Tuesday, November 19, 2013

Nobody should look

This wouldn't happen if that website had just worked!

Looking back on it, I buried the lede:

In my second year of medical school, I took a small-group course with a famously terrifying surgeon. He told us his moral motto: “A physician never takes away hope.”

I never figured out how that motto could guide doctors through a system where our patients are dying from treatable diseases. Part of my job, it seems, is precisely that: to sit down with patients and, as gently as possible, take away hope.

Consider Vanessa and Jimmy. They met in New Orleans when she was 18. She was working cleaning motels, and he took her on a tour of the tugboat he was captain of. Vanessa says they came to St. Vincent’s because the shipyard Jimmy worked for opted out of providing insurance even for full-time employees like him. They looked for insurance on the open market, but couldn’t afford it.
When Jimmy’s labs showed a dangerously high white blood cell count, we sent him to the ER. It was pneumonia, and there was a huge tumor underneath. Current guidelines would recommend screening Jimmy for this kind of cancer every year, but we have neither the equipment nor the funds to offer screening. So it got caught late.

After Jimmy was diagnosed, I helped Vanessa fill out the paperwork to request financial assistance for cancer care....

Vanessa called from a hospital in Houston in early November, distraught, asking me to help her decide whether or not to let the doctors turn Jimmy’s breathing machine off. She was afraid she wouldn’t be able to live with herself, no matter which she chose. I gave her the advice I’d give a friend: that I trusted her love for her husband and her ability to decide from a place of love. Jimmy died late that night.

Vanessa’s request for UTMB funding wasn’t approved. She has received a $17,000 bill from UTMB for the visit when Jimmy went through the ER, and a $327,000 preliminary bill from the Houston hospital.

If the Affordable Care Act had been in effect last year, they would have been able to afford insurance, get treatment early and avoid bankruptcy. I use stories like theirs—cancer stories—when I am encouraging my patients to check out the insurance exchanges.

But the real catastrophe is all those people losing their policies, and the fact the website doesn't work as advertised.   And what about those people who get treated in ER's?  Ted Cruz said that was okay, didn't he?  Turns out we don't really take care of people who can't pay:

The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.
You can compare that to this document from the Texas Attorney General's office.   Nothing in that PDF document says you have to be cured before you stop meeting "hospital criteria" entitling you to charity healthcare.  UTMB, after all, is a "public hospital."  But:  "When UTMB refuses to treat them, it falls to us to tell them that they will die of diseases that are, in fact, treatable."

This is the state of medical care in America.  And yet the serious problem of medical care in America, is whether or not a website will be up and running before Christmas, and whether or not some insured people will get to keep the cheap and probably worthless insurance policies they now have.

Bah.  Humbug.


  1. Your Dickens allusion is interesting, although I also can't help but think of the "Circumlocution Office". What is it about Anglo-American bureaucracies (both public and private) and complicated, circular rules? I remember one of my friends in grad school (hailing from Germany) having problems navigating getting a drivers' license: you need insurance to get a drivers' license and a license to get insurance! Why did we make our health care reform so complicated? Of course, ironically part of the reason why health care reform is so complicated is because of our very disgust at complicated, circular bureaucracies -- both in terms of our disgust leading to a political environment in which compromises must be made to pass any legislation, which compromises ensure extreme complications in implementing any reform, leading to bureaucracy, but also more general in our dismissal of the ability of bureaucracies to be streamlined leading to bureaucracies by necessity not ever having any pressure to be streamlined.

  2. That being said, as you point out, this

    If the Affordable Care Act had been in effect last year, they would have been able to afford insurance, get treatment early and avoid bankruptcy

    is why the ACA is so very critical. And the medical costs that are not paid due to bankruptcy or what have you? Well, somebody has to pay them, so they are still a drag on the economy.

    OTOH, the above quoted statement begs the question:

    How many uninsured/underinsured people can really afford the insurance made available to them by the ACA? Sure it's cheaper than before, but we are still requiring people (including many working class individuals) to pay up to 10% of their incomes on health insurance, which payments, although less than medical bankruptcies, still put a drag on the economy. I know if I had to pay $3000/year on health insurance as a post-doc, it would have made me come into full adulthood with even more debt and have made me even less of a contributor to the economy.

