Behavioral Sciences: Sociological Issues in America

A large sociological issue that America faces today is the impact made by people abusing the government assistance program. Medicaid was developed as a program to assist those who are truly in need of help in order to survive. Healthcare costs can be a burden to both the rich and the poor. Those costs can often make it impossible for some to seek medical care due to the fact that they cannot afford it. Medicaid was set up to help these people who need help but unfortunately there are many people who are using and abusing this system when they are not truly in need. So often, I see people who are on Medicaid driving Mercedes. This is an oxymoron and a disgrace to the people who really need this. As a nurse working in the healthcare system, I see this abuse on a daily basis and it can be very frustrating and a stressor on the provider. When researching this topic, it is very difficult to find statistics that account for members of Medicaid abusing the system. Most research has been done with a focus on providers such as physicians and hospitals filing fraudulent claims. This goes to prove a dire need for investigation into those who are seeking the assistance from this program.

There are very little if any safeguards or follow up in place to monitor the continued need for this service amongst its members. Medicaid is a system that covers it carriers very broadly. Ambulance service is included in these services as well as well checks, hospitalization, etc. Often abuse is seen within the first responder arena when EMS is called to respond to a call yet find that there is not an emergency but someone needs to ride to the doctor’s office and Medicaid will cover that. Patients often get admitted to the hospital on a frequent basis claiming to have ailments with no etiology and come to find out that patient just wanted a place to stay for awhile. So many times members of Medicaid work the system and actively chose not to go out and find employment that allows them to live better. They get comfortable with having medical needs “given” to them and them not having to work hard to pay for them or to afford insurance. Proving this or supplying numbers that show the statistics of such abuse is near impossible. A hospital will not bill in a manner that reflects this patient did not need medical care, a diagnosis will be provided from the attending physician and then the hospital bill is sent. Tracking the number of fraudulent admissions is not possible at this time. It comes down to the healthcare workers seeing this each day in the hospital.

The same goes for ambulance services. After speaking to an EMT, they stated that they see this abuse on a regular basis but when the bill is sent, it documents medical necessity therefore, numbers are unknown. A prime example is going on in my hospital currently. There is a patient; we will call him Mr. X. He has been in our hospital during this current stay for about two weeks. This is his 21st admission this year. He is admitted to our hospital when he tells his MD he wants to be in the hospital. He openly tells the staff of this. He does suffer from chronic illnesses but not at the level of him needing acute hospitalization but would be appropriate for a nursing home as he chooses not to care for himself but demands it from others. His MD, Dr. H, prescribes him pain meds each time he is admitted based on his request. Last week, he fired 3 nurses caring for him and called the police 3 times because the staff did not get him his pain meds fast enough. When Dr. H was approached in regards to this, she openly admitted to being terrified of him and stated she will order him whatever he wants to keep him happy. Another example is another chronic patient that admits on a regular basis due to sickle cell anemia. Now of course this disease can be very painful and can require hospitalization.

This patient, Ms. S, takes these admissions to a whole new level. She comes in for weeks at a time, abuses the staff, demands levels of pain medications that are not safe but manipulates the same MD, Dr. H to prescribe them, then when she feels it’s time to get a pedicure, she checks herself out, gets her nails done, and comes straight back and gets re-admitted. Both of these patients are using government assistance to pay for their care. The first of these patients, Mr. X, he is often not admitted for a true acute need therefore medical necessity is not met. But, a bill is sent out with a diagnosis and thus Medicaid pays even if it was not needed care. The other, Ms. S, she may present in a acute state needing care but two days later she is stable to be discharged but remains for another 3 weeks. This is another example of fraudulent abuse of the system. It puts the healthcare facility in a very difficult situation as they deserve to be reimbursed for the care provided but Medicaid should not have to pay for a patient that abuses the system. It’s an endless frustration for medical providers. Medicaid abuse impacts the nation as whole as well as individual states. Some are impacted more than others.

