Nurses Leaning Into Uncertainty

Throughout history, nurses have provided care to those in need despite the cultural circumstances or political scenarios at hand. Nursing care, like medicine, is a necessary service that simply needs to be provided in a society at all times. No matter that bullets are flying, elections are being disputed, or a pandemic is raging, nurses are there with their patients even as uncertainty rules the day.

Nurse Empowerment: "Now" Is Always The Time

Nurses have a long history of being significantly disempowered. Historically, nurses served as "handmaidens" to all-mighty physicians, running at doctors' beck and call. The role of the nurse has changed over the years, but we nurses still need to feel empowered to fulfill the promise of our profession.

The Consequences of Nurse Burnout

So, my friends, the votes are in and the verdict is clear. Nurse burnout has real consequences and a ripple effect that is far-reaching and pervasive. Now that we clearly know that the impact is real, just what will we do about it?

Homelessness: Action or Complicity?

With the recent revelations that the homeless population in New York City is now at its greatest numbers since the Great Depression, we are again face to face with a public health crisis of astronomical proportions.

Nursing: Trouble in Paradise?

Despite the consistently wonderful press about the trust that Americans place in the nursing profession, not to mention the heady days of new nurses being assured a plethora of jobs upon graduation, the nursing zeitgeist seems just a little diminished and subdued these days. At least for now, many new grads are hard pressed to find work and there is little to cheer about when it comes to nurses' economic standing.

Happy Patients vs Healthy Patients

Recently, I published a blog post entitled "The Disneyfication of Nursing" wherein I examined the relatively new practice of "scripting" nurse-patient interactions, demanding that nurses communicate with patients in a specific manner.

The reality is that hospitals now want to provide care with an eye towards positive scores on patient satisfaction surveys upon which Medicare will soon begin basing some of their payments. While this is an understandable---yet short-sighted--reaction on the part of facilities that receive payments from Medicare, it is clear that there is a slippery slope that may very well backfire when it comes to achieving desired patient outcomes.

The Burden of Medical Bills

A recent study released by the CDC (and reported on Medscape and other sites) states the blunt fact that 20% of American households have difficulty paying their medical bills. And the National Center for Health Statistics states that 1 in 5 Americans has lived in a family that could not pay its medical bills in the last 12 months.

Is True Preventive Care a Reality?

Last night on RN.FM Radio, we were discussing the challenges of delivering true preventive care at a time when the economics of health care often seem to be moving us in the opposite direction. Mountains of research have shown that preventive medicine and interventions can dramatically decrease the cost of health care over time, but it seems that some insurance companies still don't bite the preventive medicine bait.

Vulnerable Elders: The VNAA vs Medpac

Just today, Medpac---the Medicare Payment Advisory Commission---issued a report to Congress recommending reinstatement of co-payments for elderly Medicare recipients receiving home health services. Medpac, an independent Congressional commission, is comprised of various professionals with expertise in health care delivery and financing, with two of the current members being nurses.

The Visiting Nurse Association of America (VNAA), has categorically denounced the recommendations, maintaining that "most home health patients are elderly, female, and living on fixed incomes." The VNAA further predicts that many patients without a Medicaid supplement will undoubtedly eschew home care services due to the additional $150 co-payment being recommended by Medpac, leaving them further vulnerable to unnecessary hospitalization and avoidable complications which could be prevented by timely and affordable home care services.

Based on information obtained from the VNAA and the Medicare and Medicaid Supplement for 2010, home health patients are overwhelmingly elderly, with 34.7% between the ages of 75 and 84, and 29.1% over the age of 85. Furthermore, 63% of these patients are female, the majority on fixed incomes. The co-payments in question were eliminated by Congress in 1972 in order to foster increased usage of home care services, which are astronomically more cost effective than care in hospitals and long term care facilities.

