Commentary & Opinion: Where the Healthcare System Falters, Philanthropies Step In

While healthcare reform has been an on-and-off priority of the United States government for more than four decades, charitable organizations have worked diligently to provide for the unmet needs of many Americans who simply could not wait for change.

In recent years, escalating costs exacerbated the long-running problem, but the additional pressure of the current recession has made the situation simply untenable. For the first time in two generations, substantive reform measures seem not only possible, but probable — and within a matter of months. This is good news for many, but it does not come soon enough for the millions of Americans who need help today.

While there now seems to be a firm commitment to overhauling the nation’s healthcare system and reducing barriers to care — and in recent polls, the American public is clamoring for it — it is crucial to remember that simply providing healthcare coverage does not guarantee access to treatment.

In addition to the estimated 47 million Americans who have no health insurance at all, recent studies estimate that anywhere from 25 million to more than 70 million Americans are underinsured. These are people who have coverage but are still unable to meet their share of the expenses required by their health plans for costs such as drug co-payments or even the insurance premiums themselves. Individual consumers’ share of the healthcare cost burden has grown by 40 percent during the past decade, and more than one in five patients has been forced to abandon treatment because they could not afford to pay for it.

As millions of Americans face the alarming prospect of ever-higher out-of-pocket expenses for their families’ health care, reform must avoid replicating the existing, fundamental problem with coverage: insurance can never address the needs of individuals who cannot afford their insurance co-payments, premiums, co-insurance, or other out-of-pocket healthcare costs. And many patients who struggle to pay for treatment behave in ways that aggravate the cost of care: cutting pills in half to make prescriptions last longer, substituting cheaper but less effective over-the-counter remedies, or simply skipping prescriptions altogether can lead to additional and more serious health problems, adding to the human as well as financial cost.

Pharmaceutical manufacturers established patient-assistance programs (PAPs) years ago and have helped millions of people afford life-saving medicines. But as with public programs, many of these private PAPs assist only the neediest of patients or those who have no insurance at all. Middle-class working families often find themselves squeezed — they may have health insurance, but they still cannot afford to access the care that should be available to them. They are regarded as too well off to qualify for help, yet they cannot afford the care they need.

National co-payment charities also provide financial assistance to patients, and this is where many of those individuals who would otherwise fall through the cracks turn for help. Independent co-payment charities typically support the needs of those who do not qualify for manufacturers’ PAPs.

In the case of the HealthWell Foundation, eligibility is based on insurance, financial, and medical criteria. Patients must have insurance coverage for the therapy they are receiving, their total income must be below 400 percent of the federal poverty level (with adjustments made for household size and families living in high-cost areas), and they must be in the process of receiving treatment for one of the disease areas that the foundation supports.

HealthWell provides funding for more than two dozen different illnesses. The conditions are covered based on researched need, patient feedback, availability of funds, and cost of treatment, and range from macular degeneration and psoriasis to breast cancer, asthma, and Hodgkin’s disease. If an applicant does not qualify or there is not enough funding available for a specific illness, HealthWell refers the patient to another foundation, assistance program, or patient advocacy group so that nobody is left behind.

Unfortunately, too many Americans are just one major diagnosis away from facing financial ruin. Many families are diligent about setting aside money for medical expenses, but there is no way to predict the future, and even patients with a steady income and insurance coverage are hit hard by the difficult choices that a serious illness can present. In fact, a Harvard University study found that medical bills are the number one cause of bankruptcies in the United States, and more than 75 percent of those who declared bankruptcy due to medical bills had health insurance at the start of their illness.

With the national unemployment rate hovering near 10 percent, the ranks of the underinsured continue to grow, especially among those living with serious and chronic conditions. While some of these underinsured find help through co-payment charities like HealthWell, this is only a temporary stopgap — a few fingers stuck in an enormous dam that is about to burst. As the economy has collapsed, organizations like HealthWell have seen a substantial surge in applications for financial assistance.

During a recent six-month period, assistance programs saw a 10 percent to 15 percent jump in inquiries for assistance. On average, the HealthWell Foundation receives more than 18,000 phone calls and over 7,000 applications each month. If the economy continues to shed jobs and more Americans lose their employer-sponsored health insurance, the number of people seeking assistance will likely continue to grow. But even if the recession were to end tomorrow, the current circumstances are unacceptable.

Tens of thousands of people across the country have relied on charitable organizations like the HealthWell Foundation to pick up the slack; in 2008 alone, HealthWell awarded $105 million in grants to more than 37,000 patients.

Co-payment charities like HealthWell make a crucial difference in patients’ lives every day — patients who otherwise would not have been able to afford their treatments. Whatever structure national healthcare reform ultimately takes, philanthropies will continue to provide for the unmet needs of patients but will not be able to keep pace with the surge in need without a simultaneous surge in contributions.

Stephen Weiner, president of the HealthWell Foundation, is the chair of the Health Law practice at Mintz Levin in Boston. He has had more than thirty years of experience in the healthcare field as a policy maker, educator, and attorney representing healthcare services providers in a broad array of legal matters.