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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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Sunday, May 8, 2011
Friday, January 21, 2011
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
Monday, December 27, 2010
Compensating Physicians for End of Life Decisions - not Ending Life
Once again those who oppose Presidents Obama's initiative to improve our health system are creating anxiety and fear by crassly labeling as "death panels" time spent by patients and their physicians discussing 'end of life decisions'. Such conversations, for primary care physicians such as myself, are part and parcel of our practice. Longitudinal care is particularly unique to our specialty. It is appropriate and expected that people whom we have cared for years, sometimes decades, while they were enjoying good health, and death was a nebulous abstract, look to us to coach them thru the maze of complex, trying, and uncomfortable efforts to ‘treat’ their untreatable illnesses. They look to the physician they have trusted their health for years to decide when treatment no longer is beneficial or desired.
These conversations cannot be complete if postponed until the final hospital admission. There is not enough time. By then the patient who is too ill to express wishes for the care they want, and too weak to articulate their choices to the unfamiliar physicians whose priority is selecting treatments to retard or control, but rarely cure, the illness. Under these circumstances, patients have little choice but to defer choices of treatment to doctors whom they barely know.
To equate these intimate conversations to death panels is to extract all dignity from the process of dying. Those who suggest that physicians who have these conversations with their patients are ‘death panels’ not only disparages the physicians and the medical community, but more importantly, negates patients their right to decide the manner in which they wish to have their life end.
Re-embursing physicians for time spent in these discussions will encourage physicians to allocate their time and resources to assist their patients with these most difficulty medical decisions. It is only when a patient encounter is specifically committed to this most personal issue that the patient has the opportunity to express his/her desires and the physician has the necessary time to listen. Without these opportunities, patients will be committed to a death that is too frequently postponed to a time when there is no honor to life or dignity in death.
Monday, December 20, 2010
Bread Lines then, Health Lines Now
Three weeks ago, I traveled to Charlotte to volunteer as physician at my seventh (Little Rock, Kansas City, Hartford, Atlanta, Washington DC, New Orleans) free medical clinic for people without health insurance. As previously, there were over 1000 people cared for during the one day clinic. It has now been a full year since I attended my first clinic. Except for Kansas City and New Orleans that were two day clinics, each of these clinics have been for one day. Simply, I taken nine days from my own primary care practice to participate with other providers volunteering their time to care for over 9000 patients none of whom had health insurance and most had the chronic illness of adult Americans ( diabetes, hypertension, hyperlipidemia, coronary heart disease, obesity and arthritis) but had not seen a physician for more than a year even though most had been prescribed several medication by the last physician they had seen.
They arrived with bottles of medications empty because they could not afford to refill them or could not afford a doctor’s appointment to re-write the prescriptions. The stories of the residents of Charlotte were identical to those of the other cities that had hosted the other clinics. They either were self employed and could not afford health insurance for themselves or their family; they had lost their jobs and with that lost their health insurance; or they had part time or temporary jobs that did not provide health benefits.
As if rehearsed, the patients at Charlotte, explained the reason they had not seen a physician in such a long time with a ‘mantra’ that I had first heard in Little Rock and echoed in each of the other clinics and again in Charlotte “ I do not have health insurance, so I have no physician, and have no health care”.
Without access to care without ability to refill or pay for their prescriptions, again I saw patients with blood pressure out of control. Of the several dozen patients I personally cared for, the lowest diastolic pressure was 94. Most were above 100, some over 110. Diabetes was equally poorly controlled. The same was the situation for cholesterol. More than two thirds of the patients were obese but almost none had had seen a nutritionist.
As mentioned, Charlotte was the seventh free clinic where I had precipitated, so none of these clinical observations were surprising. What was surprising, was that there was such similarity of the stories of patients in each of these seven cities.
Reflecting on the entirety of my experiences, the Americans, most who never had previously sought free services of any sort, but now overcame their personal pride, signed up for appointment at these free clinics and then waited on line for many hours to be seen, reminded me of the long lines of people waiting on the bread lines of the great depression.
Then food was the essential. In the 1930’s medicine was something not expected by the lower and middle class and for those who did have access to care, the care they received was limited and of minimal benefit. There were no antibiotics, no intensive care, insulin had just become available for a few. The people waiting on the lines on the 1930’s did not consider health care something the government would or should provide for them. However, they did look to the government and charities to provide food.
Today, food is readily available and most people can afford to purchase, or are eligible to receive government subsidies for adequate food. In the eighty years since the bread lines, medicine has become something not recognizable by those who waited in the cold. Medical care has also become much more accessible - if one has health insurance or personal wealth.
However, the over 50,000,000 Americans who do not have health insurance they are unable avoid the complications of their chronic illnesses because they cannot benefit from the tremendous advances in medicine over the past eight decades. Without access to medical care of the twenty first century, the health of status of those we have seen at these free clinics, is not too different than the health status of the thousands of Americans who stood on the food lines.
Then many people relied on charity to put food in their stomach and food on their kitchen tables for their family. Today many people must rely on charity for medical care. Is there really much difference? Both are essential. In each instance, very large proportions of our citizens have become marginalized and their lives vulnerable.
Thursday, October 7, 2010
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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