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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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Showing posts with label CARE clinic. Show all posts
Showing posts with label CARE clinic. Show all posts
Wednesday, March 17, 2010
Thursday, December 10, 2009
Free clinics should open our eyes to the real problems
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On December 9 and 10, 2009, a massive “C.A.R.E.” clinic, sponsored by the National Association of Free Health Clinics occurred in Bartle Hall, the huge Convention Center in Kansas City. On the first day alone, with temperatures well below 20 degrees and the roads covered with ice from the snow that fell the night before, as many as 1,000 people showed up to receive health care from 1,600 volunteers, including 100 doctors, dentists, and nurse practitioners. It may end up seeing more people than similar events previous held in Houston, New Orleans and Little Rock. There is excellent coverage of the event in an article by Alan Bavley in the Kansas City Star, accompanied online by photos and videos by the Star’s Todd Feeback.
The purpose of these clinics is, of course, to provide some care to the people who attend – often the only care they have gotten in years. People were diagnosed and sometimes treated for acute conditions, such as pneumonia, or diagnosed with chronic diseases such as high blood pressure, high cholesterol, and diabetes. Indeed, most often they were really re-diagnosed; they knew they had these conditions but had been unable to afford medications or medical care. But another, even more important purpose, as Sherri Wood, Director of the Kansas City Free Clinic, says in the video, is to “put a face on the uninsured”. They are not only, or mostly, homeless, alcoholic, completely down-and-out, or even mostly unemployed. Rather, they are employed in low-wage jobs (not infrequently 2 or 3 jobs!) that do not offer health insurance, or they are employed part-time so that their employer does not have to buy their insurance. They are people, American people, our friends and families and neighbors. And they could be us; most Americans are a layoff away from uninsurance, and not too many paychecks away from dire financial straits and even homelessness.
The excellent accompanying editorial in the Star is titled “Massive free clinic at Bartle Hall a great event, but reform is still needed”. The editorial, along with the story, includes interviews with and comments from people who came for services (“Making three dollars an hour plus tips I can’t afford to see a doctor. When you have a house payment and your bills, it’s hard.”), but it also clearly states that “Although impressive, the free clinic clearly is no substitute for reliable medical care”. Yes, indeed. Or rather, No, indeed, it is certainly not. “Charity isn’t a good substitute for justice”, as I have quoted Jonathan Kozol before.
The Star editorial goes further, making the point that I have often made that a solution to the health care problem includes producing more primary care physicians. “Too many medical school graduates gravitate to high-paying specialties partly to pay off burdensome student loans.” We must, it says, “…encourage physicians to take up primary care.” It is appropriately critical of the fact that “The reform bills in Congress contain few incentives to set things right…Expanding access won’t work unless we start now to increase the supply of primary care physicians.”
So the problem is clear. And the solution is clear. Universal health coverage. Based on the principle that we need to ensure that people receive care, not that for profit companies make money. It has been figured out by every first-world (and some not quite first world) countries. It is not tricky, difficult, or even expensive (certainly not compared to what we are spending now). Not that it will happen, or happen easily, as the “debate” in Congress is currently demonstrating.
Maybe some of the opponents of real, meaningful, comprehensive health reform are just mean, evil, selfish people. I don’t rule that out. But more likely they are “blinkered”, like a horse, looking at only one aspect of the problem, such as the Kansas legislator who is proposing that our state refuse to participate in any health reform plan passed by Congress. (I am trying really hard to believe that this is his/her issue, being like the blind men of India with the elephant, not that s/he is mean, evil and selfish.) Plus the campaign contributions from the insurance companies and drug companies and health providers who are doing just fine, thank you, under the current system of literally leaving people out in the cold, help sway their beliefs.
It is time for the leaders of our country to stop compromising on a core need of our people, and ensure that everyone has access to quality health care. And they can do it in a responsible and cost effective manner through a single payer system, although there are other alternatives. The Star editorial says “A compassionate and cost-effective system would provide every American with a medical ‘home’ from which to receive preventive and needed care.”
