Friday, September 24, 2010

Living in New Orleans without Health Insurance

Free Medical Clinic Ernest Morial Convention Center

August 31/September1 2010

It was the palpable ghosts of Katrina that made the free medical clinic that occurred in New Orleans for two days on August 31 and September 1, 2010 different than the five previous ones that I had been a volunteer physician. Most of the patients acknowledged these forces when they dated the onset, or worsening, of their medical problems to the hurricane of 2005. Because the clinic was for people who did not have any health insurance, many had not seen physician for two or three years. The absence of insurance precluded them from medical care and allowed the ghosts to hold these people hostage.

The emotional trauma experienced by so many of New Orlenans over the past five years and the many promises for aid that did not materialize made them doubt the clinic, organized by the National Association of Free Clinics (NAFC) and sponsored by donations solicited by Keith Olbermann on Countdown, would show.

As in New Orleans (2009 - 675 patients), Little Rock (992 patients), Kansas City (2110 patients in two days), Hartford (1028 patients), Atlanta (1310 patients), and Washington, DC (1378 patients), the clinic opened on time and cared for all of those people who had signed up before and those who arrived unscheduled. The first day the first patient was seen at 11AM and the last seen 10PM. The following day, the clinic started at 2PM and finished at about 9:30PM. Each day, the clinic provided care for about 675 patients. In the middle of the second day the 10,000th patient cared for by these mega-clinics was seen.

Perhaps half of the people who attended the clinic were working. The self-employed could not afford insurance. Some worked where health insurance was not offered for the employees, or they were not given enough hours on the job to qualify for insurance benefits. Some had recently lost their job but COBRA was too expensive so they let their coverage drop. There was the engineer from NASA, teachers with graduate degrees, a scientist who had been studying the effects of the BP oil spill, a worker who had been cleaning up the oil spill but recently laid off, the hair dresser who lost her job with Katrina and had returned to New Orleans but could not find a job, the construction worker and the truck driver. No class of people was spared. All went to sleep hoping that they would wake in the same state of health because they knew that id they became ill, they could not afford to see a physician. A hospitalization would bankrupt them.

New Orleans was the sixth clinic where I took time from my private practice and traveled to volunteer as a physician. My affiliation with the NAFC is a personal pledge. Having believed that health care is a right of all American citizens from the day I decided to go to medical school, after participating in my first free clinic last November in Little Rock clinic, where I saw the burden of disease experienced by fellow Americans living without health insurance, I committed myself to participate in all future clinics.

The care provided in New Orleans, as at the previous clinics, was not only to see a physician but also to have blood tests for diabetes, cholesterol, anemia, urinary problems Patients could be screened HIV. Electrocardiograms, gynecological exams, visual acuity, mental health counseling, as well as referrals for mammograms and colonoscopies were available as needed. If indicated, prescriptions were written from a formulary provided by Wal-Mart for either a 30-day supply for $5, or 90 days for $10. As in the other cities, the NAFC had extensively researched the free medical services available in the metropolitan area. Before discharge from the clinic, each person received referral to free health care in his or her neighborhood. Appointments were made for the patient and the record generated from their visit was sent where the patient could receive ongoing care.

The patients in New Orleans had the same spectrum of illnesses seen in the other clinics. The same illnesses I see in my private practice. It was not the illnesses that differ. It is the severity of the illnesses that is shocking. In my office in suburban Boston, I have patients whose blood pressure is in the 160-170/88-98 ranges with a rare patient having pressures higher. In New Orleans, as in the previous clinics, the patients had pressures are in the 180-210/96-120 range with an occasional patient having even higher numbers. The same was true for diabetes and cholesterol. Again obesity was epidemic. It would not be an exaggeration to say that seventy-five percent of patients were not only overweight but also obese.