While both agencies obviously wish to facilitate the delivery of cost-effective high quality care for needy and vulnerable patients, re-imposing potentially prohibitive co-payments on predominantly elderly clients living at home on fixed incomes is not necessarily the most judicious choice for fixing the economic woes of the American health care system. Changes are certainly needed---many of them drastic---but I support the VNAA in its opposition to Medpac's proposed reinstatement of the home care co-payments.

As a nurse with 15 years of experience focused on home care, I have seen first-hand how elderly clients on fixed incomes must frequently make difficult choices, such as choosing between food and heating oil. Adding the differential of extra medical co-payments for elderly patients wishing to remain at home rather than become institutionalized is, in my opinion, a misguided recommendation that should be set aside in pursuit of more effective (and less draconian) economic measures.

The Elderly and Medications: At What Cost Health?

Recently, my elderly mother moved from the Northeastern to the Southeastern United States in order to live closer to my sister. A widow for several years, she is on what would be classified as a fixed income, and her medical insurance premiums and prescription drug plans eat up a great deal of her monthly budget.

When it comes to some of the more pedestrian prescription medications, co-pays can range from just several dollars to perhaps $20 or $30 per month. But heaven forbid that an American elder needs a medication that is not quite so generic in nature, and the monthly payments for such drugs can skyrocket through the roof, wreaking havoc with even the most well-planned budget.

We have all heard stories of senior citizens having to decide between groceries and medications, or turning off their heat in order to pay their health insurance premiums. These stories are not uncommon, and although many of these elders may be under the media radar, we all know that there are still millions of Americans struggling to retain their health insurance, obtain health insurance, or simply get by without any coverage whatsoever.

While the debate about the new health care reform legislation rages on, we must remember that many seniors like my mother are regularly raiding their hard-earned piggy banks in order to pony up enough money to purchase costly (and admittedly life-saving) medications. While the need for pharmaceutical companies to earn money and support new research is understandable, vulnerable Americans like my mother cannot continue to be placed economically between a rock and a hard place and simply offered a pillow of pity as compensation.

I agree that reform is contentious and painful, but so is making a choice between food and prescriptions. When a senior citizen skips a meal in order to fill a prescription or pay an insurance premium, it is once again illustrated that something is wrong with this picture. And when yet another uninsured child misses her annual physical and vaccinations, this flies in the face of the Surgeon General's message of the crucial importance of preventive medicine to the over all health of the nation and its citizens.

I don't have the answer to fixing this enormous challenge that our nation faces, but I can hear in my mother's voice over the phone that this simply has to change. The United States ranks behind many other industrialized nations when it comes to important markers of public health (like infant mortality, for example), and the fact that so many Americans continue to languish without health insurance would be laughable if it wasn't so tragically sad.

Every generation strives to leave a hopeful economic and social legacy for its offspring, and my mother's generation, who lived through the Great Depression, is no slacker in this regard. But when we see octogenarians eschewing good nutrition in order to pay for their basic health needs, we must realize that we are forgetting the sacrifices that our elders made for us in decades past. Change will come, but what cost we pay in the interim certainly remains to be seen.

Can Obama Do It?

Even though I rarely listen to the radio anymore and no longer have TV, we tuned into President Obama's health care speech this evening, and I felt stirrings of hope as his words flowed through the airwaves.

Not having examined the speech closely, my hope is tinged with a hint of cynicism at the ways of Washington, but with the post-humous words of Ted Kennedy spurring us on, I feel that perhaps the reform we have all been waiting for may actually come to pass.

Even as the debate rages on, millions of American children still live without health insurance, the unemployed and underemployed seek primary care in emergency rooms, and the self-employed struggle to find coverage that doesn't break the bank.

Cries of socialism abound, but the President reminds us that Medicare itself was derided as being tantamount to socialism back in the day, and that "sacred trust" is now a promise that no American would ever wish to see broken.

I hold out hope that we will see comprehensive health care reform in this decade, and that my grandchildren will grow up in a country where they will never need to choose between medicine and groceries.

Health care reform? Socialism? If every American can obtain affordable coverage and no one has to go without, then I don't care what we call it. Can Obama do it? Only time will tell.

