Tuesday, October 9, 2012

Guest Post: Speaking out for the uninsured

Dr. Laura Makaroff is the current Fellow in the Primary Care Health Policy Fellowship that I direct at Georgetown University's Department of Family Medicine and the author of the following post. Dr. Makaroff's patient gave permission for us to share her story on my blog.


I had a usual Monday seeing patients at an inner-city federally qualified health center (FQHC). Fifteen of the 16 patients I saw had health insurance. Of the 15 who had health insurance, all had some form of public health insurance (Medicaid, DC Chartered, or Medicare) which is common and expected in a FQHC setting. All 15 of these patients had multiple medical problems and multiple life stressors – also common occurrences in our patient population. I worked hard taking histories, doing physical exams, prescribing medications, coordinating care, referring for additional services, filling out forms, and providing culturally-sensitive patient education for all of these patients (but didn’t get my notes done. Those will have to be done remotely because I ran out of time at the end of the day - also a common occurrence on days spent on the front lines of patient care). All 15 of these patients left the clinic with at least some of their medical issues addressed and none of these patients were worried about going bankrupt because of their medical expenses. Certainly there are other issues they face, but bankruptcy due to medical costs is not one of them because they all qualify for public insurance.

One of the 16 patients I saw is not covered by public insurance, and she is concerned about bankruptcy due to medical bills. This young, mid-twenties professional came to the clinic yesterday to follow-up regarding a recent hospital stay for a pulmonary embolus. She went to the ER last week after collapsing while running. She was diagnosed with a large pulmonary embolus and is lucky to be alive today. She spent 2 days in the ICU with close monitoring and anticoagulation (blood thinning medication). She was then transferred to the general medical floor for more monitoring. She was discharged with appropriate bridging therapy for her anticoagulation and was told to follow up with a primary care physician.

So there she was, in tears, trying to be thankful for her life but burdened by the thought of the bills that are coming her way. She is facing tens of thousands of dollars of medical bills, if not hundreds of thousands of dollars. She makes too much money as an English-language interpreter to qualify for public insurance. She is not a candidate for the newly-approved high risk insurance pool due to her recent catastrophic coverage (she had been so afraid of a “catastrophic” event that she carried a short-term, non-renewable catastrophic health insurance plan that happened to expire one week prior to her hospital admission.) She has not been able to obtain individual insurance because of pre-existing conditions which include a high body mass index and a previous diagnosis of sleep apnea. She received yet another health insurance denial while she was hospitalized. The insurance applications missed the fact that she has been actively working on lifestyle changes (including running on a regular basis) and has lost 60 pounds in the last year. If there is a fortunate part of this story, it is that she lives in a metropolitan area where she has access to primary care at a community health center that receives funding in order to provide services to all.

Some might say that she should have not been so “risky” with her self-employment and instead “played it safe” by seeking a large employer in order to be a part of a larger risk pool. That might be the best answer for her future, but that is hardly a solution to the real problem. In addition, what ever happened to the American Dream of life, liberty, and the pursuit of happiness? Shouldn’t this patient be allowed to follow her dream of helping people with language interpretation services and be a positive contributor to society? What about the importance of individualism that is so much a part of American culture?

This patient got the care she needed and fortunately was able to stop her most expensive medication based on her recent lab results. She is able to follow up with me for necessary, repeat blood testing, but she will likely face decisions in the future that force her to decide between incurring more medical bills or getting the health care she needs.

This patient may have been an exception in my patient population on this day, but she is not an exception in the greater U.S., where high medical bills account for 60% of bankruptcies. Modern medicine can keep this patient alive, maintain her safely on necessary anticoagulation, and even look for unusual genetic disorders that may have predisposed her to having a blood clot in her lungs in the first place. The modern health care system cannot claim the same successes, and may actually do exactly what physicians vow not to: cause harm by creating insurmountable bills and a lifetime of interrupted access to care due to health insurance challenges.


  1. Just wondering - was this professional woman in her mid-twenties using hormonal birth control, a known risk factor for blood clots and pulmonary emboli, as well as other serious medical conditions, including heart attacks, breast and cervical cancer? In fact, since 2005 the World Health Organization has classified oral contraceptives as a Group I carcinogen—the most dangerous classification known - because their is sufficient evidence showing that these agents cause cancer in humans. (Other group 1 carcinogens include tobacco and asbestos.) A comprehensive meta-analysis published in the Mayo Clinic Proceedings in October, 2006 confirms this as it found that 21 out of 23 retrospective studies done since 1980 showed that women who took oral contraceptive prior to the birth of their first child sustained a 44% average increased risk of developing pre-menopausal breast cancer.