Georgia for example, has a yearly budget of over $19 billion, 22% of this is dedicated to healthcare costs. This is all tax payers’ money. Most would agree that we all work very hard for our money and to see such a risk of it being abused, it’s distressing. The deficit that this country is facing because of poor management over programs such as this is causing American citizens to question governmental strength. Many members are in legitimate need for these services but it’s the many that are not that creates this very negative impact on this nation. Another very significant issue of this abuse lies within prescription drugs. Patients have learned how to “work” the system and doctor shop in order to get multiple prescriptions filled of narcotics. They then go to multiple pharmacies to fill these prescriptions. Medicaid has seen a huge amount of pharmaceutical fraud and misuse do to this happening. There are situations that even prescriptions were filled from doctors who had long been deceased. This is just further impact to this already struggling program.

It is thought that Medicaid costs this country into the hundreds of billions in tax payer dollars. An example of the struggles that happen on a daily basis has taken a personal toil in my life. My parents were among the struggling Americans trying to work hard to make ends meet yet not able to seek governmental assistance when it was so desperately needed. My parents were affected when the economy crashed. My father was not able to find work after his job was eliminated. My mother was bullied in her job so badly that she had to leave in order to be treated fairly. In turn, they were not able to afford their house anymore and were forced to foreclose on the home they once were able to afford. My mother found employment and was able to work enough to keep food on the table but paying the existing bills was very difficult and they were harassed daily by creditors. It also meant that insurance was not possible as her job only offered benefits for her and not my father and brother.

For two years, my mother had inadequate coverage and my father and brother had none. Each day that went by, I worried that something would happen and they would be drowning in medical bills on top of everything else. My brother had to have knee surgery during this time and they will be paying off that bill for years to come. As American citizens, how can this happen? How can hard working citizens who need help not be granted that help? Isn’t this why a system such as Medicaid was designed? These are questions that need answers but it seems that the current government would rather turn a blind eye and try and set up a socialized medical system instead. This is not the answer, we need to fix the problems we have before we can try and take on an entirely new system that this country has never embraced before. I have lived with socialized medicine before and it is far from a perfect system. I believe if we can take a firm hand and start to evaluate Medicaid and the people who partake in this help, we can make this country better. Society needs to be firm in that those who take advantage of governmental assistance need to truly have a need for it and need to strive everyday to become able to come off of it. Citizens should be evaluated every three months and should show proof of continued need.

We need to require drug testing and proof that all members within the family are being cared for properly. The American people need to stand up and preach that we can do better than this and everyone should strive to teach their children, living off this system is not the answer. It’s painful to see generation after generation being taught that you can just live off this system and not strive to be better. This is the reason that people, who truly need the help, can’t get the help. The middle man is left to drown in bills or health crisis when others are abusing a system that is out of control. This sociological conflict is affecting the integrity as well as the economical stability of this nation. Critical theorizing can play a huge role in helping to make a change in society as a whole. It can help us in understanding the underlying reason as to why this system is failing at alarming rates. It can uncover the truth and possibly help in making a positive change. In looking into this issue, the conflict theory comes into mind.

The definition of this theory is based on Karl Marx, he theorized that that individuals and or groups of people in society have differing amounts of wealth and the wealthiest use this power over the poor. I can see these playing a role into the socialistic issue involving Medicaid as the poor are the ones that are in need of this program and seem to be at the mercy of the government for assistance. There are many people who are so deeply reliant on this system, they know not another way to live. The issue appears that many have learned how to utilize this system designed for the poor even when they may not be in that social class. So, it seems that society has found a way to cheat the system. America is the strong hold of this world. We are a super-power, yet this super-power has so many deeply woven issues that are being ignored by our leaders. There comes a point when the yarn can easily get tangled and this country is seeing some very large tangles that are getting bigger. A new system of healthcare awaits us and the implications of that seem even greater than our current system. We face tremulous times within the future of healthcare. I hope that one day, we can get it right.

References:

Marx, Karl. 1971. Preface to A Contribution to the Critique of Political Economy, Tr. S. W. Ryanzanskaya, edited by M. Dobb. London: Lawrence & Whishart. DEBBIE DLUGOLENSKI ALFORD, (2012) Governors Budget Report Fiscal Year 2013, retrieved from opb.georgia.gov