"...Nix costs $22.99, and this woman didn't have it."

When I am determining what to do with my monthly allotment of petty cash, two things are always at the very top of the list - get IDs for those without them and stash some cash for those who will need prescriptions filled. I've never seen such bizarre policies with prescriptions as I have here in Nashville. For example, we have a program called Bridges to Care available over at Meharry. It's a great service and there is a pharmacy onsite so that peeps who get scripts down in the clinic or ER and can't afford to fill them can get them filled for free. Bitchin, except..... What often occurs is that the folks are given scripts that aren't covered by the B to C pharmacy. One option is to take the script to another agency in order to get them to cut a check for the cost. But that means you have to take the original script to the Krogers over on Rosa Parks Blvd, get the price quote from the pharmacy tech, then hoof it over to the other agency to get them to cut you a check for that amount. Did I mention they are closed on Friday and through the weekend? Think about this for a second. You are sick - maybe with the nasty flu that went around here this winter - barely able to drag yourself out of bed or out from under the bridge you call home. You stagger down to the ER, wait 5 hours to be seen, trudge upstairs to get your script filled and then discover that they don't carry it. Now you must walk to Krogers, get the printout with the price, walk up to MAC to get a check, then walk back to Krogers to get the prescription actually filled. Riiiigggggttttt......

(Click on map for large size)

And if you've gone to an ER other than Meharry, you're in real trouble because they aren't giving away meds for free, let me tell you, and you can't take that script to the B to C pharmacy because the script has to come from Meharry physicians. The reality is that most folks just end up throwing those scripts away, or they head over to Meharry, effectively double-dinging the taxpayer and those of us with insurance who must now offset the costs of two unpaid ER visits. Some wander down to the downtown clinic, wait in line there until they get serviced, then get their scripts filled right there. Unfortunately, the sick individual has by that time interacted with at least a few folks on the way, quite possibly passing on the illness in the process. Sigh. By the way, if you're poor, in pain and not seen at Meharry, better get used to suffering because just about no-one fills "pain" scripts. Too much risk of "abuse".

And don't even get me started on the use of meds that generics can't be substituted for.....

Poverty is Hazardous to Your Health

By Katha Pollitt, The Nation. Posted September 27, 2007.

A look at the penny-wise, pound-foolish complexities of our bizarre healthcare system.

The four of us were just about to sit down to a delicious end-of-summer dinner of grilled pork ribs and corn on the cob when the phone rang. It was for my friend, Dr. Michele Barry, Yale medical school professor and chief of one of the teaching wards at Yale-New Haven Hospital, who was on call that weekend. "Tell me what's the matter," she said into the receiver, using her reassuring, unfazable doctor voice. "Hmm-hmm. And how long has this been a problem?" Michele left the room briefly to continue the conversation, and when she came back she was in full exasperated-at-the-system mode. The patient, mother of a month-old baby, was crying on the phone because for the past two days she had been tormented by head lice (Pediculosis capitis, if you really want to know). A simple problem, you might think--head lice is endemic among schoolchildren, as many a parent could tell you--and one that hardly needs a high-powered medical consultation. You just go to the drugstore, buy a bottle of Nix (permethrin) over the counter and spend a lot of time with that little plastic comb. But Nix costs $22.99, and this woman didn't have it. By then it was Saturday night, and the drugstores in her neighborhood were closed until Monday. Fortunately, there was an all-night pharmacy, so Michele prescribed her permethrin, which Medicaid would pay for. She does the same thing for women with yeast infections who can't afford $16 for the over-the-counter Monistat: She prescribes terazol (a much more expensive medication), which is covered by Medicaid.

You can see this incident as a tiny illustration of the penny-wise, pound-foolish complexities of our bizarre healthcare system, in which routine problems are treated as full-blown emergencies, and the government will pay for prescriptions but not over-the-counter medications that may be cheaper and work just as well. The President asserted that there's no healthcare crisis, because anyone can just go to the emergency room if they need care. He's wrong--ERs don't give ongoing or preventive treatment; they just patch you up in a crisis. But to the extent that ERs and free services like Yale's have become the family doctor or the CVS for low-income people, that is the problem, because they're incredibly expensive. This is the system its defenders claim we must keep because single-payer health insurance would bankrupt the nation.

But this is also a story about the way poverty and health are intertwined. If you are reading this, chances are good that you can put your hands on $22.99. It's not a huge amount of money--it's pizza and beer for two, a hardcover book, two tickets to the movies. But there are a lot of people like Dr. Michele's patient, for whom $22.99 might as well be $122.99. They just don't have it when they need it. Even the co-pays on lifesaving prescription drugs can be too much for them. "I have patients who say to me that they can't afford to get both the diabetes and the heart meds, so they're just getting one this month," says Dr. Mark Cullen, also a Yale professor of medicine, and Dr. Michele's husband.

Forget, too, the other things so necessary to good health that the rest of us take for granted. Fresh fruits and vegetables--try even finding these in an inner-city neighborhood. Clean air--poor neighborhoods are notoriously the most polluted. Safe streets. Housing in good repair. A life with no more than the ordinary amount of stress. Well, you'd be stressed out too if you couldn't afford to get rid of your head lice. What else can't Dr. Michele's patient afford if she can't afford that? Try school supplies and books for her child in a few years. Try vitamins and a good breakfast every morning.

We hear a lot these days about the struggles of the middle class. Remember M2E2--Medicaid, Medicare, education, environment--the mnemonic New Democrats adopted after the Republicans took Congress in 1994? Except for the minimum wage, even progressives now routinely frame their policies around middle-class concerns--homeownership, college loans, Social Security, affordable health insurance. (I'm not saying low-income people don't need these things too, just that they are politically salient because the middle class cares about them, as it does not care, for example, about the inner city, school integration or prison reform.) John Edwards is about the only presidential candidate who mentions the 36.5 million Americans--12.3 percent--who fall below the poverty line ($10,488 for a single person, $20,444 for a family of four), and the additional 19 percent who are what sociologist Katherine Newman calls the near poor--100 to 200 percent above the poverty line. Only Edwards talks about the need to eradicate poverty, which he claims would take thirty years. So far his antipoverty platform has mostly reaped him charges of hypocrisy in the media for having a big house and getting expensive haircuts, as if there has to be something fishy about a rich man who campaigns against poverty and asks for poor people's votes. It's as if all the media talked about in 1932 was FDR's cigarette holder. A cigarette holder! Who does he think he is?

Dr. Michele's patient is lucky--she has free healthcare, and from top doctors too. What she obviously doesn't have is enough money to live on. Any emergency, and every life has them, could push her and her baby into homelessness. Significantly, affordable housing is not on the progressive agenda (affordable mortgages is something else--that's "homeownership," a middle-class shibboleth). Yet we are still facing a severe affordable-housing shortage. The rule of thumb is that a person should pay no more than 30 percent of his or her income for housing, which means that someone at the poverty level should be paying $262 a month, max. According to the 2006 Census, only 5.6 percent of New Haven's rentable housing units cost $299 per month or less. Given that 21 percent of New Havenites are below the poverty line, the vast majority of them must be doubling and tripling up, or paying far too much of their income for housing.

If Edwards has a plan to lift out of poverty Dr. Michele's patient and the millions like her, I don't care if his locks are as luxuriant as Little Lord Fauntleroy's.