    More pertinent potentially to this patient's case is the known risk for blood clots to the lung in women using hormonal birth control. A paper published in Lancet in 2000 showed a small, but significant increase in risk for fatal blood clots to the lung for women using the newest generation of OCPs. Although the total incidence of serious adverse events resulting from the use of hormonal birth control may be low, as this patient's case may possibly illustrate, the impact can be devastating.

    Thus, this begs the questions, should the government mandate to freely dispense drugs shown to harm women and disguise it as a preventive health service, especially when the condition it prevents - pregnancy - is not a disease. If we freely go along with this as physicians, without questioning the full potential impact for our patients, are we not keeping our oath to first do no harm?

    As a physician who has spent most of my career caring for the uninsured, I have tremendous compassion for the patient described here. However, I believe that she deserves better, as do all women and men. Rather than spending millions and millions of dollars for a "preventive health service" that can actually cause harm to women, we should ensure that they can have access to accurate information and critical medications, like the life-saving blood thinners this patient had to purchase to treat a serious disease that could have possibly been prevented.

  2. I don't see why it matters whether she was taking birth control pills or not. If she was, does it make it her "fault" that she developed a rare complication? All medicines have risks, even essential ones. Plus, since she is uninsured she would have personally paid the cost of contraception as well as the expensive medical care required for the pulmonary embolus. Compassion is nice, but this lady needs insurance coverage that she couldn't get, like millions of other Americans who have health conditions that are due as much to a roll of the genetic dice than to any "personal responsibility" on her part (which it sounds like she was taking anyway).

  3. Are you serious NYFamilyDoc? It makes all the difference in the world and oral contraceptives and other hormonal contraceptives have in some studies raised the risk 6 or more times! As an interventional cardiologist and phlebologist I know this only too well. You have to wake up! Contraceptives put women at risk!

    Dominic M. Pedulla MD, FACC, CNFPMC, ABVM, ACPh
    Intervenitonal Cardiologist
    President, The Oklahoma Vein and Endovascular Center

  4. Let me respond to your comments, point by point NYFamilyDoc:
    As the cardiologist commented, it matters if she was taking OCP, because it significantly increases her risk for blood clots, including PEs.
    It is certainly not the patient's fault if she was taking hormonal birth control and experienced a severe adverse effect. However, as physicians, it is OUR responsibility to inform patients of potential adverse effects of the medications we prescribe, and all too often that does not happen. For example, just yesterday, I participated in a prenatal group visit and the clinician discussed many different birth control options. However, even though the risk of blood clots is even higher in the post-partum period, she never mentioned this as an adverse effect. If physicians fail to fully educate patients about these drugs and the potentially dangerous side effects, then how can our patients make truly informed choices?
    Yes, all medicines do have risks, and there are drugs such as blood thinners which are essential. However, physicians prescribe hormonal birth control to healthy women, so these hardly can be considered essential. If couples do want to avoid pregnancy, they can learn to successfully do so without drugs by being taught to observe signs that they are fertile and avoiding intercourse during that brief window. In fact, some methods, such as the symptom-thermal method have very high typical use rates (about 98%) which is even better than the birth control pill. Certainly these methods require couples modify their behavior, but as family physicians we are well trained to help support patients make behavioral changes.
    Finally, while having insurance is nice, it does not necessarily guarantee access to care, especially primary care given the on-going shortage of family physicians.

  5. I want to know for a friend who wants and is willing to pay out of pocket, but come to the US and will have their child while they are here for a while. They cannot find any other insurance, so they know they will need to pay out of pocket. How much generally speaking does a pregnancy cost.
    AKZ Management

  6. I had initially written a lengthy reply about how this post wasn't about OCPs and their relative risk increase for DVTs, but this piece was written about the exorbitant costs of health care, and how that cost affects our patients.
    I'll continue that theme, and not address the topic. Instead, I'll simply say that Dr. Laura Makaroff is a physician who I'd want taking care of my parents. Please continue caring, and please never forget about patient 1/16.