Tuesday, May 6, 2014

The Tale of Two Women

            Although I closed my practice of medicine, more than three years ago, two questions continue to haunt me. The first, “Is my life not worth two thousand dollars?”, came from a thirtyish African-American, woman, night supervisor in a fast-food restaurant in Atlanta. The second “Should they have spent so much money on me?” come from a thirty-two year old white woman in Boston.  During my thirty years of caring for patients, never had any so concisely conveyed what it is to live in America without health insurance.
            Several years ago, my wife and I traveled to Atlanta to volunteer at a one-day free medical clinic for anyone without health insurance.   As a psychiatrist, my wife was assigned to ‘Behavioral Health’ while I was assigned to General Medicine. Shortly after the clinic opened, my wife arrived at my cubical, wanting to see me. As I stepped outside the curtain after asking the patient I was attending to excuse me, I saw my wife was un-nerved and angry.  “What’s going on?” I asked.
            “Can you believe this? I am seeing a young woman sent to Behavioral Health because the triage physician noted she was severely agitated when she registered. They got that right, but she does not have a psychological problem. She is a neatly dressed thirtyish year old African-American woman working both a day and night part-time job neither giving her health insurance. For several months she experienced right lower side pelvic pain. After three months of wishing the pain would go away, she withdrew all of her savings just yesterday to see a gynecologist. After describing the pain to the doctor, he did a quick exam and told her she would need an ultrasound. He could perform it in his office. Her last dollar paid for the ultrasound that showed a possibly cancerous right ovarian mass. She would need a CT scan and possibly a biopsy to determine if it was. ‘How much would that cost?’ she asked.’ The doctor, indifferently, quoted her two thousand dollars. ‘I’ll be dead before I can save that amount she responded in amazement’”
            “Not having a physician, health insurance or the money for another doctor’s appointment, she did not know how to get the care she was told she needed. Fortuitously she had read about this one-day free medical clinic. Doubtful that the clinic would be helpful, but hoping otherwise, following her night shift, she changed out of her night supervisor uniform and dressed for the clinic.”
            “She was an emotional wreck when she arrived unable to say why she had come. The nurses quickly saw she was hysterical and triaged her to me in ‘Behavioral Health’ where, convinced she was facing death, she asked ‘Is my life not worth two thousand dollars?’ Will you come see her with me? my wife asked.
            Excusing myself from my station, I walked across the expanse of the Convention Hall. By the time I arrived, the woman had composed herself and was able to repeat her story. Knowing that hospitals are obliged to provide care for patients unable to pay, we arranged for her to be seen, free, at one of Atlanta’s medical centers.   My wife and I feel good about having helped, but remain overcome by the question, “Is my Life not Worth Two Thousand dollars.”
            A few years later, while driving to the hospital, I heard another haunting story of young college graduate recently moved to Massachusetts to get a job and begin paying off her student loans. Her job did not provide any benefits and she did not have the funds to purchase health insurance. But she was in good health, and felt invincible. When bruises first appeared spontaneously on her lower legs, she refused to see a physician fearing a bill she could not pay. Quickly, the bruising spread to her chest, a and friend, urged her to see a physician. She did. The diagnosis was acute leukemia. Without sophisticated and expensive treatment, she likely would die.
            Fortuitously she lived in Massachusetts and qualified for the state’s universal health coverage that gave her access to the most sophisticated treatments including a bone marrow transplant. A million dollars later she was alive and again working to pay off her student loans but questions if saving her life was worth so much tax-payer money.
            When I think back over my medical career almost fifty years age, the stories of these two young women represent all that is good and all that is bad in my profession. On the one hand, are the formidable advances – new medicines, new treatments,  imaging the human body to one-centimeter resolutions, sequencing the human genome and curing incurable diseases. The best of the best offering hope to those who would have died fifty years ago, now live because of these achievements.  On the other hand is recognizing that those who would have died fifty years ago because they could not access health care, continue to die today despite these advancements. How can it be that of these women, both citizens of the United States, one survived her disease because she lived in Massachusetts that provides health care for nearly all of its residents subsidizing those who cannot afford it, and the other may have died because she lived in Georgia where almost 20% of its residents are not insured and there is no public program to provide coverage for those who cannot afford insurance. Much has been done, much more needs to be done.

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