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cancer, Editorials, health insurance

Cancer v. the Constitution

The patient in the emergency department smelled of advanced cancer. It is the smell of rotting flesh, but even more pungent. You only ever have to smell it once.

She had been bleeding irregularly, but chalked it up to “the change.” Peri-menopausal hormonal mayhem is the most common cause of irregular vaginal bleeding, but unfortunately not the only cause.

She hadn’t gone to the doctor because she had no health insurance. The only kind of work she could get in a struggling rural community was without benefits. Her coat and shoes beside the gurney were worn and her purse from another decade. She could never afford to buy it on her own. She didn’t qualify for Medicaid, the local doctor only took insurance, and there was no Planned Parenthood or County Clinic nearby.

So nothing was done about the bleeding until she passed out at work and someone called an ambulance. She required a couple of units of blood at the local hospital before they sent her by ambulance to our emergency department.

I looked at the fungating mass on her cervix. Later the Intern wondered why she hadn’t picked up on the smell. Probably a combination of it being so gradual and denial. It’s amazing what people learn to tolerate when their options are limited.

“I’m very sorry to tell you this looks like a cancer of the cervix,” I said

She looked surprised. “Oh.” She paused in silence as she adjusted to the news. And then quietly she added, “But the doctor back home said you could fix me up. He said you can offer free care because you have the university.”

But we didn’t have free care at the university hospital. While resident salaries come from Medicare dollars, there is very little, if any, money from the State for the medically indigent. We were in the same situation as her local OB/GYN. The cost of caring for those without insurance was born by the profits from those with insurance. But medical care was becoming more expensive and what insurance companies were willing to reimburse was decreasing. In addition, with more unemployment there were fewer insured patients and more uninsured. Not a sustainable model.

She needed a biopsy to confirm the type of cancer and a CT scan to see if the tumor had spread beyond the cervix. If she were lucky, she would have a some combination of a hysterectomy, chemotherapy, and radiation with a 50-65% chance of survival. If the cancer had spread, she would have radiation and chemotherapy with about a 25% chance of surviving.

But the cancer surgeons were not allowed to offer an uninsured woman a hysterectomy. Every now and then they snuck someone in, claiming to the administrators that the patient was more emergent than they really were. But one surgery doesn’t cure stage 2 or 3 cervical cancer, or even stave it off for long. It takes multiple admissions and week after week of expensive chemotherapy and/or radiation.

The radiation doctors were also not allowed to see uninsured patients. They could not even give a dying women a few weeks of radiation to ease her tumor’s stench while it caused her to bleed to death or killed her another way. They could give her one dose today. A very temporary measure for the bleeding, but only if her blood count was low enough. It wasn’t because she’s had the blood transfusion to get her here.

There was a charity program that paid providers and hospitals pennies on the dollar for cancer care. One hospital had signed up, resigned to the fact that they were seeing those patients anyway so better to get something for the cost of the care than nothing. Our hospital administrators had declined to participate. Better to get no money and keep seeing these uninsured patients over and over in the emergency room, each time providing the same stop-gap care that has no hope of cure or even palliation like a purgatory version of Groundhog Day, than to be inadequately reimbursed for the right care.

I had never encountered this clinical scenario during my training in Canada. I had never seen a woman suffer because she couldn’t afford something as simple as a Pap smear, never mind deal with the indignities of shopping around her sorrow and hard luck to try to patch together what would inevitably be inadequate medical therapy. It is this reality of medical care in America for which I was wholly unprepared. Many times I found the residents comforting me.

I gathered my thoughts before explaining the situation. To get her care through the charity program there was a catch. A set of hoops to jump through and we could jeopardize her eligibility with specific tests. I explained the ins and outs of accessing care through the program, where she needed to go, and what specifically she must say. The Intern printed out the sheet of community resources and advocacy groups that might also be able to help her patch together some kind of treatment.

It’s not health care, not by any stretch. But as long as the Supreme Court finds it constitutional I guess they’ll sleep better than I do.

Thank you for all the feedback, opinions, discussion and debate. Comments are now closed.

Discussion

180 thoughts on “Cancer v. the Constitution

  1. Ignoring private insurance completely, the US federal and state governments alone spend MORE per citizen on health care than any other country. Other countries manage to cover 100% of their citizens while spending LESS per citizen than our government spends to cover only ~35% of the country. Why?

    A routine appendectomy costs $3k in Canada, while Medicare pays over $12k for the same routine surgical procedure. We’re simply paying too much for the care being provided. It’s not a matter of insurance, since Medicare is already single payer. So ObamaCare is barking up the wrong tree.

    The US government is extremely inept at cost containment. They passed a very modest cut to the reimbursement rates paid to Medicare doctors way back in 1998. This is essentially the poster child for how government COULD possibly rein in costs. Simply tell doctors they are going to get paid less and make them adapt. But instead, the politicians broke down under pressure from doctors. Now Congress has to scramble around finding hundreds of billions of dollars to pass a “Doc Fix” in the budget so that these modest cuts never actually happen.

    We need to use examples like a routine appendectomy to gauge how and why we’re being fleeced. Is it the hospital, the doctor, the prescriptions, malpractice insurance? Are there too many nurses involved? Too many hours allotted, too much recovery time provided? Just go through the costs one item at a time and find out how and why we pay 4x more than Canada.

    Then REFORM THE GOVERNMENT systems. They already have more than enough money to pay for health care for every US citizen, but we’re only getting 35% coverage. If we reform the government’s problems there is already more than enough money there to care for everyone. If we ignore it, there will never be enough, no matter what else we try to do.

