Managing the incurable

Dr. Mark Lundberg, Butte County’s public health officer, knows how tragic outcomes can be for people in California who find themselves in health care limbo.

During a recent phone interview, Lundberg told the story of a local woman with diabetes who earned too much to qualify for health insurance through Medi-Cal, so she had to pay medical bills out of pocket. The woman—whose identity he kept confidential—began developing eye problems, but could not afford to manage her diabetes properly. Eventually she went blind, and only then did she qualify for public coverage through disability.

“That’s not what we want in society,” Lundberg said, “to have people qualify for insurance once they become disabled from a disease we could have taken care of early on.”

Similar stories of postponed and prohibitive treatment are common in California, according to a statewide study of chronic conditions released last month by the California HealthCare Foundation (CHF). The study, conducted in 2011 and 2012 by UCLA Center for Health Policy Research, connected economic factors, including the extent of health coverage, to the reality that “many Californians with chronic conditions are delaying needed care because of cost.”

Dr. Ying-Ying Meng, a senior research scientist at UCLA who worked on the study, said the delays in care surprised her. As co-director of the center’s Chronic Disease Program, they also concern her.

“Surely [these patients] need more care, continued care, so it’s important that they have good coverage,” Meng said. “But they still face access barriers.”

Lundberg, while not surprised about the delays, concurs with Meng’s conclusion. “Part of our job in the health care profession is to try to make a case to our patients that it’s important to get check-ups for these conditions and not wait until there’s a symptom associated with the condition,” he said. “We need to do a better job of getting access to care and getting people in, to help them not delay care.”

No matter how you parse it, the CHF report (titled “Californians with the Top Chronic Conditions: 11 Million and Counting”) offers a stark diagnosis. The situation is particularly acute in rural counties such as Butte, which not only tops the rankings for prevalence of adult asthma but also rates above state averages for diabetes, heart disease, high blood pressure and serious mental distress.

“That’s not the kind of notoriety that I want for the place I like to live,” said Lundberg.

Chronic conditions are defined as long-lasting, incurable ailments that can be managed medically. As the CHF explains in introducing the study, these conditions represent “the leading cause of death and disability in the U.S., and the biggest contributor to health care costs. But there is wide variation in their incidence, with major differences depending on age, income, race and ethnicity, and insurance status.”

Researchers also found variations based on geographic location. In Northern and Sierra counties—including Butte—statistics show 45 percent of adults with at least one of the five aforementioned conditions, compared with 36 percent in Orange County.

In the CHF study, UCLA researchers discovered that Californians with chronic conditions delay getting care and filling prescriptions far more commonly than Californians overall. Most striking are the numbers for psychologically distressed adults: around 34 percent put off treatment and 27 percent put off prescriptions, versus overall state rates of 15 percent and 10 percent, respectively. Asthma patients are second, with 21 percent putting off both treatment and prescriptions.

Some key findings in the report:

About 40 percent of California’s adults have at least one of the five chronic conditions highlighted in the study.

High blood pressure is the most common, affecting 7.6 million people (27 percent).

Age relates to prevalence: Californians 65 and older are nearly three times more likely to have a chronic condition than 18- to 39-year-olds (70 percent versus 26 percent).

Income relates to prevalence: Adults living under 138 percent of the federal poverty level are nearly twice as likely to have at least two or more chronic conditions than those in the highest income group—those who earn 400 percent or more of the federal poverty level (14 percent versus 8 percent).

Several of the determinations seem intuitive. Naturally, aging adults would have more serious health issues than younger adults, and uninsured/low-income patients would face more trade-offs than insured/higher-income patients.

But Meng pointed to a deeper context: “This [research] gives data to those [presumptions] that seem obvious, but at the same time is also sending a message. With these chronic conditions, some primary prevention can be done.”

Striding toward a more healthful “food environment” and “physical-activity environment” could reduce obesity, Meng said. That in turn could help prevent heart disease, high blood pressure and diabetes.

“Surely these conditions are related to age, but it doesn’t mean that everybody getting older has to have those conditions,” Meng said.

As for economics, when people have chronic conditions, she says, they should have better insurance coverage with a better benefits package including prevention and maintenance. “If they end up delaying care and they end up in the hospital,” she added, “that will be even more costly.”

Since the CHF/UCLA report is a snapshot of 2011-12, developments since the study period may be yielding improvements. Butte County is currently developing a Community Health Improvement Plan to address chronic conditions, socioeconomic issues and substance abuse.