When I first started medical school, I had a very oversimplified understanding of health insurance. Everyone needs health insurance, I thought; sure, it may be expensive, but not having insurance is gambling with your health. How hard could it be to get patients connected to this potentially life-saving intervention that has been shown to improve health access and outcomes?
Then I got involved in the University of Michigan Student-Run Free Clinic, a wonderful opportunity for students, under the mentorship of faculty physicians, to serve a mostly rural and uninsured or underinsured population in Michigan. Serving our patients opened my eyes to the complexities of health insurance and health disparities in access to care.
I learned that choosing a health insurance plan is terribly complicated. Our patients have many reasons for being uninsured. Our broken health care system has let these patients fall through the cracks.
As Social Services Coordinator during my M1 year, my goal was to improve health care access by bridging our patients to insurance, helping them navigate and apply for Medicaid (insurance for low-income individuals) or individual Marketplace plans. Many of our patients had been denied Medicaid coverage because their income exceeded the eligibility requirement. I helped them explore Marketplace options and demystified the health insurance jargon—deductibles, premiums, out-of-pocket maximums, etc.
I explained to one patient, “This deductible, $1500, is the amount you have to pay before the insurance will pay for your health care.” She replied, “That’s outrageous! I have to pay this premium every month just to end up paying another $1500 before my insurance will kick in?” Her workplace did not offer health insurance as a benefit, and she was left with no other options. She left and chose to remain uninsured.
Another patient, also ineligible for Medicaid, had lost her job the year prior, and lost her health insurance and access to insulin with it. She delayed care for her diabetes due to cost, and she presented to our clinic with very poorly controlled blood sugars as well as completely preventable, irreversible nerve and kidney damage. I walked her through the lowest-price Marketplace plans. With one glance at the premiums, she said, “We can’t afford this. My husband and I have a car and mortgage to pay off.”
I am grateful that our clinic is poised to help patients in this gap–those who are ineligible for Medicaid but cannot afford health exchange plans. However, it weighs heavily on my heart that our patients are forced to choose between health and other social needs.
I believe that health is a fundamental human right to which everyone should have equal access. The existence of and need for our free clinic suggests that the larger health system has failed our patients. They come to us as a last resort, often after having delayed or forgone medical care because they couldn’t afford it. The process of obtaining insurance or applying for charity care programs is a difficult one to navigate. The process is full of jargon, which further prevents patients from being able to access the health services they need.
I want to make sure that my future patients have equitable access to health. Personally, this involves caring for the whole person and understanding the social barriers that prevent our patients from thriving. Part of my education must center on better understanding the social determinants of health and the health care system. This knowledge will equip me to advocate for policies that improve my patients’ health beyond their medical needs. Being a clinician-researcher will allow me to use data to identify and bridge gaps in our system that our patients are slipping through.
Inspired by my experiences at the Student-Run Free Clinic, I am pursuing a dual degree. I am diving into health services research through U-M’s Master of Science in Clinical Research (MSCR) program. I will take this year to learn more about the experiences of the underinsured and understand the health systems and policies that dictate my patients’ access to care.
The MSCR program has two components: didactic coursework and a research practicum. The U-M School of Public Health offers amazing courses that will build my foundational knowledge in epidemiology and health policy. I am learning to understand and analyze health from a public health framework. Meanwhile, I am immersing myself in a year-long research project to develop the skillset and tools to become an independent health services researcher in my future career.
My research project, led by Dr. Jeffrey Kullgren at the Ann Arbor VA, focuses on helping underinsured patients to better afford their care. We seek to develop an intervention to help patients with chronic diseases—specifically those who are enrolled in high-deductible health plans—to practice cost-conscious consumer strategies in health care. Such strategies may include saving for anticipated health expenses; talking to providers about costs; and comparing health costs between different locations. Patients with chronic diseases require regular medical care. High deductible health plans impose a high burden of cost-sharing. I look forward to discovering how these patients utilize their health plans and practice cost-conscious approaches. I hope that our work makes it easier for patients to understand and plan for their health expenses.
Research has the power to shape policy. I aspire to improve the health system so that all patients can receive quality care regardless of their ability to afford it. I am deeply grateful to have the opportunity to learn and serve at the Student-Run Free Clinic, an experience that has shaped how I see and approach patient care. In the future, I hope to use these new perspectives and research skills from this dual degree year to develop patient-centered interventions and advocate for policies targeted at improving health outcomes and health disparities.
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Tiffany Hu is a 4th year medical student at Michigan. She is interested in internal medicine, health policy, and medical education. She also loves travelling for good food.