Why can't all diseases get organized, well intentioned, humane care? Why does a man who has his own business have to play Russian Roulette with his life in trying to get treatment for his Rectal Cancer? Thanks to Obama's Patient Protection and Affordable Care Act most people in the U.S. who make 133% of the Federal Poverty level and below will automatically qualify for health insurance and will get the much needed care they haven't been getting up until now.
"Can you do a breast exam, too, Doctor?" I was seeing a new patient at my community clinic for the uninsured. She was an Armenian woman who had lost her full time job two years prior and thus lost her medical insurance. She also had high blood pressure, but hadn't taken any medicine since losing her insurance. She proceeded to tell me that she noticed that her nipple was going inside her breast for the last six months and it started hurting 3 months ago. I immediately became worried. I had her change into a gown and upon lifting up the gown I immediately saw a very deformed breast. She was right; the nipple had completely inverted due to a huge mass pushing it in. My heart sank. Six months?! I thought to myself. She read my expression, "Is it bad?" "Yes, it's very bad." When I asked her why she didn't see a doctor earlier for this, she said that she didn't know where to go. "Why didn't you go to the emergency room?" I don't have the money. The message was clear. In the U.S., if you are sick and you don't have insurance, there is no where for you to go unless you have money. She didn't know that California provides everyone, despite their ability to pay, breast cancer screening for free. And, if diagnosed with breast cancer, one immediately qualifies for MediCal which pays for breast cancer treatment. But how would she know this? Google? Word of mouth? But, actually, what everyone knows is that if your sick in the U.S. without insurance and you are not wealthy, your toast.
Last month I saw a new patient, a man in his 50's. "Possible Rectal Cancer" was written by my medical assistant on his chart. This was his story: he had noticed that he had rectal bleeding several months ago. He paid out of pocket to see an internist about 6 weeks prior to my visit. Based on her exam, she was worried about rectal cancer and wanted to refer him to a specialist for a colonoscopy and biopsy, "but I didn't go. They told me it would cost thousands of dollars; I can't afford that. So, I came here for a second opinion.” Rectal bleeding and weight loss. I was already worried. As I examined him, I saw a mass protruding from the rectum and felt the mass extend inside...rock hard and bloody. I can't explain the feeling that I get when I confirm my worst fears for my patients. But it's just not the feeling of concern for cancer. It's this utter sense of loss and impotence in the face of an aggressive disease....months into the deadly disease. Rectal Cancer is curable! But not after doing nothing for months! I get a heaviness in my chest that extends into my stomach because I know that this could have been averted had money not been an issue. Why does someone who can afford medical care get treatment and one who can't afford medical care doesn't? I calmly sat down and told him, “I'm 100% sure that you have rectal cancer,” hoping my lack of ambiguity that often comes natural to clinicians when talking about cancer would scare him into getting treatment. “Here are your options: you can go to the county ER and they'll get you into Colorectal Surgery within weeks where they'll take good care of you. You might get hospitalized right away, but your vitals are stable and your hemoglobin isn't too bad, so you might not. You'll probably wait 36 hours to see a doctor given that you're so stable. Or, you can go to Cedars Sinai's ER, not wait too long and most likely you will get what they call 'Charity Care'. I have seen many indigent patients get really good care there, unlike other community hospitals. But, I can't guarantee that.” “I can't wait 36 hours. I just can't.” I understood. And with that, I gave him an appointment with me in a few weeks and a look that pleaded, “Please go to the ER.” The heaviness in my stomach stayed with me all day.
As I returned to the charting room to tell my colleague about my breast cancer patient, I asked her in desperation, “Should I just send her to the ER?” “No, refer her for a diagnostic mammogram and biopsy. Once the biopsy comes back positive for cancer, she'll get MediCal immediately and you can send her to a surgeon at Cedars.” Normally, many surgeons don't except MediCal, in my experience, but Breast Cancer care must reimburse well. As she described the process to me, I couldn't help but think how it sounded so....well organized....well intentioned....humane. People with cervical cancer, end stage kidney disease needing dialysis and pregnant women get the same immediate care.
Why can't all diseases get the same organized, well intentioned, humane care? Why does the man who has his own business have to play Russian Roulette with his life in trying to get treatment for his Rectal Cancer? Thanks to Obama's Patient Protection and Affordable Care Act most people in the U.S. who make 133% of the Federal Poverty level and below will automatically qualify for health insurance and will get the much needed care they haven't been getting up until now. Yet flawed, it's a start at getting poor people covered. We'll still be doing the same desperate search for urgently needed care for immigrants. By the way, if you're pregnant in this country and make under the 133%, you get health insurance immediately....even if you're an undocumented immigrant. For nine months (and six weeks after a normal vaginal delivery), a pregnant woman gets excellent and humane care. We're not in the hole as a result...just less babies in the ICU. Kudos to those that lobbied for that law! Now let's just extend it to everyone. Humane medical care for everyone.