Cutting Deep
Imagine having to choose between paying your electric bill and taking your sick daughter to the doctor. That’s the kind of dilemma facing working-class families these days in Texas, where the state budget has been balanced on the backs of more than 150,000 kids who’ve been thrown off the health insurance rolls. Here’s what happens when the Legislature and the governor start cutting deep.
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The best way to grasp the problem of uninsured children is to visit any emergency room in Texas, especially one that specializes in pediatric medicine. The scene isn’t as dramatic as something you might see on ER—a few kids who are having difficulty breathing because of asthma, a diabetic teenager whose blood sugar has plunged precariously low, and lots of kids with ordinary ailments who have nowhere else to go since their parents can’t afford health insurance. Here you will hear stories like the one Dr. Cynthia Beamer tells about the fifteen-year-old boy with the ruptured appendix. A pediatric ER physician at Christus Santa Rosa Children’s Hospital, in San Antonio, Beamer often sees children with appendicitis whose families have waited until the eleventh hour to bring them to the emergency room. Sometimes these patients’ appendixes have already burst; she once saw nine such children in one week. In the case of the fifteen-year-old boy with the ruptured appendix, he had tried, in vain, to treat his symptoms at home with Alka-Seltzer and Pepto-Bismol. He had waited for four days before telling his father that he needed to go to the emergency room. “This child was in terrible pain, but he was trying to be stoic,” Beamer says. “I asked his father why he hadn’t sought out medical attention earlier, and the boy told me, ‘It’s just me and my dad, and we don’t have any money.’ He was very frank about the fact that he had been trying to spare his father the expense of hospitalization.”
Treated early, a child needing an appendectomy will spend one or two nights in the hospital. But if the child’s appendix has already ruptured, he or she faces a minimum of five nights, and longer if complications develop. Preventive care, which CHIP provides, costs far less than treating health problems that have reached a more critical state. Take, for instance, the expense of treating asthma, which is one of the most common reasons children end up in the emergency room. A recent study by the Harris County Hospital District showed that the cost of inhaled corticosteroids, which can prevent asthma attacks if taken daily, ranges from $94 to $103 per month. But treating a full-blown asthma attack, including a visit to the emergency room and an average three-day hospital stay, runs $9,209. If the patient’s family does not have health insurance and cannot afford to pay, the hospital has to absorb some—or all—of the cost. If the hospital happens to be a public facility supported by local taxes (which is where low-income families usually end up), the cost is passed on to the taxpayers. Not quantifiable are the other benefits of treating asthma early: A child is less likely to miss school, to develop bronchitis or pneumonia, and to suffer from lifelong lung disease. Still, for families who are struggling to get by without health insurance, the combined cost of asthma medication and regular doctor’s appointments is often prohibitive, which is one reason why, if you glance around an ER, you will likely see so many children wheezing in the waiting room.
Many of the chronic illnesses ER pediatricians encounter, like asthma and diabetes, could be better managed if parents had health insurance that enabled them to afford regular checkups and prescriptions for their children. Instead, too many kids have to be treated episodically. “If they’re having an asthma attack, I can stabilize them,” says Dr. Christine Koerner, the chief of pediatric emergency medicine at Lyndon B. Johnson General Hospital, in Houston. “But I’m just treating the superficial problem, not the underlying cause.”
After being discharged from the emergency room, kids are often sent home with prescriptions that need to be filled. For parents of the uninsured, who must pay the full price at the pharmacy, there are hard choices to make. If money is tight, do they opt to fill only the least expensive of their child’s prescriptions? Or do they stretch out the intervals between dosages or try to make do with home remedies instead? What if their child is diabetic but they can’t afford enough syringes or vials of insulin? “Sometimes they’re having to decide whether to buy medicine for their kids when it means they might not have enough money left over to buy groceries and pay the rent,” says Dr. Joan Shook, the medical director of the emergency department at Texas Children’s Hospital, in Houston.
The problems doctors see among uninsured children are not limited to chronic diseases. “Kids will have fractures that are five days old by the time they get here,” says Shook. “If a fracture isn’t set promptly, a child can incur a permanent disability.” Other complications arise when kids lack access to routine medical care. Texas currently ranks forty-fifth in the nation for its rate of immunization, one reason the incidence of whooping cough has doubled here in the past two years. If children do not have regular checkups, even controllable health problems may worsen: Uncorrected vision can impair a child’s performance in the classroom; untreated ear infections can lead to hearing loss; unfilled cavities can lead to abscesses and the loss of teeth. “We see these beautiful young people who are trying so hard to look well groomed—girls who have taken so much care to apply their makeup and to do their hair—who won’t smile or who cover up their mouths with their hands,” says Dr. Celia Neavel, the director of adolescent health services at the People’s Community Clinic, in Austin. “It’s only when you examine them that you see the holes in the backs of their mouths where they’ve lost permanent teeth. It’s heartbreaking.”
