CALIFORNIA: GOVERNMENT HEALTH INSURANCE IS ONLY FOR THE VERY PATIENT

You really can die waiting

Marketing consultant Ivanna Zelaya did not have health insurance in August 2005 when she fell asleep at the wheel of her car and plunged off a Northern California freeway. Zelaya, of San Jose, spent three weeks in a coma. After she awoke, she spent months more at Stanford Medical Center recovering from a lacerated liver and brain injuries.

Zelaya qualified for Medi-Cal, the state's health coverage for the needy and disabled, because her injuries impaired her ability to work. But it took 10 months for the state to enroll her, Zelaya said. As a result, she still did not have coverage by the time she left the hospital and was unable to get follow-up neurological tests, rehabilitation or pain treatment.

Zelaya is the lead plaintiff in a recent lawsuit charging that the state is causing needless suffering and even death among thousands of people with disabilities illegally forced to wait months for medical care due to a staffing shortage in a state office. State law says it should take no more than 90 days to sign up qualifying applicants with disabilities for Medi-Cal. But, according to the Department of Social Services, the process is now taking an average of 145 days -- and as in Zelaya's case, sometimes even longer.

People with disabilities must first get approval from a state office in the Department of Social Services that determines whether they are really impaired. That office has a backlog of about 12,000 Medi-Cal applications, the department said. "There's no practice of catching people who are critically ill or near death and getting them enrolled quickly, triaged quickly or effectively," said Kimberly Lewis of the Western Center on Law and Poverty, one of the attorneys who filed the case this month in San Francisco Superior Court. The suit asks the court to order the state to end the delays and take immediate action in cases where people with urgent health needs have been waiting longer than three months for approval. The groups filing the lawsuit reviewed more than 2,000 Medi-Cal disability applications from 2005 and found that none of them was approved within the 90-day time limit.

Shirley Washington, a spokeswoman for the Department of Social Services, said the department could not comment on pending litigation. The backlog and the wait were even worse last year, when close to 16,000 people with disabilities were waiting for their Medi-Cal applications to be approved and the state was taking an average of 310 days to process each file, the Department of Social Services said. Due to state budget cuts several years ago, staffing in the Disability and Adult Programs office, which handles the applications, has been cut. The state has hired an additional 35 workers over the past two years, which has helped cut the backlog and the wait time, Washington said.

But the suit says that is still too slow, especially when the consequences can be fatal. "Our concerns are, you have a 90-day deadline by law. You have a 12,000- or 13,000-person backlog, and your goal is to try to reduce that the next couple of years?" Lewis said. "That's not good enough."

One cancer patient, unable to pay for chemotherapy, died without treatment while waiting for Medi-Cal, the suit says. Eva Baez, 58, of Livermore filed an application for Medi-Cal in January after learning she had a tumor in her liver. In March, doctors discovered a second tumor and urged her to get chemotherapy immediately. But Baez already owed $100,000 in hospital fees, so she did not begin treatment -- even though she was unable to eat or move around and was in constant pain, the suit says. State workers finally approved Baez for Medi-Cal in June, but by then it was too late. She died a few weeks later, according to the suit.

In Zelaya's case, the wait prevented her from getting rehabilitation services, pain treatment and neurological tests after she was discharged from the hospital, according to the lawsuit. When she was readmitted to Stanford Medical Center with infections several times, the hospital's financial services representatives would call her hospital room, telling her they might have to transfer her to a public hospital because she did not have insurance, she said. "I don't mind paying ... what I owe," Zelaya said. "But they were sending me to collections, and I wasn't working, I was on disability, and I couldn't even talk."

With help from an attorney, Zelaya finally got approved for Medi-Cal in June -- almost a year after her accident and seven months after the legal time limit. Her Medi-Cal was backdated, and it retroactively covered some, but not all, of her hospital costs. By that time, she said, she had already forgone medical care that she needed, such as rehabilitation services. She got stronger on her own by following exercise programs on television. "I couldn't have physical therapy," she said. "I couldn't walk when I first came out of my coma. I couldn't talk too well. ... I can talk better now. I did this all on my own."

Zelaya's struggles with Medi-Cal didn't end after she finally was enrolled. The state requires people with disabilities to recertify annually that they are still impaired and therefore still eligible for coverage. Soon after she obtained coverage, Zelaya got a thick letter in the mail. "Two weeks after they approved me, they sent me a package of 100 pages telling me my Medi-Cal was going to expire because it's been a year since I've had it," she said.

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Public hospitals frequently evoke anger

Glided over below is the aggressive response evoked from patients and their relatives after they have not been seen to even after many hours of waiting. Only the phrase "and their families" gives the game away

Public hospital staff have been forced to call for help to deal with aggressive and violent patients almost 4500 times in the past year. State Government figures show there were 4427 "Code Black" calls for emergency response teams across the state's public hospitals in 2005-06. This was 201 more than in 2004-05.

Responding to the figures, Health Minister John Hill will launch a public appeal for South Australians to treat doctors, nurses and other healthcare workers with respect. Code Black is a staff call for help when a patient's actions threaten their safety or that of others. A team, including a doctor, nurse and security guard, responds to each call. Mr Hill said the Health Department was setting up a taskforce to study hospital violence and develop strategies to deal with patients whose conditions caused dangerous behaviour. He said the number of Code Blacks represented less than 0.3 per cent of the total patient contacts, and that most inappropriate behaviour was caused by illness and not deliberate aggression towards staff. This included patients affected by drugs or alcohol, older patients with dementia, patients with organic brain syndrome and patients confused or upset after surgery.

While some incidents related to violence, Code Blacks were often called to prevent an incident which could cause injury from occurring or escalating.... Mr Hill said he was determined to make hospitals safe for staff and patients and their families. "Our health professionals are well regarded in the community, but sometimes we forget to say 'thanks' for a job well done," he said. "And when families and friends are anxious about the health of their loved ones, sometimes there are harsh words directed to the well-meaning nurses, doctors or volunteers who are nearby. "I want people to think about their actions towards health workers in our public hospitals, medical clinics and surgeries, and remember to treat them respectfully. "Working in hospitals is a vocation which asks for a very high level of commitment and care. These people are very special and valued." Mr Hill said incidents where a member of the public or a patient was deliberately aggressive to a health worker were uncommon, but acknowledged they happened.

He urged family members "who are aware that their loved ones sometimes react with anxiety or aggression in a hospital setting to let the nurses and doctors know as soon as they arrive at a medical facility or hospital". "If staff are made aware of the potential for sudden changes in a patient's behaviour, they may be better prepared and there may be less potential for injury to the patient, staff or family." The taskforce would include consultation with the Australian Medical Association and the Australian Nursing Federation. It would also look at strategies to address an ageing population and increased incidences of mental illness.

Australian Medical Association state president Dr Chris Cain said doctors and nurses were sometimes confronted with difficult situations and that Code Black was "one way to ensure these problems are dealt with through a system that indicates the nature of the problem and response required". RAH enrolled nurse Tammy Bornhoeft, 29, has been pinched and scratched by patients in her care and said staff in the general medical ward referred to a Code Black response team at least once a week. "I have nearly been punched out and it can feel very threatening," she said. "I deal with many patients with dementia and alcohol withdrawal and they can become aggressive and kick, verbally abuse you . . ."

Australian Nursing Federation state branch secretary Lee Thomas said nurses and doctors needed increased protection "against a range of different behaviours from patients and their families". "Aggressive behaviour is blamed on alcohol, drugs, grief and illness," she said.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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