You Have Already Paid!

Let's understand that we already are paying for those patients who have no health insurance and because they have no insurance, and have most likely not seen a physician for years, we are probably paying more for their care than we will under President Obama's Affordable Care Act. How could this be, you may ask?

Let's just consider a 57 yr old man who has not had health insurance for several years either because he is independently employed or because his employer has not given him sufficient hours to qualify for health benefits. He has not had the money to pay out of pocket to receive any routine care. Previously, when he he was able to afford insurance, he was being treated for hypertension and diabetes. 

Now he develops an acute chest pain and calls 911 and is taken to the emergency of the closest hospital. It is very likely, that he is in this situation in part because his blood pressure  and diabetes are completely uncontrolled and have been since he was last able to see a doctor - five or sic years ago.

He is admitted to the coronary care unit with an acute coronary syndrome. Cardiac cathiterzation is done and he is taken for  emergency coronary by-pass surgery. After five days in the surgical intensive care unit he is transferred to a step down unit and discharged three days later. He leaves the hospital with blood pressure, cholesterol, and anti platelet medications with a bill of $75,000.

Someone has to pay. It may be 'free' to the patient, but the hospital will not absorb this charge. The hospital will look to the city, county, state  to offset the charges. The city, county and state will then ook to their constituents for these funds and this is called taxes in some form or another.

Under the President's plan should this same patient get admitted to the hospital with the identical symptoms and problems, the same treatment would be given and the charges would also be $55,000. The only thing that would change is that the federal government would pay. How does the federal government obtain the money to pay? It collects taxes.

The care administered to the patient does not impact on the care available to  you. You will not pay more for this care, in fact you may pay less, because under the President's plan the patient will have insurance that will allow him  to receive ambulatory care to control the patient's risk factors and therefore reduce the chances of the patient requiring emergency cardiac by-pass surgery.

So let's understand that already, before the President's reforms go into effect,  everyone with health insurance is already paying for the hospital care of those without insurance. Let's understand that the impact on those with insurance of caring for those without health insurance is already occurring because the care is already given.

It is not an issue of paying more or getting less. Let's be honest with ourselves.

Oh, and if you say that you do not want to pay taxes to our cities, counties and states so they can pay for the care of the uninsured, think again. The hospital will still deliver  the care, at least until they have no funds and can no longer remain open. Then when it comes your time to need the hospital, it will not be there and you may have to travel longer distances to receive your own emergency care. It may take longer to get to the hospital and this may just be too long for your heart to "hold on" until the doctors and nurses can start caring for you. In the extra time it takes to get to the emergency room, your heart vessels may progress from partial to complete closure and you may not be able to benefit from bypass surgery.  Distance is time and time is critical in emergency - do you really want to even think about being in that position? 

You can't mean it!

Let's get serious! The Heath care debate has begun anew as the 2012 election approaches and the distortions of the politicians and selfishness of the electorate are becoming loader. I don't get it. Are we, as a nation, so selfish that we can not find it in our hearts and pocketbooks, to extend access to health care to the 16% of our fellow Americans? Are the cheers of 'let him die' that bellowed from the audience of the second debate of presidential candidates representative of the majority of us? I doubt it. However, the rest of us, beginning with the potential leaders of our country remain silent. In this debate, there can be no silent bystanders. Those of us who cringed when we heard those heartless people pronounce a death sentence for a hypothetical fellow citizen, have not raised our voices in support of the small, but very significant, changes to our health 'system', established by President Obama's Affordable Health Act. As with any social change, it is vital to have perspective. The five day work week and the eight hour day were not the first improvements to our labor laws, nor was the voting rights act the first achievement in the struggle for the civil rights of Afro-Americans. History is important! It is not so much a question whether the Affordable Care Act went far enough. It is a question of whether we will fight to support this step and be able to improve on. All of the possible future presidents of this country who were on the stage when the audience cheered to let the person who did not purchase health insurance die were silent. Images of a Roman amphitheater spun through my head! 'But we can't afford it!' Nonsense. We have been paying for the costs of the uninsured all along. Come on! Do you really believe the care the uninsured receive when they end up in the hospital, are not paid for? Of course they are. If it is not from a federal program, it is from the state, or city or county all entities we support with taxes in some form. Again why do those who understand the basic function of government, not stand firm and loud and speak up? Lastly I have to say something about taxes. They are what allows the wheels of government move similar to the oil we use to lubricate our cars. When the Oil is low, I believe we all know that if we do not fill up on oil, our car will not continue to run, and if we are foolish enough to drive when the oil meter flashes red, the cost of repair will overshadow the cost of a quart if oil like an elephant does a mouse. Arguing that we cannot afford to pay for health care for the uninsured and under-insured may save you 'chump change' but your children and grandchildren will need to pay with real money, very real. But who cares about them, particularly if they for some reason, do not purchase health insurance.

