleep and recreation time, truly a better work-life balance, and he’s happier and better rested as a result.

Studies show that worksite health programs, particularly those with a disease management component such as a worksite clinic, pay for themselves. Most programs cut employer health care costs by half to two thirds within three to five years of operation. This is because chronic diseases, such as high blood pressure and diabetes, are better controlled with improved access to health care services. Problems are caught before they become catastrophic and expensive.

‘Culture of wellness’

Employers report that creating a culture of wellness at work is an excellent retention tool thereby decreasing employee turnover and training costs, and building valuable institutional wisdom and experience among their workforce. Worksite centers also help decrease workplace injury claims, boost productivity and reduce absenteeism, also big cost savers.

Adult Americans spend approximately one third of their lives at work, and because employees spend so much of their lifetime at work, worksite-based interventions have great potential for huge positive impact on the health of our nation.

Whether or not an American has health insurance is only part of the equation. Access to quality health care is another critical component. Someone with health insurance may still have to wait three months for a primary care appointment, drive 60 miles to the nearest clinic, or have cost prohibitive out-of-pocket health insurance co-pays and deductibles. Or simply work so much he or she does not have time to go to their health care provider.

At the policy level, we need tough conversations about the health care delivery system to improve actual access. We must leverage built environments such as worksites, schools, community centers, churches, and neighborhoods to provide better access to health care.

Many employers are already on the bandwagon. Lawmakers and the health care community must catch up to improve the health of as many Americans as possible.

Angela Moss, PhD, MSN, APN-BC, RN, is an assistant professor in the Department of Adult Health and Gerontological Nursing with the Rush University College of Nursing. She is director of the Office of Faculty Practice.

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