"Health Care Off the Books"

Health Care Off the Books is a scholarly work with a format that resembles a thesis (what I investigated, my methods, what I found), based on the author's many years studying health care in a large city, annotated with extensive references from the sociology literature.  

For a significant portion of America's urban poor, a $15 copay presents a significant problem, as does the cost and time involved in getting transport to a medical facility.  This is of course not a strictly urban problem; I remember patients at the Veterans Administration Medical Center in Lexington Kentucky who had to travel three hours from Eastern Kentucky and often had to pay friends to provide that transport. 

The book notes how patients share their medications and share their medical devices (crutches, braces etc.)  These transactions can be charitable or for compensation, involving either left-over medication, or temporary loans until the recipient can get a scrip filled.

Sometimes the system itself is unnecessarily punitive, as in this example -

"In 2011, I visited the public aid office that serves people in and around Jackson Homes.  I had heard from residents that going to this office was often an unpleasant experience and what I observed is telling.

Another woman approached the desk, and she and the worker I had just spoken with began to argue.  The woman was concerned about when she was going to be called to the back room to meet with one of the case managers.  She explained that a case manager had come out and called her name but that, because she was on the far side of the room, she didn't hear her.  Her name had subsequently been moved to the bottom of the wait list.  She was visibly frustrated and tried to explain to the worker why this wasn't fair.  The worker argued back, explaining that if you don't get up when you are called, you have to wait again.  The woman replied that it's ridiculous that she would have to wait another two and a  half hours to have her name called again.  The worker didn't seem like she was going to change her mind.  I walked away before the situation was resolved...

I turned to a woman sitting near me and asked if she had been waiting for a long time.  She replied that she had and that she had arrived before the office opened at 8:30 a.m.  She explained that when she got there, there was a line almost a block long running down the side of the building.  She also told me that a case manager had already called her name, but that by the time she got up to the desk, she was told she had been too slow and she was not seen.  She was told to sit down again.  It appears that this is a common occurrence..."

Physicians who work in such settings can be helpful ("Doc, the small pills cost me the same as the bigger ones"  "OK, I'll write for the higher dose, and you can split them in half") or obstructionist (not writing for refills in order to generate return visits and more income).

The book is not a polemic decrying the system - just a sober analysis of what inner city impoverished people do to obtain health care in the American system when they are uninsured.  Some of the worst aspects of the health care system have improved since the implementation of the Affordable Care Act, but obviously much remains to be done.