Speak the Truth

Opposing the implementation of President Obama's Affordable Care Act, has become the touchstone of the Republican party. They resist any progress to implement this act  that will provide health insurance to over 25 million Americans, who until it is fully enacted, have no health insurance and therefore no access to care.  American citizens who have no insurance have no doctor and therefore receive no care. I have witnessed this over and over again as a volunteering physician at  eight free medical clinics staged across the country and it has been confirmed in the Commonwealth Fund's latest biennial health insurance survey. But facts as these do not deter New York state senator Gregory R Ball from opposing this legislature as his 'Republican duty'. Could we ask what is his duty to the citizens of New York state whose welfare he is pledged to uphold? 

The candidates who seek the presidency of our country boast that this bill is harmful and a step toward a socialist state. The governor of Texas, Mr Rick Perry, shows no shame that his state has the greatest percent of his citizens without health insurance and therefore without access to care. He claims “Well, I’ll tell you what the people in the state of Texas don’t want: They don’t want a health care plan like what Governor Romney put in place in Massachusetts. What they would like to see is the federal government get out of their business.” 

As a physician who has practiced primary care for nearly 40 years, I have never once had a patient complain in any way about Medicare or show any interest in surrendering their Medicare card. Could the Texas governor please tell the truth? Would those who moderate these 'debates' please challenge him and his fellow Republicans to tell the truth about health care in this country? Would they please challenge these would be presidents what evidence they could possibly show that the Affordable Care Act will lead to death panels?  They have it so backwards. Our health system has death panels now. They can be seen among all those without health insurance.  I also have been a participating physician in Massachusetts health reform and have witnessed time and time again the enormous benefits that it provides its citizens. The medical services I have been able to provide to patients with Massachusetts' health insurance, have allowed many to regain self respect, return to meaningful work, and become tax payers.

What does it say about our country when we allow politicians to promote un-truths and use these lies as stepping stones to higher office? What does it say about us as a community when we do not provide health insurance to all of our citizens while allowing those who earn millions of dollars each year to pay little or no tax?

Speak out to falsehood.

Ralph Freidin, MD

Sept 2011

To the Editor,

As a primary care physician of thirty years, I read with interest Drs Peter Bach and Robert Kocher’s Sunday New York Times op-ed piece, “Why Medical School Should be Free”. Their postulate is that if medical schools were tuition free (using federal funds), thereby eliminating the financial burden with which so many medical students assume upon graduation they would be more apt to select a career in primary care medicine. Those graduates who still wished to become specialists would need to pay (at about $50,000/year) for their post-graduate training. Although this is a good start to redirect the waves of med students, my experience tells me Drs Bach and Kocher’s incentive is insufficient.

For decades, fewer medical graduates selected a career in primary care. This is not news to medical schools or hospitals where postgraduate training takes place. Reasons for this migration away from what was the most highly sought after career track when I graduated in 1969 are many. Some of the most obvious include being required to take on more responsibility to coordinate care without a commensurate increase in compensation, lack of professional prestige and disproportionate compensation.

According to Bach and Kochler’s calculation, the difference in annual compensation between specialist and primary care is $135,000 ($325,000 minus $190,000). Over 30 years, this becomes $4,050,000. Would you forfeit 4 million dollars in the long term for the short-term investment of $50,000 for 4 years for specialized training?

Medical schools select bright college graduates, educate them for four years in the deductive reasoning of medical diagnosis and pass them on for further clinical training. The young physicians then enter a system that does rewards them for using procedures and technology rather than their most unique skill - applying intellect and knowledge to solving problems.