Of Tetanus and Fishing Line

"I heard you have free shots here, and I think I need a Tetanus shot." He is a friendly middle-aged man with a thick accent.

"Well yes, I usually do, but I don't have any Tetanus today. I'm sorry. But call me in two weeks and I'll have some for sure. Is it urgent?" I ask.

"Not really," he says. Pulling up his sleeve, he reveals a fairly large slice on his bicep, sewn together with blue fishing line.

"I work as a carpenter, and I often cut myself," he explains. "Whenever I do, I get out my needle and fishing line and stitch it up myself." He is obviously proud but simultaneously nonchalant.

"Wow. That's impressive," I reply, examining his needlework and the reddened area around the wound. "Do you know when your last Tetanus was?"

"Not really," he replies, "but I'm sure I'll be OK."

"You can go to several places that offer free care. They may have Tetanus in stock."

"No thanks. I'll call you in a few weeks and get it then. No problem."

I give him my card and tell him to call me in a week or so. My vaccine order is late this month and I feel badly that I wasn't able to make the order in time for this month's clinic. His DIY stitching was indeed impressive, but it drives home the point that there are millions of Americans just like him who have no health insurance and no way to receive even the most basic medical care without a great deal of effort and expense.

So, this man carries fishing line and a (sterile?) needle in his toolbox when he's on the job. How many people walk around with poorly healed wounds, unnecessary infections and God knows what else while corporate executives make off with billion-dollar severance packages?

It's enough to make me want to go fishing and leave it all behind.

New Nurses: Where to Go?

It seems that newly graduated nurses who want to remain in New England may need to rethink their job-hunting strategy.

According to nursing students that I know who are graduating next month, the lack of nursing jobs in New England---especially in the Boston area---is an enormous disappointment. According to one student I spoke with today, only four of her fellow graduates have landed a post-graduation job, whereas in previous years, recruiters were falling over themselves to hire new grads as fast as they could pass the state boards.

While a nursing shortage still seems to be cooking in the health care cauldron, the economic engine driving the creation of new nursing jobs is sputtering, at best. And while New England currently seems to have a hiring freeze in place, states like Texas, Florida, California and Montana are apparently the places to go for new nurses---or seasoned ones---to find gainful employment.

If hospitals and health care facilities are still short-staffed but unable to hire, what are they doing to their nurses whom they still employ? Are double-shifts and mandatory overtime being touted as the answer to the shortage? With hiring freezes in place, do the nurses on staff work harder, care for even more patients, and sprint headlong towards burnout? What are the human resource consequences when conditions prevent new nurses from being brought into the workforce despite an ongoing shortage?

I'm no expert, but I can see that the nursing economy has been hit hard by the current economic downturn, and if I was a new nurse just out of school, I would think outside of the box, look as far afield as I could, and be willing to travel wherever the work was. Be it Florida, Texas or Montana, getting one's feet wet as a novice nurse is crucial, and spending some time in an unfamiliar region of the country might not necessarily be a bad thing, especially if one is young, unattached, and prepared to relocate for gainful employment.

I have encouraged many people to go to nursing school, and I hope that those who have heeded my advice don't rue the day that they made the fateful decision to become a nurse. But like all situations, this current economic reality will also pass, and nursing's economic and employment landscape will also change.

Lucky and blessed to myself have an interesting (but not terribly well-paying) job, I wish these new grads luck, and hope that they can navigate these current waters with grace and a modicum of patience.

Every nurse deserves a job, and every patient deserves a well-educated and well-paid nurse. My hope is that this current crop of new grads will find the employment they need, the experience they desire, and rest assured that they have chosen their new career well, no matter the current economic conditions.

Electronic Medical Records and Wal-Mart?

Every week, I receive emails asking me to review a product, comment on an article, or react to something happening in the world of health care. From nursing to union organizing, the requests come in fairly regularly.

