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Dead Man Walking
The Ne England Journal of Medicine ^ | October 23, 2013 | Michael Stillman, M.D., and Monalisa Tailor, M.D.

Posted on 10/26/2013 9:28:04 AM PDT by Praxeologue

“Shocked” wouldn't be accurate, since we were accustomed to our uninsured patients' receiving inadequate medical care. “Saddened” wasn't right, either, only pecking at the edge of our response. And “disheartened” just smacked of victimhood. After hearing this story, we were neither shocked nor saddened nor disheartened. We were simply appalled.

We met Tommy Davis in our hospital's clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient's privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences.

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer.

The year before, he'd had similar symptoms and visited a primary care physician, who had taken a cursory history, told Mr. Davis he'd need insurance to be adequately evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and ineligible for Kentucky Medicaid, however, he'd simply used enemas until he was unable to defecate. By the time of his emergency department evaluation, he had a fully obstructed colon and widespread disease and chose to forgo treatment.

Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation. As his wife sobbed next to him in our examination room, he recounted his months of weight loss, the unbearable pain of his bowel movements, and his gnawing suspicion that he had cancer. “If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

For many of our patients, poverty alone limits access to care. We recently saw a man with AIDS and a full-body rash who couldn't afford bus fare to a dermatology appointment. We sometimes pay for our patients' medications because they are unable to cover even a $4 copayment. But a fair number of our patients — the medical “have-nots” — are denied basic services simply because they lack insurance, and our country's response to this problem has, at times, seemed toothless.

In our clinic, uninsured patients frequently find necessary care unobtainable. An obese 60-year-old woman with symptoms and signs of congestive heart failure was recently evaluated in the clinic. She couldn't afford the echocardiogram and evaluation for ischemic heart disease that most internists would have ordered, so furosemide treatment was initiated and adjusted to relieve her symptoms. This past spring, our colleagues saw a woman with a newly discovered lung nodule that was highly suspicious for cancer. She was referred to a thoracic surgeon, but he insisted that she first have a PET scan — a test for which she couldn't possibly pay.

However unconscionable we may find the story of Mr. Davis, a U.S. citizen who will die because he was uninsured, the literature suggests that it's a common tale. A 2009 study revealed a direct correlation between lack of insurance and increased mortality and suggested that nearly 45,000 American adults die each year because they have no medical coverage.1 And although we can't confidently argue that Mr. Davis would have survived had he been insured, research suggests that possibility; formerly uninsured adults given access to Oregon Medicaid were more likely than those who remained uninsured to have a usual place of care and a personal physician, to attend outpatient medical visits, and to receive recommended preventive care.2 Had Mr. Davis been insured, he might well have been offered timely and appropriate screening for colorectal cancer, and his abdominal pain and obstipation would surely have been urgently evaluated.

Elected officials bear a great deal of blame for the appalling vulnerability of the 22% of American adults who currently lack insurance. The Affordable Care Act (ACA) — the only legitimate legislative attempt to provide near-universal health coverage — remains under attack from some members of Congress, and our own two senators argue that enhancing marketplace competition and enacting tort reform will provide security enough for our nation's poor.

In discussing (and grieving over) what has happened to Mr. Davis and our many clinic patients whose health suffers for lack of insurance, we have considered our own obligations. As some congresspeople attempt to defund Obamacare, and as some states' governors and attorneys general deliberate over whether to implement health insurance exchanges and expand Medicaid eligibility, how can we as physicians ensure that the needs of patients like Mr. Davis are met?

First, we can honor our fundamental professional duty to help. Some have argued that the onus for providing access to health care rests on society at large rather than on individual physicians,3 yet the Hippocratic Oath compels us to treat the sick according to our ability and judgment and to keep them from harm and injustice. Even as we continue to hope for and work toward a future in which all Americans have health insurance, we believe it's our individual professional responsibility to treat people in need.

Second, we can familiarize ourselves with legislative details and educate our patients about proposed health care reforms. During our appointment with Mr. Davis, he worried aloud that under the ACA, “the government would tax him for not having insurance.” He was unaware (as many of our poor and uninsured patients may be) that under that law's final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to comprehensive and affordable care.

Finally, we can pressure our professional organizations to demand health care for all. The American College of Physicians, the American Medical Association, and the Society of General Internal Medicine have endorsed the principle of universal health care coverage yet have generally remained silent during years of political debate. Lack of insurance can be lethal, and we believe our professional community should treat inaccessible coverage as a public health catastrophe and stand behind people who are at risk.