Only when compensation and respect for physicians whose skill is to listen, question and translate equals those whose skill is dexterity and mechanical will the trend reverse.

Ralph B Freidin, MD

57 Bedford Street

Lexington, MA

To the Editor

I read "Health Reform in Massachusetts" as a primary care physician participating in Commonwealth Care since its inception, and as a volunteer in one day clinics providing free medical care for Americans who have no insurance.

In my office, Massachusetts health reform has allowed patients to benefit from advances in medicine that previously were beyond reach. They are now able to control their chronic illnesses and now longer relay on expensive episodic emergency care. Many have become contributors to society.

At each clinic, from Hartford to New Orleans, people repeat the same refrain "No insurance, no physician, no medical care". They are burdened by complications of chronic illness. Diabetes, hypertension, osteoarthritis and coronary heart disease are advanced to a degree I witnessed before passage of Medicare and Medicaid. Each clinic has had 5-7 patients with acute exacerbations of their illnesses necessitating transportation to an emergency room.

The success of Massachusetts’s health reform should not be measured only in dollars, but also by its positive impact on its citizens.

Columbia College Today May/June 2011 "Caring for Those Without Health Insurance

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Columbia College Today May/June 2011 > Alumni Corner
Alumni Corner
Caring for Those Without Health Insurance
By Dr. Ralph Freidin ’65

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In 1965, Medicare and Medicaid were passed, Martin Luther King Jr. marched to Montgomery, Malcolm X was assassinated, President Lyndon B. Johnson’s Voting Rights Bill became law, more troops went to Vietnam and many were protesting the war. This was the social backdrop of our class.

My years on Morningside Heights were a time of social change and student activism. The corner of West 116th Street and Broadway was as much a classroom as Hamilton Hall. Although pre-med, I minored in history. The highlight of my four years was Jim Shenton ’49’s renowned seminar “United States during the Era of Disunion.”

Professor Shenton wove the milestones of current American history into his seminar, leaving me with indelible lessons of the tide of American history.

I left Morningside Heights in June 1965. In September, I drove to St. Louis to begin my first year at Washington University Medical School. With Medicare and Medicaid promising access to care to millions previously excluded, I entered medicine believing that it would be a tool for social change.


Dr. Ralph Freidin ’65 examines a patient at a free clinic in Washington, D.C., last August.
PHOTO: CHRIS USHER
Quickly, I learned that the view from Morningside Heights was not that from the heartland. Columbia had prepared me well for medical school, but not that my profession’s vision of social responsibility started and stopped at the hospital’s door.

Starving for the pulse of social change, I heard the words of my Columbia swimming coach, Richard Steadman: “Defeat is not a discouragement but a call to be better.” I started thinking of ways to get the medical school and hospital to extend its services to the inner city three miles from its door. With the support of two young faculty members, some of my classmates and members of the Pruitt-Igoe Men’s Club, we established a health center in Pruitt-Igoe, St. Louis’ largest public housing project.

For the first 10 years after graduating from medical school, I taught and practiced primary care and internal medicine in municipal hospitals. By 1980, I had a family of two young children and a wife with her own professional career. The problems of people marginalized in our health care system were too taxing for this stage of my life. I left inner-city medicine and joined a small private practice in Lexington, Mass.

Last summer, I saw a report of a one-day medical clinic in New Orleans that had provided free care to almost 1,000 people without insurance. The clinic, spread across 102,000 square feet of a convention hall, was my small neighborhood health center on steroids.

Believing health care was a right of every American citizen, undoubtedly learned in CC, history classes and Professor Shenton’s Civil War seminar, I called The National Association of Free Clinics (NAFC, freeclinics.us). Two weeks later, I was on a plane to Little Rock. I was asked to triage the waiting line, looking for someone who needed urgent care. The people began to line up two hours before the doors opened at 10 a.m. By the time the first scheduled patient was seen, more than 200 patients were waiting.

More than 80 percent were working but none had health insurance. Some were self-employed but could not afford the premiums of individual policies. Some had several jobs, none of which provided health benefits. Others had been laid off and could not afford COBRA.