Not long ago, I was asked by a website called Software Advice (who offer free advice on software to consumers) to examine a new partnership between Wal-Mart and eClinicalWorks. It seems that Wal-Mart, in its infinite wisdom (or lack thereof) has decided to go into the Electronic Medical Record (EMR) business, partnering with eClinicalWorks to sell a $25,000 software and hardware package to physicians at Sam's Club outlets.

In terms of EMRs, I'm no expert, and while I have used a number of EMRs that were variable in quality and usability, I cannot speak to the quality or usability of eClinicalWorks' products. However, as a consumer, I know that I have never set foot in a Wal-Mart due to the fact that I am staunchly opposed to Wal-Mart's labor practices, their dumbed down sales pitch, and their ubiquitous ability to sap the life out of local business wherever they pitch their (ever enlarging) tent.

The article by Software Advice about these unlikely bedfellows makes a good point that "team members" at Sams Club and Wal-Mart outlets will no doubt be woefully inadequate in their ability to provide adequate information to potential buyers of this software, and physicians who suffer buyer's remorse after taking home their new acquisition may rue the day they set foot in Wal-Mart to buy toilet paper and subsequently walked out with an EMR they didn't know they needed.

The Software Advice writers seem to feel that eClinicalWorks' software is a quality product that can deliver the goods, and I have no qualm with that opinion. But when it comes to Wal-Mart sticking their noses into such a specialized area of health care delivery, my squeamishness meter goes through the roof.

Good luck to eClinialWorks as they partner with a wholesale behometh that has basically co-opted the local store in towns from Canada to Mexico and beyond. Many readers of Digital Doorway most likely are already aware of my disdain for such companies as Wal-Mart, and if I were a doctor shopping for an EMR, I would certainly not plunk down my credit card for a $25K investment sponsored by a retail giant whose reach is already far too long. In the words of someone famous and dead, caveat emptor!

Obama Administration and Congress Invest in Nurses

Several major American nursing organizations are applauding the support demonstrated by Congress and the Obama administration for the nursing profession, with newly allocated funding that should have a profound impact on every aspect of nursing, including the central focuses of education, practice, retention and recruitment.

As part of the American Recovery and Reinvestment Act (H.R. 1), $300 million were awarded to the National Health Service Corps and $200 million will be divided between the Nursing Workforce Development Programs (Title VIII of the Public Health Service Act) and the Health Professions Training Programs (Title VII). $10 billion will also be allocated for the National Institutes of Health, with $7.4 billion distributed to various Institutes, including the National Institute of Nursing Research, further demonstrating that nursing's contributions to both the clinical and research worlds is indeed taken seriously.

The provisions in H.R. 1 allow for money to be distributed directly to nursing students and schools of nursing, with allocations for Title VII programs like Scholarships for Disadvantaged Students and the Faculty Loan Repayment Program.

Additionally, the monies allocated for the National Health Service Corps will fund scholarships and loans to nurse practitioners, certified nurse-midwives, primary care physicians, dentists, mental and behavioral health professionals, physician assistants and dental hygienists.

In blog posts leading up to President Obama's inauguration, I voiced cautious optimism (and some considerable doubt) that an Obama administration would pay close enough attention to the nursing shortage, addressing not only the need for increased scholarships and education funding for nursing students, but also funding to address the lack of qualified nursing professors available to educate new nurses. Seemingly, multiple levels of the nursing profession have been addressed under the auspices of these new programs, and the money allocated will not only provide scholarships for nursing students, but will also offer loan repayment programs for those nurses who might wish to teach but would likely be dissuaded by the relatively low salaries offered to nursing professors.

I am heartened by this news, and foresee a blossoming of the nursing profession at a time when a universal nursing shortage (and an economy in apparent free fall) inform the overarching zeitgeist that currently casts a pall over the entire health care industry. Yes, most nursing schools are filled to capacity, yet that capacity is generally hobbled by a profound shortage of professors, a reality which very well may be addressed as these funds become available.