The evidence that children who have health insurance lead healthier lives than children who lack it is overwhelming. Insured kids require fewer emergency room visits than the uninsured, need fewer hospitalizations, and miss fewer days of school. They see doctors more frequently, have more checkups and preventive medical care, and are more up-to-date on their immunizations. A 2002 study by the Children’s Defense Fund found that uninsured kids are twice as likely to go without needed prescription medication and eyeglasses, three times as likely to go without necessary dental care, and four times as likely to have essential medical care delayed because of its cost. Community health clinics, where the uninsured can receive care on a sliding scale, are in short supply around Texas and are often so swamped with patients that they must turn new ones away. Waiting lists can be months long. Emergency rooms continue to absorb the overflow; in the Houston area, the number of ER patients has more than doubled in the past decade. Public hospitals like Lyndon B. Johnson General Hospital, where more than half of the patients are uninsured, have been hit the hardest. “It’s very common to have waits of fifteen or sixteen hours in our emergency center,” says Dr. Margo Hilliard, LBJ’s senior vice president. “That happens two or three times a week.”
The recent cuts in CHIP have only made the problem of uninsured children worse. “When flu season hits and kids are lined up and down the halls of our emergency center,” Hilliard says, “we will have a greater number of patients to care for and decreased funds to work with.” The Center for Public Policy Priorities, a progressive think tank based in Austin, estimates that Harris County alone has lost $136,452,782 in combined state and federal CHIP dollars. That deficit, along with additional costs that rise when the number of uninsured patients increases—like charity care and bad debts—will be passed on to Harris County homeowners through their property taxes next year. None of these problems are unique to Houston; across Texas, property owners are feeling the pinch. “Whether we pay up front or on the back end, we’re still going to pay,” Hilliard observes. “It’s naive to think that if we make cuts to CHIP, kids will stop getting sick.”
SONIA AND ARMANDO Botello live on a leafy street in a working-class neighborhood on the northern edge of Houston, where the hum of lawn mowers competes with the thumping beat of hip-hop bass lines. Here, the Botellos and their four children are caught in the netherworld between poverty and just getting by, a place where one illness, or one big car repair bill, can cause you to lose your foothold. Sonia is a slight, cheerful woman in her early forties who works as a custodian for a local charitable organization. Armando, her husband of 21 years, loads precooked meals onto airplanes at nearby George H. W. Bush Intercontinental Airport. Sonia used to believe in upward mobility and the idea that hard work could earn her family a better life. Now she can barely remember what it feels like just to run in place, because she and Armando always seem to be falling behind. They have no credit cards and no savings to speak of. They spend all of Sonia’s take-home pay—$500 every two weeks—on rent alone. They have two assets to their name: a 1983 Mustang that runs erratically and a three-year-old pickup that they struggle to make payments on. If it’s not the electricity that is in danger of being cut off, it’s the gas or the phone. Every month they budget down to the penny, and every month they come up short.
The Botellos both work full-time, and still, they are barely making it. Sonia, who spends the better part of her workdays mopping floors and scrubbing bathrooms, started to feel that they were losing ground three years ago, when Armando lost his job. Throughout most of the nineties, her husband had been employed at a Houston sandpaper company, where he had worked his way up to the title of branch manager and its relatively generous $15-an-hour pay. Then came September 11, 2001. The business faltered, and despite Armando’s nine years of service, he was laid off several weeks later. The family lived off Sonia’s salary and Armando’s unemployment benefits for as long as they could. But as 2002 wore on without any job offers, they gradually exhausted their life savings. After a year out of work, Armando found the catering job that he holds now, which pays him $9.75 an hour, $840 less per month than he made before. He and Sonia now catch glimpses of each other when one is rising for work or easing into bed. (Because they can’t afford child care, Sonia leaves the house before dawn and returns before school lets out. Armando’s shift starts as hers is ending.) “Sometimes we both get so frustrated,” Sonia said as she sat in the fading afternoon light of her kitchen this fall. “We never planned on working this hard and having nothing to show for it.”
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