Wednesday, March 17, 2010

The Sharp End of Ideology

This powerful piece was written by Robert Ferrer, MD, MPH, who has previously written guest blogs. It is too bad that the pundits and policy wonks will not see it.

On any given day there are five to ten of them on our hospital service. In the room that our clinical team uses to discuss patients we reserve one of our two white boards just for them. As a group they are defined by three characteristics: they have suffered from diabetes for many years, they have lacked steady health insurance and medical care, and they are in various stages of dismemberment. Uncontrolled diabetes has damaged their blood vessels, and the ensuing gangrene or bone infections brings them to our hospital, where we care for their medical problems while the surgeons amputate toes, feet, or lower legs. The patients often lose these parts in sequential episodes as their circulation worsens and the complications progress.

Most are men, and many of them are younger than you would expect, in their late thirties or early forties. Almost all have been recently working, though the operation they now require will usually end their employability in the blue collar jobs they occupy. When we ask when they last received regular care for their diabetes, the only mystery is where they*ll fall in the range from "a year ago" to "never". And therein lies what makes these complications especially sad, because with patient education and periodic low-tech evaluations, most of the amputations could have been prevented.

The fact that they are so often not prevented emerges from an unhappy synergy between two epidemics: diabetes and uninsurance. Among large American cities, San Antonio ranks near the top for both; a quarter of its residents lack health insurance and about 1 in 10 have diabetes, though in the less affluent parts of town the diabetes statistic is closer to 1 in 4. Being poor puts one at risk for both diabetes and being uninsured, but being poor in particular locales is especially risky. What those locales share is stingy public insurance programs, (for example, the earnings ceiling above which adults with children no longer qualify for Texas Medicaid just 26% of the federal poverty level -- about $5200 for a family of four -- and, as in most states, childless adults without disabilities don*t qualify at all), and many jobs that don*t come with health insurance. In many cities, as in ours, a large number of undocumented immigrants also add to the number of uninsured.

So there are three of the big conundrums of national heath care reform: the scope of public insurance, expanding coverage under private sector insurance, and what should be done about non-citizens. (A fourth, costs, will come up later). Framed in this way, as bloodless policy questions far removed from the daily realities of the ward, the urgency is drained out of them. Raised yet another level of abstraction higher -- Socialism! -- the debate becomes an absurd joke, the cruelty of which will be felt by those who will needlessly lose limbs in the coming years if reform fails yet again.

For the patients who occupy the beds on our wards -- high-risk people in low-benefits occupations living in a low-services state -- the list of responsive policy options seems very narrow. The realistic options are heavily regulated public or private plans based on large risk pools and with adequate subsidies to ensure that cost is not a barrier to regular care. Less important than the exact mechanism, however, is that there be a path to coverage short of losing a leg, becoming disabled, and qualifying for coverage through disability benefits. As for the non-citizens, our county decided in 1997 to respond to the compelling local needs by creating a publicly funded plan that allows the working poor to access full-spectrum health care on a sliding repayment scale. Hard-liners may balk at reform that even considers these types of arrangements, but what is the alternative? Deporting people with gangrenous limbs or failing kidneys? Continuing to provide only expensive, last-minute rescue care?

Although we have much yet to learn about controlling health care costs, one clear message is that preventing complications among high-risk patients with chronic disease will yield important savings. A typical hospital bill for a diabetic patient having an amputation runs to $10,000 or $20,000 or more, not because of the surgeon*s fee, but because the patients* other diagnoses, often including antibiotic-resistant infections and failing kidneys, complicate their treatment. Investing in access and regular care before a crisis occurs saves money - as well as limbs, kidneys, and hearts.

Meaningful reform cannot be postponed any longer. George Orwell wrote that in political discourse, *words fall upon the facts like soft snow blurring the outline and covering up all the detail.* Through the seasons of debate, the the urgent needs of those suffering for lack of care have been buried beneath the snow of words. But those needs are still there, regardless of the political calculations. To pretend that there is not a way forward to a workable conclusion coldly discards the opportunity to ease the suffering for millions of our people. If that happens, many will feel the metaphorical phantom pain of another lost opportunity for reform. And a smaller subset of the vulnerable among us will experience the real thing.

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