These are difficult economic times for many Americans, and as President Obama's economic recovery plan is actualized, we will begin to see the ways in which the plan may succeed and fail. Over all, I feel optimistic that, in terms of the nursing profession and the profound shortage therein,we will sense a discernible sea change if the allocated funds are targeted and distributed as proposed. While I have not seen the fine print (and we all know that the large print can giveth and the small print taketh away), my hope is that the fine print will in no way diminish the potential impact of such an historically and economically significant investment in the future of nursing.

Despite the dire warnings and the hand wringing occuring nationwide as the unemployment roles grow, perhaps some optimism, positive movement and job growth within the nursing profession will have a ripple effect throughout the health care industry. And for this we can only hope.

Chronic Disease and Optimism for the Future

A recent press conference sponsored by the Partnership to Fight Chronic Disease (PFCD) revealed a startling statistic: chronic disease costs the American taxpayer more than two Wall Street bailouts per year. (To listen to the press conference or download a transcript, click here.)

According to PFCD, 45% of Americans live with a chronic illness; poorly controlled asthma sends 5,000 people to the ER every day; and obesity rates of American teenagers has tripled in the last 20 years.

Perusing the PFCD website, it's obvious that there is a great deal of optimism being verbalized vis-a-vis the opportunity that Barack Obama and his administration have in terms of addressing chronic illness and health care reform. Improvement in the management of chronic illness is seen as a clearly bipartisan issue by many in the know, and a number of members of Congress are apparently already preparing policies vis-a-vis these issues in advance of Mr. Obama's inauguration and first 100 days of governance.

In terms of technological advances, there are many policy-makers and consumers who are calling for a national Electronic Medical Record (EMR) that will streamline information, track prescription drug use and medical visits, as well as allow more continuity of care. This type of system would also allow for easy access to immunization records, would simplify facility-to-facility patient transfers, and facilitate care of patients who have moved or who need health care while traveling. Furthermore, chronic disease care could also be greatly enhanced by such centralized record-keeping, providing crucial financial and medical data about the overall state of American health---and its medical management. While pundits (justifiably) worry that a government-run EMR could raise Orwellian privacy concerns, perhaps some type of third-party oversight could assuage such fears as the project moves ahead.

Obviously, something needs to be done to address the state of disarray in which we find health care in America. We are less healthy, more obese, taking more chronic medications, and experiencing greater levels of stress than ever before. Sadly, 40 million of us are still uninsured (a pathetic statistic which I am apt to belabor ad nauseum here on Digital Doorway), and the percentage of us suffering from chronic conditions such as diabetes and heart disease is currently rising.

As 2009 beckons, the Obama-Biden transition team is revving its engines and preparing for an all-out attack on the American economy, including the economics of health care. In my virtual peregrinations, I am seeing that a great deal of optimism is being expressed vis-a-vis the future of health care and chronic illness management in the United States. As the economy inevitably rises from the ashes and financial stability returns to the markets, many feel that the health care
infrastructure will also revive itself with government-funded resources aimed at curbing chronic illness and improving public health. As a newly-minted Public Health Nurse, I am quietly joining that chorus of optimism, and will do my best (from my lowly municipal position) to support those valuable and forward-thinking efforts.

Young Adults, Healthcare and the Economy

A recent study by Medco Health Solutions reveals that the current economic downturn and increasing healthcare costs are having a severe effect on young adults.

With an increasing number of young adults in their 20s and 30s living with chronic health conditions, health insurance and prescription drug coverage are no longer just issues for middle-aged and older adults. The survey further revealed that young adults are considerably less savvy when it comes to finding ways to save money on healthcare.

Other recent reports show that the prevalance of mental illness among young adults is significantly high, but only a small percentage ever actually seek treatment. With potentially 50% of young college-age adults meeting criteria for substance abuse disorders, personality disorders or other conditions, it is disconcerting that less than 25% are under active medical care.