Few had seen a physician in the past year. Almost half had not seen a physician in the past six years. All had the same reasons for having neglected 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 discouraged them from seeking further care.

A man with a below-knee amputation was in a wheelchair. He hoped the clinic would help him obtain the prosthesis request his medical insurance had denied.

A woman grimacing in pain had cancer treatment two years ago but was unable to continue treatment without insurance.

Another woman was wearing a trench coat to cover her emaciated frame. She had had three seizures in the past two weeks. A local emergency room where she had sought help told her that the level of her seizure medications was “OK” and discharged her. No follow up was arranged. During her seizures she had bitten the inside of her mouth and tongue. She could not eat. When I told her that we would care for her and arrange for further care, I could not see an intact tooth in her broad but crooked smile.

A man with labored breathing and a sweaty brow was slumped in a wheelchair. His weak voice told me five days ago he was in the intensive care unit of a local hospital for “swollen legs and chest heaviness.” At discharge, he was handed a list of unaffordable medications that he did not understand. Continuing care was not arranged. He had unstable angina. I wheeled him to the front of the line and called the EMTs to take him back to the hospital.

Had the free clinic not existed and his daughter not insisted that he come, would the cause of his death been his heart disease or the failures of our health system?

It was not the spectrum of illness I witnessed that was different. It was the severity of illness. It was not just diabetes; it was uncontrolled diabetes with diabetic complications. It was not just hypertension; it was blood pressures of 190 over 120.

There were five patients sent by EMT ambulance directly to the emergency room who may well not have seen the next day were it not for this clinic. At the end of the day, I had spoken to several hundred people and heard their stories of living in the wealthiest country in the world without health insurance.

I was overwhelmed. Every patient’s story ended with the haunting refrain of the chorus of a Greek tragedy: “no insurance, no cash, no doctor, no medication.”

Before leaving, I was asked if I would be at the next clinic in Kansas City that was scheduled in five weeks. Without hesitating, I said yes and that I would travel to any clinic organized by the NAFC. I have been to Kansas City, Hartford, Atlanta, Washington, D.C., and New Orleans. My seventh and most recent clinic was in Charlotte, N.C.

I have no professional affiliation with NAFC. My commitment to it is personal. I pay for my travel and take time from my private practice to do this.

I thank my years at Columbia for fostering my social awareness as well as my preparation in the basic sciences and American history for my career in medicine that has continued to bring challenges and satisfaction.

Dr. Ralph Freidin ’65 has practiced internal medicine and primary care in Lexington, Mass., for the past 30 years. He blogs about health reform at theunseenpatient.blogspot.com.

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Invitation to the "Undoers" of President Obama's Health Reform

by Ralph Freidin on Friday, January 21, 2011 at 11:29am

As a physician who has always believed that health care is a right that should be available to every citizen, it is distressing to listen to the distortions of those who are trying to undo President Obama's health reform.

Over the past year, I have volunteered my professional services at seven of the NAFC's clinics that Nicole Lamoureux and the National Association of Free Clinics have organized. Whatever the city, be it Hartford, CT or Little Rock, ARK, the patient’s stories are variations on the same theme: "I have no insurance, I have nor doctor, I have no healthcare."

It is an embarrassment as a physician and American citizen to see fellow Americans whose health status is closer to the health of patients I cared for 45 years ago as a young physician than it does of the patients I care for now.

To help those who wish to undo the most significant piece of health reform since Medicare passed in 1965, the year I entered medical school, better appreciate the need for the reforms of 2010, I extend my personal invitation to any of the 'undoers' to spend a day or part of a day as Nicole's and my guest at the next clinic. I will be providing primary care, and it would be my pleasure to have an 'undoer' sit with me and hear the people tell their personal stories of trying to access health care without insurance.

After witnessing the health of their fellow citizens, any fair minded person will have a very heavy conscience should they continue to spread untruths about President Obama's health reform. They will understand the injustice perpetuating a system that neglects over 50,000,000 people - one sixth of American citizens.

I can be reached at my office 781 862 7500; on my cell 617 620 9623, or by email

rmfreidin@comcast.net

Thank you

Ralph B Freidin, MD

some of the 1200 people cared for at the Atlanta Free Clinic

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