by Neil Shulman

hen Grady Hospital, the only public hospital in the Atlanta metropolitan area, announced last spring that it would increase the price of prescription drugs for indigent patients from as low as 50 cents to $10, cash only, there was an anguished community outcry. More than 26,000 patients, many on life-sustaining medicines, would not have access to discounted drugs. Already, cancer patients were not showing up at clinics for vital therapy. Emergency rooms could expect to be flooded.

But the hospital had a $26.4 million deficit, and Grady's Board of Trustees felt that the price increase was essential to maintain the hospital's fiscal viability.

Grady's proposed pharmaceuticals policy was America's health care crisis in microcosm. Throughout the country, hundreds of thousands of people are suffering or dying every year because they can't pay for medications. Of late, the matter of prescription costs has surfaced as Congress considers changes in the Medicare program, with politicians sensing a galvanizing issue for the 2000 elections. That debate is focused on the serious problems of the elderly. Ignored are the younger-aged "medically indigent" -- the many who cannot afford the medicines they need, whether they are employed or unemployed, low or middle income, with poor insurance or no insurance.

While an additional $4.6 million in public money was found for Grady and the minimal prescription fees reinstated, the fundamental problem remains everywhere. Access to medication is often the ultimate bottleneck in the American health care system. Even if doctors, clinics, or hospitals donate their services, patients are helpless unless they can afford the medications prescribed. Since the United States is the only industrialized country that places no ceiling on the price of drugs, prescription prices are out of reach for millions of Americans.

So what is a typical scenario? One third of untreated patients with severe high blood pressure will develop kidney failure, heart diseases, other heart- or kidney-related problems, or have a stroke or die within 26 months. A minimum-wage worker faced with a $200 monthly bill for blood pressure medicine has to spend a quarter of his or her income to cover it. Many patients in this circumstance receive no assistance for medication until their kidneys fail and they need dialysis, which costs the government a minimum of $45,000 a year per patient. Or they get no help until their damaged hearts require surgery, or they become paralyzed, requiring nursing home care at tens of thousands of dollars a year.

The holes in the supposed safety net are growing bigger by the minute. Medicaid often does not provide coverage for the working poor, and it too frequently does not kick in with essential treatment until the patient develops an irreversible disability. So the waitress with heart problems is told that she is not disabled and can work if she just takes her medicines and gets a job where she can sit. Of course, companies are reluctant to hire her because of her illness and the burden of underwriting her health care. Because she can't afford her drugs, her condition worsens to an irreversible stage; then she becomes eligible for Medicaid. Such cases provide a continual flow of clients for attorneys specializing in disability law. Retroactive payments from Medicaid settlements feed the lawyers.

Medicare reimburses for medication only while the elderly patient is in the hospital. Carol Dembe, an emergency room doctor at a Philadelphia hospital, repeatedly treats the same patients with recurrent crises such as asthma attacks and seizures. Medicare pays for the emergency-room visit. Patients who cannot afford their medicines go home without their prescriptions filled and bounce right back to the emergency room a few days later. The cycle continues at a higher cost to the system than if the medications were provided at a nominal fee.

Pharmaceutical company programs for poor patients are usually Band-Aid approaches, rife with restrictions, rules, paperwork, and bureaucracy, and are available only if a doctor takes the time to apply and then reapply for the program for each patient. Some of these programs are generous, but with so many pills and so many policies, hunting for discounts often overwhelms harried doctors and pharmacies.

Public hospitals across the country are trying to solve their financial woes by cutting pharmaceutical services. Charity Hospital in New Orleans gives indigent inpatients a three-day supply of medications when they are discharged; after that there are only minimal discounts, if any, and patients have to pay up front. The Medical College of Georgia Hospital in Augusta attempted to close its pharmacy completely; it retreated under pressure from the state. The University of Texas hospital in Galveston substantially raised its co-pay, to a range of $10 to $45 per drug, and in Brooklyn, Kings County Hospital charges its indigent patients $10 per drug per month.

The medication crisis manifests itself differently in communities that cannot support public hospitals. There the problem appears in clinics and doctors' offices. In a small rural community clinic in South Georgia near Albany, one nurse reports spending 25% of her day searching for, applying for, or reviewing applicable programs funded by pharmaceutical companies. Jack Birge, a private practitioner in Carrollton, is so frustrated by the paperwork, rules, and bureaucracy that he's given up applying for these programs. A family physician in rural California bypasses the system altogether by asking family members of dead patients to bring in their unused medications so he can keep his living patients alive.

Patients develop their own dangerous innovations. They might take their medications every two or three days instead of daily as directed. A physician assistant in rural Pennsylvania reports that a mother with a child suffering from pneumonia planned to get a prescription for him and then split the drugs among her four other sick children. In North Dakota, physician assistant Jackie Hollevoet says many elderly patients with multiple diseases, such as diabetes, high blood pressure, and arthritis, roll the dice and buy the medication for the one disease they perceive to be the most serious. Health care provider Daniel Lynam in Elizabeth City, North Carolina, says his patients often don't show up for appointments when they can't afford medications. He visited one patient at home and gave him the money for his medicines. The patient was so thankful that he offered Lynam two live chickens.

A 55-year-old woman in Hamilton, Georgia, who was applying for a job as a nanny, had a stroke. Now half her body is paralyzed because she could not afford her blood pressure medicine. Injuries resulting from missed medication are not always confined to the ailing individual. A North Carolina woman who couldn't afford insulin had such high blood sugar levels that she became dizzy while driving the school bus.

Government is not going to act on its own to reverse this crisis. The best hope for preventing tragedies and perhaps for jump-starting the dormant forces for health care rights, may, therefore, lie in local struggles such as the one in Atlanta.

Corporate profits may be higher, and the Dow Jones may soar. Jobs may be more plentiful, but workers' security is tenuous and disaster could be around the corner. Every month, 100,000 Americans lose their health insurance. In the most vulnerable position are the disabled, old people on fixed incomes, people with chronic illnesses, and those who are very poor or just skating along the edge of poverty.

Americans demand seat belts on buses because they might swerve off the highway. They contribute to disaster victims, or to children stuck in wells, or to students massacred in high schools. But those who are healthy cannot see the suffering of those who worry over how they'll pay for the lifesaving drugs they need every day.

We must tell these stories to Americans. We must make noise. We must make news. The health care crisis is a true scandal, and it should not take public funerals of those dying from lack of medication to dramatize its consequences.

The above comments were excerpted from an article which appeared in The Nation.

From the Director  /  Letters

The Grady Crunch

The Healing Fields

Getting into the Act

Moving Forward  /  Noteworthy

Grady's Crisis is America's

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