If the lack of health insurance, the prohibitive costs of prescription medications, or exponentially increasing college tuition is keeping young adults from seeking medical or psychiatric treatment at a very vulnerable time of development and maturation, important outreach and motivational education needs to be set in motion in order to counterbalance such a trend. Whereas older adults might make healthcare expenses more of a personal economic priority in times of fiscal stress, perhaps young adults are less likely to eschew social outings, travel, and other activities in order to save money to cover their healthcare costs. This trend is worrisome since untended health maintenance issues early in adulthood can often come back to haunt the unsuspecting person in middle age.

I am not at all suggesting that young adults are categorically frivolous or laissez-faire about their health, but studies do clearly suggest that they are less likely to understand how to manipulate the economic system to their personal advantage vis-a-vis healthcare expenses. Additionally, having once been a young adult myself, health is generally not as great a priority when one is twenty-something as when one crosses the threshold into middle-age and the first half of one's life comes to a resounding close.

Universal healthcare and free higher education would most likely go a long way towards easing the economic strain on today's young adults, but I would be interested to see a study comparing the healthcare-seeking habits of European young adults (who already have free medical care and higher education) and their American counterparts. It would be revealing to ascertain if it is indeed the cost of healthcare that prevents young adults from seeking care, or if it is more of a developmental issue which is part and parcel of the maturation process.

While considering the underlying causes of the phenomena revealed by the studies mentioned above, it is important to consider what social and economic interventions might increase access to medical care for this important population, as well as what forms of education and outreach might prove to be positively motivational to that desired end. Increased access to affordable healthcare is certainly a very good first step, and while students attending college are required by law to have health insurance, young adults who choose to not go to college---or who simply cannot afford it---are left with few economically viable options once they can no longer be covered under their parents' policies.

Young adults are our future, and it is in our best collective interest to make sure that they receive the necessary preventive healthcare that can detect chronic disease---or even the potential for such disease---long before any lasting damage is done. Healthcare should be affordable, accessible, and understandable for our young adults, and in these hard economic times, too many young people may see healthcare as a luxury that they simply cannot afford. I hope that the new administration in Washington will decrease the costs of both healthcare and higher education, ease the burden on American young adults, and simultaneously educate this population about the crucial importance of detecting chronic illness before it starts to take its toll.

As the father of a young man in his twenties, I have a vested interest in his stellar generation reaching their productive middle-age with good health, economic security, and the means to live a long, happy, healthy and satisfying life.

Temporarily Joining the Ranks

So, dear Readers, as of 12:01 am today, my wife and I are officially uninsured. Caught in that painfully ubiquitous American conundrum, we are both gainfully employed, both starting new jobs (that, admittedly, don't pay exceedingly well), and our new insurance will not kick in until January 1st. With several chronic illnesses between us and a number of medications we take on a regular basis, this could be cause for concern.

Counting our blessings, we indeed realize that, unlike the majority of the other 38 million uninsured Americans waking up this morning, our uninsured status is, in fact, temporary. A month from now, as we ring in the New Year, we will also ring in the renewed security that paying monthly health insurance premiums can bring. Our privilege is not lost on us, but having just been to the emergency room on Thanksgiving Day, I am given pause to remember that life and illness do indeed sometimes happen on their own schedule. But like I've said before, middle class privilege is something we do not take for granted, and our very survival is in no way threatened by this unfortunate but temporary turn of events.

Meanwhile, my incredulous friends in Canada and Europe wonder how such a "powerful" country can leave so many of its citizens in the lurch, many actually going bankrupt when they cannot pay their medical bills. My response is that the United States' free market system coupled with an ingrained Puritan work ethic and "pick-yourself-up-by-your-boot-straps" cowboy mystique leads many mainstream Americans to think of themselves rather than of others, assuming that those who "have not" probably don't deserve it anyway. Ronald Reagan's evisceration of Public Assistance---further decimated by Bill Clinton in the 90's---painted "Welfare Moms" as deadbeats who purportedly birthed children just to get on the dole. We were all expected to make it on our own, and those who didn't were expected to eat our crumbs.