I hope that most of our congressmen and other leaders are compassionate, and am certain that they wish to be cost-effective. But they need to abandon pandering to big contributors and keep this core value front and center: Quality health care for all.
.
On December 9 and 10, 2009, a massive “C.A.R.E.” clinic, sponsored by the National Association of Free Health Clinics occurred in Bartle Hall, the huge Convention Center in Kansas City. On the first day alone, with temperatures well below 20 degrees and the roads covered with ice from the snow that fell the night before, as many as 1,000 people showed up to receive health care from 1,600 volunteers, including 100 doctors, dentists, and nurse practitioners. It may end up seeing more people than similar events previous held in Houston, New Orleans and Little Rock. There is excellent coverage of the event in an article by Alan Bavley in the Kansas City Star, accompanied online by photos and videos by the Star’s Todd Feeback.
The purpose of these clinics is, of course, to provide some care to the people who attend – often the only care they have gotten in years. People were diagnosed and sometimes treated for acute conditions, such as pneumonia, or diagnosed with chronic diseases such as high blood pressure, high cholesterol, and diabetes. Indeed, most often they were really re-diagnosed; they knew they had these conditions but had been unable to afford medications or medical care. But another, even more important purpose, as Sherri Wood, Director of the Kansas City Free Clinic, says in the video, is to “put a face on the uninsured”. They are not only, or mostly, homeless, alcoholic, completely down-and-out, or even mostly unemployed. Rather, they are employed in low-wage jobs (not infrequently 2 or 3 jobs!) that do not offer health insurance, or they are employed part-time so that their employer does not have to buy their insurance. They are people, American people, our friends and families and neighbors. And they could be us; most Americans are a layoff away from uninsurance, and not too many paychecks away from dire financial straits and even homelessness.
The excellent accompanying editorial in the Star is titled “Massive free clinic at Bartle Hall a great event, but reform is still needed”. The editorial, along with the story, includes interviews with and comments from people who came for services (“Making three dollars an hour plus tips I can’t afford to see a doctor. When you have a house payment and your bills, it’s hard.”), but it also clearly states that “Although impressive, the free clinic clearly is no substitute for reliable medical care”. Yes, indeed. Or rather, No, indeed, it is certainly not. “Charity isn’t a good substitute for justice”, as I have quoted Jonathan Kozol before.
The Star editorial goes further, making the point that I have often made that a solution to the health care problem includes producing more primary care physicians. “Too many medical school graduates gravitate to high-paying specialties partly to pay off burdensome student loans.” We must, it says, “…encourage physicians to take up primary care.” It is appropriately critical of the fact that “The reform bills in Congress contain few incentives to set things right…Expanding access won’t work unless we start now to increase the supply of primary care physicians.”
So the problem is clear. And the solution is clear. Universal health coverage. Based on the principle that we need to ensure that people receive care, not that for profit companies make money. It has been figured out by every first-world (and some not quite first world) countries. It is not tricky, difficult, or even expensive (certainly not compared to what we are spending now). Not that it will happen, or happen easily, as the “debate” in Congress is currently demonstrating.
Maybe some of the opponents of real, meaningful, comprehensive health reform are just mean, evil, selfish people. I don’t rule that out. But more likely they are “blinkered”, like a horse, looking at only one aspect of the problem, such as the Kansas legislator who is proposing that our state refuse to participate in any health reform plan passed by Congress. (I am trying really hard to believe that this is his/her issue, being like the blind men of India with the elephant, not that s/he is mean, evil and selfish.) Plus the campaign contributions from the insurance companies and drug companies and health providers who are doing just fine, thank you, under the current system of literally leaving people out in the cold, help sway their beliefs.
It is time for the leaders of our country to stop compromising on a core need of our people, and ensure that everyone has access to quality health care. And they can do it in a responsible and cost effective manner through a single payer system, although there are other alternatives. The Star editorial says “A compassionate and cost-effective system would provide every American with a medical ‘home’ from which to receive preventive and needed care.”
I hope that most of our congressmen and other leaders are compassionate, and am certain that they wish to be cost-effective. But they need to abandon pandering to big contributors and keep this core value front and center: Quality health care for all.
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