Seventy percent of our clinic patients have no health insurance, and they are all frighteningly vulnerable; their care is erratic, they are disqualified from receiving certain preventive and screening measures, and their lack of resources prevents them from participating in the medical system. And this is not a community- or state-specific problem. A recent study showed that underinsured patients have higher mortality rates after myocardial infarction,4 and it is well documented that our country's uninsured present with later-stage cancers and more poorly controlled chronic diseases than do patients with insurance.5 We find it terribly and tragically inhumane that Mr. Davis and tens of thousands of other citizens of this wealthy country will die this year for lack of insurance.

TOPICS: News/Current Events
KEYWORDS: obamacare; poverty; uninsured
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How do we counter an article such as this?

My initial thought is that the patient should have gone to emergency in the first instance.

1 posted on 10/26/2013 9:28:04 AM PDT by Praxeologue
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To: Kennard
Finally, we can pressure our professional organizations to demand health care for all.

Not really much to say when this is the upshot from these two geniuses.

Don't doctors take Econ classes as undergraduates, or are all those now taught by Paul Krugman types?

2 posted on 10/26/2013 9:35:00 AM PDT by Trailerpark Badass (There should be a whole lot more going on than throwing bleach, said one woman.)
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To: Kennard

He could have been sent to India, Thailand or other countries where the original $10,000 would have been more than adequate!

3 posted on 10/26/2013 9:36:52 AM PDT by BillM (.)
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To: BillM

Yes. When the British need an operation faster than 3-6 months, they go to India. See ‘The Best Exotic Marigold Hotel’.

4 posted on 10/26/2013 9:40:06 AM PDT by originalbuckeye (Never yield to force; never yield to the apparently overwhelming might of the enemy)
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To: Kennard
tens of thousands of other citizens

Give these folks help, leave everyone else alone.
Surely it wouldn't cost a Trillion dollars to help these 10's of thousands.

5 posted on 10/26/2013 9:41:40 AM PDT by kanawa
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To: Kennard

“........We find it terribly and tragically inhumane that Mr. Davis and tens of thousands of other citizens of this wealthy country will die this year for lack of insurance.”

Seems to me lack of medical care rather than insurance is the cause. Perhaps if we all looked to the medical industry, and ourselves we could handle this problem without the government. Government has a tendency to get in the way of progress, and make things far worse than if they had just stayed the ‘H’ out of the issue.

NOT TO SAY the insurance industry couldn’t participate in this, but without government restrictions designed to impede, and cause a direction towards an agenda.

We have to get the government the ‘H’ out of our business period. It’s none of theirs. Look what they’ve done with the opportunity.

6 posted on 10/26/2013 9:42:26 AM PDT by rockinqsranch (Dems, Libs, Socialists, call 'em what you will. They ALL have fairies livin' in their trees.)
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To: Kennard

How do we counter it? Here’s a start:

1. Philosophically, in order for one person to get medical care without paying for it, another person must pay for medical care without getting it.

2. Go to a “loser pays” civil tort system; if you sue your doctor for malpractice and lose, you pay his legal expenses. This cuts down on “defensive medicine” and the attendant costs.

3. Charge everyone who gets a particular service the same amount. The guy in the story was billed $10,000 for one hospital visit. Had he been insured, the hospital probably would have accepted $2000 from his insurance company as payment-in-full.

There was a story going around a month or two ago about a guy who needed an operation, and was expected to pay the insurance deductibles in advance, which he couldn’t afford. He spent some time discussing the situation with the hospital, anesthesiologist and surgeon and ultimately paid cash for the entire operation in an amount less than what his insurance deductible would have been.

There’s a place in Oklahoma (Oklahoma Surgery Center) that performs surgery, cash-only for about 20% of what traditional hospitals charge.

How’s that for a start?

7 posted on 10/26/2013 9:43:21 AM PDT by DuncanWaring (The Lord uses the good ones; the bad ones use the Lord.)
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To: Kennard

My initial thought is working full time and indigent don’t add up. Both he and his wife had full time jobs. Yes insurance for individuals is expensive and they truly might not have been able to afford it. But there are still offices that can take payment arrangements. His symptoms started a year before he was seen in the clinic mentioned. Why did it take him so long to take advantage of their services? Why didn’t he at least try to find an insurance policy that would cover hospitalization?

Access to insurance does not always equate to access to health care. Doctors in this story are the one who decided they could not examine the man let alone treat him unless he had insurance. They offered no alternatives to this patient for funding sources or even payment options. And they have the nerve to blame a lack of socialized medicine for this?