If I sound cynical, it's because there has been a great deal to be cynical about in the last decade of American life. With the economy in shambles, healthcare on the rocks, two never-ending wars, and poverty and hunger on the rise, some healthy cynicism is indeed in order.

So, as the Obama administration revs its engines, I wait patiently along with my fellow citizens, hoping for some change, but admittedly less starry-eyed than many of my brethren. I honestly expect little to change in the next year in terms of the machinations of American healthcare economics, although I do hold out hope that the ranks of the uninsured will somehow be decreased as rapidly as possible. Changing such an entrenched system will not be easy, and some say it is truly impossible with so many economic and political toes to be stepped on. Well, the poor, uninsured and hungry in this country have been repeatedly stepped on throughout the decades, so if the insurance industry cries "foul" as it suffocates, let's simply call it just desserts.

This next month of "insurancelessness" does certainly give me a lot of food for thought. I am grateful that this chapter will be short-lived, but I am all too well aware that, for many others, it is a chapter that seems to never end.

Hospitals and Consumers on the Edge

Economically speaking, times are tough all over. People are losing their jobs, the unemployment rate is rising, and retailers and consumers alike seem to be facing a lean holiday season.

On the healthcare front, a number of U.S. hospitals are now in the difficult position wherein they now must buy back debt incurred from "Variable Rate Demand Notes" (VRDNs) and other forms of loans that hospitals use to do many things, including making capital improvements to their facilities. According to some reports, U.S. hospitals may be forced to buy back up to $8 billion dollars of debt, not an easy task in these cash-strapped times.

For hospitals, the economic times are indeed challenging. Patients with outstanding bills are less likely to be able to pay on time, if at all. Many employers are scaling back health insurance coverage for their employees, thus patients are often stuck with hospital bills that they cannot afford. Additionally, the numbers of uninsured and under-insured patients is rising in most states, and charity care is becoming increasingly burdensome for hospitals and health systems that provide such services. As some patients shift to Medicaid, hospitals also understand that reimbursement rates from Medicaid and Medicare often cannot match those from some private plans, thus revenues hemorrhage from numerous economic blood vessels simultaneously.

Equally troubling for hospitals, borrowing is exceedingly difficult, despite dire need for improvements to facilities, upgraded IT equipment and systems, and rising labor costs. With increased costs of utilities, food, supplies, and health insurance premiums for their own workers, hospitals also understand that many patients will continue to cancel or postpone many elective surgeries and procedures that bring much needed revenue to hospitals' bank accounts. With consumers charged co-pays of $200 to $400 for elective procedures such as colonoscopies and vasectomies, hospitals face a serious decrease in such procedures which are much less costly since they generally involve a stay of less than 12 hours from registration to discharge.

From The Wall Street Journal to regional news outlets in the mid-West, the signs all seem to be the same: hospitals are in for a difficult season as the economic belt tightens on the healthcare industry.

As a self-appointed advocate for the uninsured and vulnerable in this country, I am seriously concerned that an enormous cohort of Americans currently face a significant decrease in the availability of affordable preventive healthcare in all regions of the country, not to mention access to many specialists and other providers.

Overall, my fear is that the availability of free and low-cost care will suffer in the current economic climate, and patients in need of care will need to travel further and further afield in search of providers willing to see them, a burden that may keep numerous people from seeking medical attention at all. When access to medical attention is limited, it is frequently the uninsured and under-insured who are left in the healthcare dust, and there are millions of children who will fall into this unfortunate group as their parents simply struggle to make ends meet.

There will be much for the new Obama administration to consider when assessing the current (horrible) state of the American healthcare system. As impatient as we all are for change, it may be many months before any improvements are even suggested for fixing healthcare in this country.

Meanwhile, as hospitals struggle with their bottom line and millions of uninsured Americans struggle to stay healthy, we all must hope that there is still a possibility that the damage, as extensive as it may seem, can still be undone. And as for those millions of uninsured children out there, it should never get any worse than this.