Again the patients had the same comment I first heard in Little Rock and all the other clinics, “I don’t have insurance, I don’t have a doctor, and I don’t have medical care”. The stories from New Orleans were similar to all the other cities. It was not geography that made the story. It was the hardship of living in America without health insurance that made the story. One patient who had glaucoma, whose prescription had run out about two years before, was using his cousin’s eye drops. The vial of drops he brought with him had expired in 2005 and was for allergies not glaucoma. A fifty eight year old woman, had diabetes and a previous stroke. She was using her husband’s diabetic medications and had not had any blood tests for over a year managing her sugars as she had when she had insurance but without the results of blood sugars to make changes in her medications. She was also taking a medication to thin her blood as a prevention against another stroke but had not had the level of her blood thinner checked in the two years since she had lost her insurance.

As before, patients brought their bottles of medication. They were almost always empty. Most could not afford to see a physician to have them refilled. If they did have the prescription refilled, the cost of the medication made it very difficult to continue on the medication. What I did notice in New Orleans, more so than in previous clinics, was that the medications patients had been prescribed in the past were frequently were some of the most expensive medications. I may have seen a hand full of generic prescriptions, but most were for the newest and pricier drugs.

Because of the prevalence of obesity, gastro-esophageal reflux disease was also very common. Patients with this problem again had the most expensive medications. Most of them had never been treated with less expensive acid suppressing medication. Of those I saw, none had been counseled about eating behaviors and diet that provoke the symptoms of heartburn and reflux.

As in the previous clinics, there were hands full of t patients who had life threatening problems and had to be transported by ambulance to the closest emergency room. I sent a 64-year-old obese woman to the emergency with symptoms of acute pulmonary edema and accelerated coronary artery disease. She had not seen a physician since the symptoms began six months ago nor did she understand the significance of the worsening of the shortness of breath she felt every time she lay down or the chest discomfort brought on with three or four steps that had been accelerating in the past week. She was one of the several dozen people these clinics had cared for who very likely would not have seen the next day if it had not been for the care provided in these clinics.

I saw patients for about 10 hours the first day in New Orleans and eight hours the second day. In Washington, DC, I worked for almost 12 hours with one short break. So did many of the other professional and non-professional volunteers. Being able to help people who had been excluded from health care for many years was rewarding. However, as a physician who has been practicing medicine for almost forty years, it was uncomfortable to be a member of a profession that has failed to care for the millions of people who work hard, contribute to the economy, but cannot afford to access medical care.

What is particularly distressing, is that while the these clinics serve a fraction of the millions of Americans without health insurance, there are many groups around the country that are actively working to reverse the health reforms that Congress passed earlier this year. Some claim the reforms are too expensive, but do not take into account that they are already paying for the care of the uninsured when they arrive in the emergency rooms with critical illnesses that more than likely could have been cared for at a fraction of the cost in a doctor’s office. Even this does not take include the loss of productivity the person were he or she healthy enough to work.

I find it difficult to understand why the medical schools in the cities where the NAFC has had their clinics, have minimal presence. Despite many personal invitations, these schools that are preparing the physicians of the future have only provided one or two junior faculty and two or three medical school students.

Even with so many citizens who have no health insurance, only one member of Congress has attended and none have participated.

Where are they?

Some politicians scare people by calling the recent health reforms death panels and get a stream of press coverage. But no one speaks of the death panels that exist in the lines of people in need of care lining up and waiting hours to be seen at a free clinic. It is the millions of people, who with the new reforms, will be able to receive coverage and access to care that are, and should be, the focus of reform. Estimating the cost of these reforms cannot be done without taking into account the monies already spent on their care.

As the mid-term elections approach, Americans who have health insurance should hear the story of those citizens who live in America without health insurance. Those who argue against it should visit and spend a day talking to the people attend these clinic so they can better understand the consequences of not providing health care for every one.

The most poignant story from all of these clinics was from a woman who volunteered to escort patients from one station to another at the clinic in Kansas City. At the end of the clinic, she came over to the woman who directs these clinics and gave her a long and emotional hug with the remark, “thank you for letting me volunteer for this event. I did not know that the person I was wheeling through the clinic was my neighbor.”

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