As I walked past her office the nurse practitioner asked me to speak to a man at one of the public health clinics. His blood pressure was 190/120. He was asymptomatic. With further questioning, he was well acquainted with his diagnosis of hypertension. Years ago he had taken a combination of three medications to control his hypertension. Due to excessive cost and a lack of insurance, he had discontinued seeing his doctor and stopped taking all medications. He had a strong family history of both heart attacks and devastating strokes. He works full time in food service at a large Mississippi employer. Health insurance was available through his employer, but the premiums were so large that he could not afford to survive day-to-day and pay for his health insurance. To many of us this decision would seem to be unacceptable, reckless. To him it was perfectly logical; an acceptable risk to benefit ratio given the weight of his monthly financial pressures.

We all think of hypertension as the silent killer, but working close alongside is being uninsured (or underinsured). A 2002 report from the Institute of Medicine identified a 25% increase in mortality attributed to lack of health insurance.1 This increased risk of death is not dissimilar to that from hypertension.2 Although we have made remarkable gains in insurance coverage over the last 15 years, large segments of our population remain vulnerable to being uninsured. Children and older people have very high rates of insurance coverage, but working age adults have been stuck with relatively high rates of being uninsured. In Mississippi, with one of the highest uninsured rates in the country, one in five working age adults does not have health insurance. This rate has remained stubbornly stable over the past decade. This rate is even higher (~25%) among those living below 138% the federal poverty level. Members in this income bracket are typically covered under Medicaid expansion in states that have accepted federal funding for that purpose. Approximately half of uninsured working age adults in Mississippi have a full-time job and another 20% are working part time.3 Mississippi’s primary issue is not that people are not working, but that the system is not designed for insurance to be available or affordable for so many of our hard-working neighbors. In a CDC study from 2020, the number one reason people did not have health insurance was that it was inaccessible due to cost.4

For those of us working in healthcare, it is abundantly obvious that health insurance is essential to access health care. There are no general programs to provide healthcare for the uninsured that do not require a substantial outlay of cash payment. Community health centers, which come closest to filling this gap, still require sliding scale payments based on income, and additional charges such as labs must be paid, often at retail rates. Furthermore, specialist care is almost out of the question outside of acute care scenarios. But there are other possible options.

I learned early in my career that being a physician was much more than being a medical scientist. We are often part counselor, part social worker and part friend. Although there are many other support personnel that assist in these endeavors, few people have the same breadth of understanding of the healthcare system as physicians. I referred my hypertensive patient to a local free clinic where I work regularly. Free clinics provide an invaluable service for people with limited resources, but their impact can only go so far. I am hopeful that he will in fact qualify for one of the current ACA (Affordable Care Act) private plans available from healthcare.gov. There is a provision in the ACA in which patients with premiums that exceed 9% of their income can qualify for these subsidized plans. Given his income level he may be eligible for premiums as low as $10 per month. Time will tell. If he does not, we will try to stitch together a patchwork quilt of the best potential options, but nothing will grant him full access to the advances of modern medicine but access to insurance coverage.