    Also, would the ACA necessarily ensured that Jimmy get treated early and thus avoid death and in addition expenses that we all get stuck with due to medical bankruptcy? Who says that the kind of screening Jimmy needed every year would always be covered by his health insurance. After all, every so often, there is a big brouhaha about "unnecessary medical tests", which insurance companies use as cover to deny claims and restrict what tests are done. Heck, even if Jimmy showed up in the hospital, there is no guarantee that the insurance would even pick up the tab for a chest x-ray: when I was in college, I had an asthma attack that did not respond to my inhaler, so I ended up in the ER where they ran a chest x-ray and my family's platinum-level coverage denied payment for the chest x-ray. After all, there are a lot of unneccesarily medical tests, dontcha know.

    Again, the ACA is better than the status quo because of the "death panels": rather than insurance companies getting to decide what procedures they will suddenly (and, as the Church Lady would point out, conveniently) not pay for, it will be a hopefully disinterested government panel of experts. However, there will still be political pressure to "save money" and "not spend money on un-neccessary medical tests": how long do you think ACA "silver level" insurance policies would actually be required to cover the sort of yearly screening Jimmy needed to catch his cancer on time? My guess is not long.

    Similarly, how long do you think subsidies will last for health insurance until they get cut because ... deficits! government spends too much money! ...? My guess is that the second someone with granite countertops is discovered to get a single $ of subsidy for health insurance, it will be made a political football and all subsidies, including those to the working poor, will get cut before you can say "SCHIP". OTOH, count on the GOP to complain about every working class family who can't afford to move out of a 1 bedroom apartment because they have to spend 9.5% of their income on health insurance due to a mandate that originally came out of the Heritage Foundation's health care reform proposal?

  3. And as my wife, a lawyer and former investigator pointed out, why did Obama not have someone telling him "he had spinach in his teeth"? Obama should have realized that the insurance companies would try to sabatage the ACA, not because they dislike it (they must love the ACA for giving them more business) but because they want reform to leave a bad taste in people's mouths so that any further reforms to health care (that might really hurt insurance companies) won't have any political momentum.

    At the very least, the website should have been fully tested, and if the ACA were impractical to implement in a timely manner, Obama should have spoken publically about why and what Congress needed to do to pass a workable reform before the ACA was even set in stone. What does it say about Obama's leadership that this wasn't done? And what does it say about our political system that there is no political way Obama could have tried to pass a better, more workable reform without being widely denounced as a socialist unwilling to "compromise"? After all, as I tried to point out to my wife, the people complaining the loudest about Obamacare are those whose politics (whether of the tea party variety yanking the Overton window rightward or of the "the truth is somewhere in the middle" faux centrist variety that believe that, no matter what, the Democrats are too liberal and must compromise) put us into a position where the only politically practical "reform" is exactly the sort of unworkable Rube Goldberg machine about which they are complaining?

    Which I guess brings me to my earlier point: what is it about (Anglo-)American "pragmatism" and dislike of unwieldly bureaucracies that causes us ironically to build such bureaucracies and how do we get the culture which brought us William of Ockham to actually learn to keep it simple?

  4. Obama should have realized that the insurance companies would try to sabatage the ACA, not because they dislike it (they must love the ACA for giving them more business) but because they want reform to leave a bad taste in people's mouths so that any further reforms to health care (that might really hurt insurance companies) won't have any political momentum.

    Or, more to the point: the insurance companies don't have anyone's best interests at heart except their own, which is to say: their bottom line and their ROI. The deal with the Devil here is in not just setting up Medicare for all in the first place.

    But that was NEVER gonna happen. So we get this Rube Goldberg mechanism which has been sabotaged from the moment Obama signed it into law. Recall the system was designed with the idea all states would have exchanges and broaden Medicaid. Then the Supreme Court said "I don't think so," six months before the start date.

    So a bad situation was made worse.

    In answer to your question about bureaucracies: for the same reason we don't have a parliamentary system. We recognize so many competing interests and insist on giving them a voice (so the filibuster, and checks and balances, etc., etc., etc.) that every government agency must at least listen to competing interests and make unwieldy structures which avoid the dreaded "tyranny".

    Even though Medicaid and Social Security seem to work pretty well, and fairly simply, all things considered.