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.