As a doctor for the uninsured for 17 years in Los Angeles I'm still blown away on a daily basis on how horrific the medical system is for the poor!
The resident presented her case to me, “I've got a 51 year old woman with diabetes, hypertension, hyperlipidemia complaining of chest pain for the past couple of months. It's on the right side and radiates down her right arm, not related to activity, but she gets it with nausea and vomiting.”
So as a physician, when a patient presents with chest pain, there are two things we look at to help us decide whether to pursue a workup for angina (chest pain caused by the lack of oxygen to the heart muscle usually caused by blockage of the arteries that bring oxygenated blood to the heart muscle). First, the chest pain itself...we call it “the story”. Is the story typical for angina, such as chest pain or pressure in the mid chest or left side with activity or stress (basically something that increases the heart rate), that lasts for several minutes (5-20), radiates down the left arm, relieved with rest with concomittant symptoms such as shortness of breath, nausea and/or vomiting, sweating and a feeling of “doom”?
Second, we look at one's risk factors for heart disease. The risk factors are: a known history of a previous heart attack, diabetes, a family history of a 1st degree relative who had a heart attack at a young age (less than 60), hypertension, smoking, men over 45 or "postmenopausal" women and hyperlipidemia. If the patient has significant risk factors or “the story” is typical for angina, we must pursue the work up for angina.
Back to our patient: not the best story since the pain is on the right side and not with activity, but she has a whopper of risk factors, so we must pursue the work up. We get an EKG that didn't show that she had a heart attack, but when compared to an old EKG, there were some significant changes that could be consistent with heart muscle injury.
I called our referral coordinator, “What's quicker, a stress echocardiogram or a nuclear medicine scan?” (these tests can tell us if she's really lacking oxygen to the heart muscle with activity)
“There both the same, 9 to 12 months,” she answers without a bat of an eye.
You see, I work at a Community Clinic in L.A. And this patient is uninsured. We send all our cardiac testing to one of L.A.'s county hospitals. I just looked at her searching for some other answer.
“Well,” she starts to reveal, “ we are allowed one treadmill test per month from this other source, but only Dr. Smith is allowed to approve it.” I continued to look at her, at a loss of words as to why this patient deserved the treadmill test more than any other patient from our four medical sites.
“All right, I'll give you the referral. We have one open for September.”
“I'll take it!” We added medication to lower her heart rate and open the heart vessels treating her as if she had angina and hoping she wouldn't have a heart attack until we can test her.
Later the same day, another resident presented another patient: a 52 year old woman with hypertention and a family history of a heart attack (her mom died at 51 of a heart attack!) without insurance complaining of a few weeks of experiencing chest pain in her mid chest after 15 minutes of walking, relieved with rest! Great story, great risk factors! Ok...I've already used my one ticket for a special treadmill test. EKG looked ok. Put in the referral of a stress echocardiogram, knowing it would take 9-12 months, started her on the same medications as the previous patient plus a baby aspirin and nitroglycerin to use in case rest doesn't relieve her chest pain (however nitroglycerin does not prevent death from a heart attack). And we gave her precautions for when to go to the Emergency Room.
The same day...another patient! A 51 year old uninsured man with hypertension also complaining of chest pain with walking over the past couple of months, relieved with rest! Really?! EKG looked ok, started the same medications, filled out the form for the study that may happen sometime next year, and gave the same ER precautions.
The rate of the uninsured in the U.S. Is now up to 52 million individuals! Twenty-two thousand people die every year because of being uninsured. I just gave you three examples of why someone might die from being uninsured. Heart disease is the number one cause of death in the U.S. The American Heart Association states this year that 6.5 million of the uninsured suffer from heart disease. “They are far less likely than their insured counterparts to receive appropriate and timely medical care and as a result, suffer worse medical outcomes, including higher mortality rates. The underinsured often encounter similar problems. “ Furthermore, a 12-year study of more than 7,000 Americans showed that individuals without health insurance, especially those with heart disease, stroke, high blood pressure or diabetes, experience a dramatic improvement in health when they become eligible for Medicare coverage at age 65. (Duru OK, Vargas RB, Kerman D, Pan D, Norris KC. Health Insurance status and hypertension monitoring and control in the United States. Am J Hypertens 2007;20:348-353. )
And now congress is entertaining the idea of cutting Medicare and Medicaid?! Are you kidding me? What do we need to show those against health care for all that individuals in the U.S. need quality and timely health care in order to decrease mortality and improve one's quality of life? Maybe those wanting to cut access to health care don't care about poor people. But at least it's more cost efficient to provide health care to all. Studies show that the uninsured use the emergency room more frequently for non emergent care, creating hospitals to go in debt or worse, to close down. Furthermore, the uninsured take longer to seek emergent care, thus presenting to the hospital worse off, requiring longer hospital stays, again straining the safety net even more. In my eyes, it's a moral injustice for individuals to risk their health by avoiding primary care and delaying emergent care, but at least we can all agree, at least providing access to quality and timely care saves communities money. I can't convince people to care about poor people, but I can at least make the case to save money.