8 posted on 10/26/2013 9:44:55 AM PDT by lastchance ("Nisi credideritis, non intelligetis" St. Augustine)
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To: Kennard
Here's how it used to go:

Guy goes to ER, gets admitted to the county hospital, attached to the local medical school, and gets admitted, worked up, operated on, and rehabbed, and sent home for recovery, chemo, radiotherapy, followup later. Hospital and doctors eat the bill, some covered by Medicaid, some covered by Medicare, and some passed on to those who do pay, with charities like The Little Red Door taking up slack. Also, most big hospitals have foundations that take in money and pay for care for poor patients. Surely you have had an appeal to give to some local hospital foundation. It is still happening this way in a large part.

But, if there had been, over the past 100 years, no government interference in either health care, or labor law, or this man's life earnings, then, the price of the workup, surgery, etc., would have been MUCH LESS, and the amount of capital he would have had available MUCH MORE, to the extent that he would have been able to pay for his own health care by cash (for the routine things) and having insurance (for the catastrophic things) all along.

The only answer to efficient health care delivery to the most people possible is by free market, cash-on-the-barrel, horsetrading, laissez-faire, economic freedom.

And charities will be able to handle the rest, especially in a wealthy country such as ours.

9 posted on 10/26/2013 9:47:42 AM PDT by caddie
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To: Kennard

Are they, the providers, who took oaths, turning away patients who can’t pay? Where does their part lie in how much they charge for services? Where is their charity?

10 posted on 10/26/2013 9:50:16 AM PDT by conservative cat
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To: Trailerpark Badass

Missing ingredient is— the doctors in the article fail to mention how much they are paid. And they DO get paid significantly from the system they are castigating. Poor people die, rich people die. Preventive care is not ever “free” and to date the “free” stuff has been paid by the people who ARE insured and being raked over the coals on ever increasing premiums for mandated coverage. (Example: why should an 80 year old male or female have to pay for pre-natal care or obstetrics care in their policy?— Answer: they are paying for what the govt. mandates they pay— for services they cannot and do not use). How “legal” is that.

Nothing quite like socialist physicians, who still want top dollar for their services. Ok, bozos— enjoy obongocare— your income will soon show it. Then you can unionize for a waiver. LOL.

11 posted on 10/26/2013 9:53:21 AM PDT by John S Mosby (Sic Semper Tyrannis)
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To: Kennard
Horrible story, but some discrepancies. This is KY-poor state, much cheaper rent tax, etc. than E coast,W coast.. The man had 10,000 savings because they both worked full time. Good for him. However, could not some of that gone for at least catastrophic ins? And you are right about the emergency room--tests would have been ordered. However they would have been billed--i.e. goodbye savings.

I agree something should be done.

Obamacare is no more the answer than the former situation. People are mostly now on Medicare or Medicaid, which both save themselves from bankruptcy by cutting reimbursement. Drs. (many) do not take these patients or limit numbers. Now, the govt. will dictate who drs. will see as well as what is allowed for each patient.A better idea than forcing pre-existing diseases on ins. companies, a much better idea would have been cross state competition and a fund for catastrophic conditiions that indigent could apply for. Cut out aid to a few Muzzie countries to pay for it.

As it stands, medical care for everybody is going to get worse, even for those with platinum plans (congress etc.)A panel led by the likes of Dr. Ezekiel Emanuel and Cas Sunstein, both of whom are on record for rationing and throwing seniors off the cliff (because they have had their chance, you know). And it will not be just oldies. Sunstein is on record that children under age 13 or so cannot be given pricey procedures because "THE STATE DOES NOT HAVE ENOUGH INVESTED IN THEM" to make it worth while. We now exist, you know, solely to serve the state. And just who is "The State"? Obama, Pelosi, Reid, Ezekiel etc.

Did anyone watch Megan Kelley's interview with Ezekiel last night? The man is frightening, so d@#n sure he has all the answers, talking over Megan (per all libs), and dissing her questions. He is Rahm Emanuel's bro--go figure.


12 posted on 10/26/2013 9:53:28 AM PDT by vaudine
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To: DuncanWaring

“Point to a system where this person would receive care as you demand.”

Allow the writer to point, and then demonstrate that no, they patient would not have received timely care.

Then tell them to go find a solution, because taking my money at the point of a gun is not going to work, either.

13 posted on 10/26/2013 9:54:30 AM PDT by patton (“Really? Have you tried chewing cloves?”)
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To: Kennard

People don’t die for lack of insurance. They die for lack of medical care. If they had lots of cash, or were treated at a discount or free, they wouldn’t need insurance.

Insurance is really, really helpful, if you have a good policy, but I think it is like the “guns don’t kill people— people kill people” thing. Insurance can do a lot to help, but, at bottom, people save people.

