Sunday, January 17, 2010

Living in America Without Health Insurance



The line formed long before the doors opened to the Convention Center in Kansas City, Missouri. This was the third free medical clinic arranged by the National Association of Free Clinics. Previously, they had had clinics in New Orleans and Little Rock. All were organized to provide free services for anyone without health insurance and to arrange for continuing care through the resources in their local community.

Services were provided by hundreds of volunteer health professionals. There were thousands of concerned citizens who also gave their time. Many came long distances. I traveled from Boston to Kansas City for the two-day clinic. Four weeks before I had been in Little Rock, Arkansas for a one-day clinic.

My job was to triage the registration line for anyone in need of urgent care. This allowed me to walk through the crowd and hear the stories of tens of citizens while they patiently waited to be seen. I thought my thirty three years of practicing primary care medicine in municipal hospitals and the community would have prepared me for what I was about to see. It did not.


More than 80% of those who came for care had jobs - one and sometimes two and three - but their employers did not offer insurance. Others did not work enough hours to qualify for their employer’s health benefits. Some were self employed but could not afford premiums. Some had lost their jobs. Some were looking for work. None had medical or dental insurance.

More than 60% of them had not seen a physician in the past year, and 48% had not seen a doctor since 2000. A third did not go anywhere. If they had seen a physician, they could not afford to fill their prescription. The charges they had incurred in one visit intimidated them from returning. Any care they may have received was fragmented and without follow up.

All had the same reasons for neglecting their health. Without insurance, they could not afford to pay for a physician visit. Without insurance they could not afford to fill their prescriptions. Without insurance, they could not afford any surgical procedure. If they had been sick enough to need emergency care, they were then saddled with an enormous bill that intimidated them from seeking further care of any sort.


A man, who had had a below knee amputation, sat awkwardly in his wheel chair. Having lost his insurance, he hoped the clinic would assist him obtain the prosthesis his medical insurance had denied devastating his hopes to walk again, return to his job and to provide for his family. No insurance, no physician, no prosthetic leg.

A woman grimacing in pain had cancer treatment two years ago but was unable to continue treatment. No insurance, no physician, no medication.

Another woman wore a trench coat to cover her emaciated frame. Her seizures had recurred three times in the past two weeks. She had sought help in an emergency room only to be told that the level of her seizure medications was “OK” and then was discharged. No follow up was arranged. During her seizures she had bitten the inside of her mouth and broke several carious teeth. She could not eat. No insurance, no physician, no follow up care.

A young man with labored breathing had been given a wheelchair. Struggling to speak, he told me five days ago he had been treated in the intensive care unit of a local hospital for “leg swelling”. He did not understand why his legs had swelled then or why the swelling had recurred. For a month, he experienced chest pains walking across his living room. He needed three pillows to avoid awakening from sleep breathless. At discharge, he was handed a list of unaffordable medications that he did not understand. Continuing care was not arranged.

He was immediately pulled aside, examined, an EKG was taken, and an ambulance was called to take him back to the emergency room with an acute coronary syndrome. Why was this man’s leg swelling and chest pains incompletely evaluated before discharge? Was it because he did not have health insurance? Had there been no free clinic, and his daughter not insisted that he come, he may have died. No insurance, no physician, incomplete hospital care.

A young man avoided eye contact. His slouched posture told me he did not want to talk, but had something to say. Later, I learned the suicidal plans of three people had been averted. Surely he was one. Without a free clinic, would their plans have succeeded? No insurance, no physician, no treatment.

By the end of the two days, we had cared for 2434 people. I was overwhelmed. It was not the number of patients. It was not their illnesses. They had the same diagnoses one would expect among any group of young and middle-aged adults - hypertension, diabetes, emphysema, degenerative arthritis, coronary heart disease, chronic pain, carious teeth, as well as depression.

It was the severity of their illnesses: untreated diabetes with hemoglobin A-1-C of 12.6 because the person had run out of medications months ago; blood pressures of 190/120 that had never been diagnosed; advanced osteoarthritis with crippling pain but never treated with more than over the counter medications. No insurance, no physician, no operation.

Every patient’s story ended with the same refrain: “ No insurance, no physician, no access to care.” It was spoken in hypertension, diabetes, heart disease, depression, and every other diagnosis.


Could I really be in America? It certainly did not feel that way, at least not America of the 21st century. I had not seen patients with this burden of illness, since my first year in medical school 45 years ago - before Medicare was fully implemented. Viewing the rows of patients filling the Kansas Convention Center, I again felt as ashamed by the failings of our medical system of 2010 as I had as a medical student by the system of American health care of 1965 walking by the rows of patients waiting to be seen in the hospital’s outpatient department.

Without health insurance, these hard working, tax paying citizens from New Orleans, Little Rock, and Kansas City, have been denied the benefits of the medical advances of the last four decades. I am sure there are others just like them in every community of America.

The American Medical Association claims to support health reform, but they were not in Little Rock. Absent was the American Association of Medical Schools planning the education of tomorrow’s physicians but remote from the health crisis of today.

There were no deans of medical schools or officials from the American College of Physicians or Pediatrics. Could there be a more important mission for professional societies or medical schools than assuring all citizens have access to basic medical care. My profession shames me.

Absent were the politicians, bragging with self-righteousness, that they cannot support a ‘public option’ citing a multitude of hypocrisies and fictions. They pretend to reform our health system without reforming health insurers. How can a country so materially rich be so morally bankrupt?

The cost of reform is not the question. We already incur the expense with the loss of manpower and the extraordinary cost of emergency and end of life care. The question is how much it costs not to reform. The question is how much do we value our neighbor? The question is how long will our nation allow 43 million citizens to be marginalized without health insurance?

We squabble over health reform and across the country patients suffer and die daily without proper care. No informed person can honestly believe that without strong intervention private insurers will write policies to alleviate the suffering I witnessed in Kansas City and Little Rock. My country embarrasses me.

Doing nothing cannot be an option. Ralph B Freidin, MD

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