We are not Islands

As another hurricane has hit Texas causing flooding and loss of life, I think it is important to look at how we, as a society, treat the less fortunate.  Texas declined the medicaid expansion of the Affordable Care Act, and so its citizens are chronically at risk. This morning I read a review by Danielle Ofri, MD, of the book, "No Apparent Distress," by Rachel Pearson, MD (https://www.nytimes.com/2017/08/25/books/review/rachel-pearson-no-apparent-distress.html?_r=1).  In it, Dr. Pearson's stories about those who fall through the cracks are described.

I have spent most of my career working in "safety net" hospitals. Yet, even here, there are requirements for copayment. In the case of scheduled surgeries, copayment may be required in advance. Sometimes, this may be more than $2000. Clearly, a fee this high might cause a patient to question if they should wait. And many do. Sometimes, the disease will progress, and be more costly to treat. But, this usually affects primarily the patient and their family. And, often the taxpayer.

Medical diseases like diabetes and hypertension can also be far more costly if treatment is delayed. A common medication for hypertension costs less than $10 per month, yet a hypertensive brain hemorrhage may require a week in ICU at over $2000/day, followed by weeks of rehabilitation, and perhaps never returning to the pre-hemorrhage level of functioning. And, at the time of the hemorrhage, care is mandated by EMTALA (the Emergency Medical Treatment and Active Labor Act). So, again, we must all bear the increased costs of delaying care. While this is an unfunded mandate, doctors and hospitals must either recoup the costs or decide to go out of business, so they don't need to provide the care. But, closing Emergency Rooms affects anyone who needs one. So, this may affect all of us.

Infectious diseases pose even more of a threat to all of society. When I was a medical student, many of the homeless had been exposed to a non-toxin producing variant of diphtheria. Thus, if the typical toxin producing variant developed in the area, they and those who had received the DPT vaccine (https://en.wikipedia.org/wiki/DPT_vaccine) would be best protected. Since a booster is recommended every 10 years, many healthy adults would be unprotected simply because they didn't keep up with revaccination. But, this is just theoretical.

About 20 year ago, I took care of a toddler who had tuberculous meningitis. He was neurologically devastated by it. His infection was traced to a daycare provider with a chronic cough. This worker couldn't afford to take time off to spend at least half a day at a public clinic to have the cough checked out, so continued to work with children, who are the most likely to be devastated by tuberculosis. And, yet, how many of us pay for childcare? And, do we always check on the workers? Since these workers often are low paid, many are immigrants. 

Cysticercosis is another disease that may spread from the less fortunate. It is a pork tapeworm often encountered in third world countries. But, humans can have both gut and tissue, such as brain or eye, involvement. The gut involvement is caused by eating infected meat. The tissue involvement is caused by eating infected feces. Yet, pay for both agricultural workers and food service workers is low, so many are immigrants. In the field, workers may have no toilet facilities or bathroom breaks. Food service workers may also not have optimal hygiene. Health education is scant for such occupations with low pay and frequent turnover. Testing and treatment is rare. So, such workers may not only have tissue involvement, but, also gut involvement. So, all of us are at risk. In 1992, several Orthodox Jews were reported to have cysticercosis (http://www.nejm.org/doi/full/10.1056/NEJM199209033271004#t=article). 

We do not exist as islands. We interact with other people. We may eat meals prepared by others. Our children may be cared for by others. The most affluent may be able to have their domestic help tested and treated for various infectious diseases. Less affluent people likely can't insist on this. But, most of us, at least occasionally, eat food grown and prepared by others. So, if the least fortunate can't afford care, the more fortunate may also suffer. It is not only ethical for a society to help the less fortunate; it is also beneficial for the more fortunate.

Looking forward or looking back?

Today I had my, now semi-annual, visit with my oncologist. He ordered the usual surveillance labs and other tests. I have learned that some of these go through easily, some mean phone calls to my insurance. These phone calls are a nuisance for me. But, as a physician myself, I know how to phrase the reason so that things are approved. I know this is far easier for me than for an average patient. Yet, I worry that things will be harder in the future.

Every cancer patient has a pre-existing condition, as does every premature child, mental health patient, and many others. Before the Affordable Care Act (ACA), that meant that every person with a pre-existing condition could be denied coverage, forced to spend down their savings, and finally fall on the mercy of Medicaid, which differs some in the various states. They might then be limited in choices of providers. They finally would need to go to those facilities that are termed "safety net" hospitals.

I have spent most of my career working in safety net hospitals, teaching the next generation of physicians. I know we help a huge number of patients. And, we provide quality care. But, we sometimes lack in some technologies because we try to function on a shoestring budget. With the ACA, things eased a bit, since more of our patients had funding. But, still, not all technologies are available. In my case, my hospital did not have the ability to provide care had my disease turned out to be slightly more advanced. Yet, we often see patients with more advanced disease since they have tended to wait for care, if only because they might have to take a day off work due to travel time and waiting time, and so wouldn't be paid for that day. Even now, many patients miss appointments just to avoid taking time off work.

Waiting to see the doctor or have a test allows disease to advance. That makes it more costly to treat, and treatment less likely to be effective. Yet, plans are being made to force patients to have "more skin in the game" by forcing them to have higher costs when they seek care. Poor patients currently have relatively higher costs. So increasing their costs will force further delays in needed care, and so make US health outcomes worse. Last year, when life expectancy fell for Americans, poor Americans already had a life expectancy 14 years less than richer Americans (https://www.nytimes.com/2016/12/08/health/life-expectancy-us-declines.html). So, poor people have been putting their lives on the line with their health decisions.

Fortunately, I am able to have insurance and to argue for the care that I need. But, as a physician, I also have sworn to care for my patients, and will are for their care. And, I feel all people deserve quality health care. It is not a luxury, but a necessity.