14 posted on 10/26/2013 9:56:53 AM PDT by married21 ( As for me and my house, we will serve the Lord.)
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To: John S Mosby
Nothing quite like socialist physicians, who still want top dollar for their services. Ok, bozos— enjoy obongocare— your income will soon show it. Then you can unionize for a waiver. LOL.

See if they enjoy the Soviet-like status of "doctors" in their brave new world.

Doctors are only esteemed in cultures which value human life.

15 posted on 10/26/2013 9:57:44 AM PDT by Trailerpark Badass (There should be a whole lot more going on than throwing bleach, said one woman.)
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To: Kennard

Mr. Davis should have said he was Hispanic.

16 posted on 10/26/2013 9:59:08 AM PDT by jch10 ("Normandy was closed when we got there too!")
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To: Kennard
I do not even try to counter them.
I no longer go to doctors due to finances. I do not blame anyone except Charlie MacAlister, it just is. About 10 years ago an uninsured driver made a point to try to kill me. My medical bills damn near bankrupted me and my wife. Yes Virginia, I had medical insurance but they would not cover motorcycle injuries. I asked for and received nothing from the government. Now I have medicare (Oh joy joy) for all the good that is. But all I can buy is a ‘Medicare Supplement’, but at this time I cannot afford it, because I am still paying for Charlie MacAlister crippling me. As much as I can I use what my Grandparents used, home remedies. So far so good. But this is my problem NOT my family's, not the church's and for damn sure not the Government's.
I am sick and tired of the whiners out there. F***ing crybabies have damn near bankrupted this nation.
17 posted on 10/26/2013 9:59:28 AM PDT by Tupelo ( Snatching defeat from the jaws of victory. An old Republican Tradition.)
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To: Kennard

I want everyone to have medical care, too. I just don’t think nationalized health care is the way to do it. That way leads to health care rationing and bureaucracy. The free market combined with private charity can address our health needs much better than top down government controlled care.

There are many problems with health care, and many of them are caused by government interference. Government mandates that insurance cover all sorts of things that customers may not want or ever need, and government mandates prevent insurance policies from being easily portable across state lines.

Insurance also isn’t meant to cover every expense. Try buying an auto insurance policy that covers gas and oil changes. Yet, we expect health insurance (or the government) to cover every medical expense? That’s really going to be expensive.

If the free market was allowed to set prices and people were allowed to buy insurance policies that were tailored to their actual needs, I think most of this doctor’s concerns would be answered. Eliminate the bureaucracy and the cost of care would likely be reduced considerably.

Finally, we have to remember that in a free society each individual is ultimately responsible for themselves. No one has an obligation to take care of me. I’m responsible for my own health care decisions, and if that means I have to work harder, forgo certain comforts to afford paying for care, or ask (not demand) my fellow humans for charity, so be it.

In the case cited by the doctor, we don’t know what kind of spending decisions the guy with colon cancer made before he got to his dire situation. A colonoscopy, for example, is far less expensive than treatment for late stage cancer, but the individual had to make that a priority back when he was healthy. Also, we don’t know the man’s medical history. Did colon cancer run in his family? Did he smoke (a big risk factor in colon cancer)? If so, then that colonoscopy should have been a priority over spending on other things.

18 posted on 10/26/2013 10:09:25 AM PDT by CitizenUSA (Conservatives are not anarchists!)
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To: Kennard

Let me suggest to my fellow MD that this is a very small-n study, with strong heartstring tugs, yes, but little objectivity or understanding, which is ultimately designed present a naive political - not medical - opinion of the most damagingly left-wing sort.

Let me also suggest that there is no obstacle to this doctor paying out of his own pocket for treatment for people he sees.

Let me also suggest that there is no obstacle to this doctor starting a charity that targets medical professions and the rest of the healthcare industry for VOLUNTARY donations to support care for the indigent.

Instead, this doctor spends his time writing a propaganda article for a rag which, while prestigious as can be due to leftist media hype, is put out by an organization so left-wing that only 17% of MDs chose to join. His solution is to take money and freedom from the citizenry at large - at the point of guns, and under the boots of thugs and the watchful eyes of spy agencies - to do what he won’t do or try to do himself.

Coward with a cause.

19 posted on 10/26/2013 10:14:19 AM PDT by dagogo redux (A whiff of primitive spirits in the air, harbingers of an impending descent into the feral.)
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To: Kennard

Nobody forces a hospital or Doctor to bill for services. If they feel so bad, why did their organization take the guy’s last $10,000?

20 posted on 10/26/2013 10:15:47 AM PDT by blueunicorn6 ("A crack shot and a good dancer")
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