Dead Man Walking: People still die from lack of health insurance

At the recent meeting of the Association of American Medical Colleges (AAMC) meeting in Philadelphia, Clese Erikson, Senior Director of the organization’s Center for Workforce Studies, gave the Annual State of the Workforce address. It had a great deal of information, and information is helpful, even if all of it is not good. She reported on a study that asked people whether they had always, sometimes or never seen a doctor when they felt they need to within the last year. On a positive note, 85% said “always”. Of course, that means 15% -- a lot of people! – said “sometimes” (12%) or “never” (3%). Of those 15%, over half (56%) indicated the obstacle was financial, not having the money (or insurance). There are limitations to such a survey (it is self-report, so maybe people could have gone somewhere, like the ER; or maybe they asked your Uncle George who would have said always because he never wants to see a doctor even though you think he should for his high blood pressure, diabetes, and arthritis!) but it is not good news.

Of course, as former President George Bush famously said in July, 2007, "I mean, people have access to health care in America. After all, you just go to an emergency room." Many of us do not think that this is a very good solution for a regular source of care in terms of quality. Also, if you have had to use the ER regularly for your care and already have a huge unpaid stack of bills from them, it can make you reluctant to return. This likely contributes to the “sometimes” responses, probably often meaning “sometimes I can ride it out but sometimes I am so sick that I have to go even though I dread the financial result.” Following this ER theme, another leading Republican, Mitt Romney, declared repeatedly during the 2012 Presidential campaign, that “No one dies for lack of health insurance,” despite many studies to the contrary. And despite the fact that as Governor of Massachusetts he presumably thought it was a big enough issue that he championed the passage of a model for the federal Affordable Care Act in his state.

People do, in fact, die for lack of health insurance. They may be able to go to the ER when they have symptoms, but the ER is for acute problems. Sometimes a person’s health problem is so far advanced by the time that they have symptoms severe enough to drive them to the ER that they will die, even though the problem might have been successfully treated if they had presented earlier. Or, the ER makes a diagnosis of a life-threatening problem, but the person’s lack of insurance means that they will not be able to find follow-up care, particularly if that care is going to cost a lot of money (say, the diagnosis and treatment of cancer). If you doubt this still, read “Dead Man Walking”[1], a Perspective in the October 12, 2013 New England Journal of Medicine, by Michael Stillman and Monalisa Tailor (grab a tissue first).

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.

Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation...“If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

The story gets worse. And it is only one story. And there are many, many others, just in the experience of these two physicians. “Seventy percent of our clinic patients have no health insurance, and they are all frighteningly vulnerable; their care is erratic.”  And the authors are just two doctors, in one state, a state which (like mine) starts with a “K” and (like mine) is taking advantage of the Supreme Court decision on the ACA to not expand Medicaid, and which (like mine) has two senators who are strong opponents of ACA, which means, de facto, that they are opposed to ensuring that fewer people are uninsured. I cannot get their thinking, but it really doesn’t matter, because it is ideology and they have no plan to improve health care coverage or access. So people like Mr. Davis will continue to die. This same theme is reflected in a front-page piece in the New York Times on November 9, 2013, “Cuts in hospital subsidies threaten safety-net care” by Sabrina Tavernise:

Late last month, Donna Atkins, a waitress at a barbecue restaurant, learned from Dr. Guy Petruzzelli, a surgeon here, that she has throat cancer. She does not have insurance and had a sore throat for a year before going to a doctor. She was advised to get a specialized image of her neck, but it would have cost $2,300, more than she makes in a month. ‘I didn’t have the money even to walk in the door of that office,’ said Ms. Atkins.

In a recent blog about the duration of medical education, I included a graphic from the Robert Graham Center which show the increased number of physicians that the US will need going forward, mostly as a result of population growth but also from the aging of that population, along with a one-time jump because of the increased numbers people who will be insured as a result of ACA (this will, I guess, have to be adjusted down because of the states that start with “K” and others that are not expanding Medicaid). Ms. Erikson included this graphic in her talk at AAMC, with numbers attached. Just from population growth and aging, we will require about 64,000 more physicians by 2025 (out of 250,000-270,000 total physicians).The one-time jump because of the ACA is about 27,000, bringing the number to 91,000.

But, of course, there is a big problem here. The projection that we will need more doctors because we have more people, or because our population is aging and older people need more medical care, is one thing. But the need for more doctors because more people will be insured? What is that about? Those people are here now, and they get sick, and they need care now, no less than they will when they are covered in the future. I do not mean to be critical of the Graham Center or Ms. Erikson for presenting those data. I do, however, think that we should emphasize how offensive is the idea that we will need more doctors just because more people will have coverage. They didn’t need doctors before, when they didn't have insurance?

If there are people who cannot access care, we need to be able to provide that care. We will need more health care providers, including more doctors, especially more primary care doctors. We need health care teams, because there will not be enough doctors, especially primary care doctors. We need the skills of health workers who can go to people’s homes, and identify their real needs (see the work of Jeffrey Brenner and others (see Camden and you: the cost of health care to communities, February 18, 2012). We need to ensure that people have housing, and food, and heat, and education – to address the social determinants of health.

Decades ago, I heard from someone who visited Cuba a few years after the revolution. He said he mentioned to a cab driver the dearth of consumer goods, such as shoes, in the stores. The cab driver said “we used to have more shoes in the stores, but now we first make sure that they are on children’s feet before we put them in stores windows.” There was enough before the revolution, enough shoes and enough milk, as long as a lot of people were not getting any. The parallel is that now, in the US, if we seem to have enough health clinicians, it is because there are lots of people not getting health care.

This is not ok. It isn’t ok with the ACA, and it isn’t OK without it.

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[1] Stillman M, Tailor M, “Dead Man Walking”, Michael Stillman, M.D., and Monalisa Tailor, M.D.

October 23, 2013DOI: 10.1056/NEJMp1312793