Coverage? Getting There. Access? Not Yet

Pamela Merritt

The promise of universal health care coverage appears to be within America's grasp. But health care reform must address barriers to access beyond coverage to be truly universal.

Universal health care is one of the top policy issues in this historic election year. Like many voters, I've been reading each candidate's plan and the many critiques of those plans. One thing is for certain, for every article written in support of a universal health care plan there is an article written denouncing it. Debates swirl over coverage and mandates and how it will all ultimately get funded.

Mike Huckabee, who is still campaigning for the Republican nomination, believes that the current system is irrevocably broken but he opposes federally mandated universal coverage. Senator John McCain, Huckabee's opponent and the presumptive nominee of the Republican Party, opposes federally mandated universal health care coverage. Both candidates for the Democratic nomination, Senator Clinton and Senator Obama, support universal health care with the difference being in the details.

The payoff to these debates may be health care coverage for all Americans and the assumption is that health care coverage for all equals universal access to quality medical care. Most experts agree that proactive and preventative medical care is the ideal prescription for a long and healthy life. Early detection of certain cancers can mean the difference between survival and death while the prevention and early treatment of heart disease would save millions of lives. Prevention of sexually transmitted diseases and infections through education and treatment programs would work to support the reproductive health of thousands.

However, the assumption that universal coverage will result in universal access is flawed. Many Americans face barriers to accessing medical care that go beyond coverage.

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Socio-economic barriers bar access to quality health care. Some women must battle against inadequate childcare or a lack of child care options that hinder their ability to make medical appointments. Securing reliable transportation to and from medical facilities is a very real challenge that often requires elaborate planning to overcome and may result in financial hardship or debt.

I know a single mother who spent several days trying to secure child care for her son so that she could go to a doctor's appointment after school. The closest medical facility was only open Monday through Friday and her daycare closed at 5 o'clock in the evening. Since she couldn't afford a taxi cab and the bus would take too long the woman had to ask a relative for a ride. She was forced to reschedule her appointment several times when either her child care provider or transportation fell through. As a result, the woman missed her monthly appointment.

Lesbian, gay, bisexual and transgender Americans also experience barriers to accessing health care. From the medical forms required to check in for an appointment to the language used during that appointment, there are factors at play that discourage patients from seeking medical care.

LGBT individuals often face homophobia when coming out to their medical care provider. Heterosexist assumptions create the false perception that lesbians and bisexual women are not at risk for sexually transmitted infections. Many medical providers lack any basic knowledge about the lives of LGBT Americans and that lack of knowledge stands in that way of quality healthcare while putting patients at risk.

I am reminded of the documentary Southern Comfort directed by Kate Davis, which followed the last year in the life of a female to male transgender person who was dying from cervical cancer. Robert Eads lived in rural Georgia and could not find a doctor willing to treat him for cervical cancer because he was transgender. The film follows Eads through his last year of life while his family and friends struggle with the possibility that his death was preventable but for transphobia.

Many Americans and immigrants face a language barrier when seeking medical care. Hospitals and clinics struggle to fill the need for translators while patients face risks stemming from miscommunication over symptoms or a misunderstanding about the proper dosage of medication. The denial or delay of medical care due to a language barrier is discrimination (Title VI of the 1964 Civil Rights Act) and medical facilities that receive Medicaid or Medicare must provide language assistance to patients that demonstrate limited proficiency in English. But with demand for translators higher than the supply many patients are not provided one and many doctors have not received training in how to work with a translator.

The promise of universal health care coverage and the access it could provide appears to be within America's grasp. People wouldn't be debating the details they didn't believe in that promise, but universal health care must address barriers to access beyond coverage to be truly universal. In order to insure universal access to health care those barriers will need to be discussed at the policy table too.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”

News Law and Policy

Anti-Choice Group: End Clinic ‘Bubble Zones’ for Chicago Abortion Patients

Michelle D. Anderson

Chicago officials in October 2009 passed the "bubble zone" ordinance with nearly two-thirds of the city aldermen in support.

An anti-choice group has announced plans to file a lawsuit and launch a public protest over Chicago’s nearly seven-year-old “bubble zone” ordinance for patients seeking care at local abortion clinics.

The Pro-Life Action League, an anti-choice group based in Chicago, announced on its website that its lawyers at the Thomas More Society would file the lawsuit this week.

City officials in October 2009 passed the ordinance with nearly two-thirds of the city aldermen in support. The law makes it illegal to come within eight feet of someone walking toward an abortion clinic once that person is within 50 feet of the entrance, if the person did not give their consent.

Those found violating the ordinance could be fined up to $500.

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Harassment of people seeking abortion care has been well documented. A 2013 survey from the National Abortion Federation found that 92 percent of providers had a patient entering their facility express personal safety concerns.

The ordinance targets people seeking to pass a leaflet or handbill or engaging in “oral protest, education, or counseling with such other person in the public way.” The regulation bans the use of force, threat of force and physical obstruction to intentionally injure, intimidate or interfere any person entering or leaving any hospital, medical clinic or health-care facility.

The Pro-Life Action League lamented on its website that the law makes it difficult for anti-choice sidewalk counselors “to reach abortion-bound mothers.” The group suggested that lawmakers created the ordinance to create confusion and that police have repeatedly violated counselors’ First Amendment rights.

“Chicago police have been misapplying it from Day One, and it’s caused endless problems for our faithful sidewalk counselors,” the group said.

The League said it would protest and hold a press conference outside of the Planned Parenthood clinic in the city’s Old Town neighborhood.

Julie Lynn, a Planned Parenthood of Illinois spokesperson, told Rewire in an email that the health-care provider is preparing for the protest.

“We plan to have volunteer escorts at the health center to make sure all patients have safe access to the entrance,” Lynn said.

The anti-choice group has suggested that its lawsuit would be successful because of a 2014 U.S. Supreme Court decision that ruled a similar law in Massachusetts unconstitutional.

Pam Sutherland, vice president of public policy and education for Planned Parenthood of Illinois, told the Chicago Tribune back then that the health-care provider expected the city’s bubble zone to be challenged following the 2014 decision.

But in an effort to avoid legal challenges, Chicago city officials had based its bubble zone law on a Colorado law that created an eight-foot no-approach zone within 100 feet of all health-care facilities, according to the Tribune. Sidewalk counselor Leila Hill and others challenged that Colorado law, but the U.S. Supreme Court upheld it in 2000.

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