    Posted by KC | March 31, 2012, 1:18 am
  2. Thank you Dr. G or this horrifying yet accurate article. I am a “non traditional” first year medical student. I am not from a “privileged” family. My husband has also been unable to receive care for his medical condition despite going through all the appropriate appeals to the insurance company with physician support for medical necessity. I have a family and will come out of medical school with over 200k in debt. The federal subsidized loans are being taken away from all medical students as of July, increasing our debt load. This year’s match was very tough. There were hundreds of fourth years competing for 8 remaining pediatric residency spots in the scramble, meaning hundreds of potential primary care physicians are unable to receive training in the field this year. In the face of decreasing medicare funding, many residency programs are letting residency spots go unfilled. I know many people in the public view docs as rich country clubers, but the vast majority of docs I have encountered are generous caring chevy-driving members of the community. I am disheartened looking at the future of medicine in the US without the ACA. Currently we are cutting care and seriously threatening medical training. How can we possibly hope to take care of an ever expanding and aging population? I just wonder wonder why the individual mandate is being met with such opposition. The fine for not carrying insurance would only be $95 if a person wanted to opt out. Yet, if that same person was in a vehicle crash, s/he would still be treated when brought to the ED due to EMTALA. The physicians are not the enemy. I don’t need to nor do I expect to be wealthy. I hope to be able to pay back my loans, provide for my family, and enjoy my work. I cannot imagine doctors looking at dying patients and withholding treatment if they had the power and resources available. As students, we are constantly being taught to practice “evidence-based medicine”, but I wonder where the evidence is supporting patients with a treatable cancer dying without treatment. How has the policy of medicine strayed so far from the principles. I know I am a fresh med student idealist, but just have hope for the future and I shudder to think what may come when we continue to turn our backs on our neighbors. Thank you for sharing your experience and having this conversation.

    Posted by CMac | March 31, 2012, 1:43 am
  3. I work for the ambulance service here in Britain and take patients to our local large teaching hospital, Addenbrookes in Cambridge, continually. People are seen and treated and don’t usually give a thought to the cost of their treatment. People don’t have to worry about bankruptcy due to medical costs and can have their health issues attended to without that fear hanging over them. I lived and worked – in a hospital – in Southern California for a number of years and often compare the two systems of healthcare.

    Whenever we transport somebody who does nothing but moan and complain about the NHS I firmly relate to them my experiences of living in the US. To begin, I tell them (nicely of course) that the 50 mile round trip journey we are making in California would probably cost them in the region of £50-60 PER MILE. Also, the treatment they are about to receive is probably in the region of several thousands of UK pounds. Cost to them – nothing.

    We pay 12%, after income tax allowance, from our income for National Insurance, which covers health care, amongst other things. Ok, in Britain we do seem to pay a lot of tax but, having seen both sides of the water, I know where I would rather be, healthcare wise, as I get older! By-the-way, my wife is American and she also knows where she would rather be, healthcare wise.

    Posted by David St. Laurent | March 31, 2012, 4:30 am
  4. The U.S. is one of the world leaders in deaths from preventable causes (http://www.commonwealthfund.org/Newsletters/The-Commonwealth-Fund-Connection/2011/Sep/Sep-26-2011/Whats-New/US-Last-in-Preventable-Deaths.aspx, We also lead the world in bankruptcy related to medical costs– in other industrialized countries such bankruptcy is unknown. We are number 1.

    http://www.medicynic.com

    Posted by medicynic | March 31, 2012, 5:45 am
  5. I call BS on this story…part of the oath Drs. take is “to do no harm”, plus Federal law requires persons presenting themselves at an Emergency room are to be treated whether or not they have insurance…no one can be turned away. That is one reason some many hospitals are closing their ERs or the whole hospital.

    Posted by David | March 31, 2012, 7:37 am
    • “I call BS on this story…”

      On what grounds? EMTALA doesn’t require treatment. It only requires that the hospital to stabilize the person in the ER. They don’t have to perform surgery and cure them, just stabilize and send them on their way. Anything more is charity care.

      Posted by Steve Hirsch | March 31, 2012, 11:55 am
  6. I posted here last night. My post was respectful and relevant. Yet it never appeared.

    Posted by Rod Lamkey | March 31, 2012, 8:03 am
  7. Just want to share my recent experience: I’ve lived with clinical depression that has not responded to any treatment. When i found out about a new treatment called Transcranial Magnetic Stimulation, i felt hopeful since the research showed a high success rate. I called one of the centers that advertised for it to make an appointment for an evaluation, only to find that they only take 2 insurances (for partial coverage), mine not included. It’s a 5-day-a-week treatment course that lasts 6 weeks. When i inquired about the cost for it cash, i was shocked that it i would be charged $500 for evaluation and $300 for every time i would get treated, totalling $9,500. I guess this treatment was only advertised and available for the fortunate was ones under the 2 insurances and rich people. I don’t know what the average person would have to do to whip out $9,500 in 6 weeks. I certainly can’t.

    Posted by HopingforChange | March 31, 2012, 8:22 am
  8. If a system of health care is publicly financed and privately delivered, it is called a single payer system. Now, there are many, particularly the Republicans when referring to the single payer system say that it’s “socialism”. In the United States the Republican Party has historically had negative associations with socialism and is one of the main factors the United States is the only wealthy industrialized nations that does not provide universal health care. The Republican imply that the private run health care system if a single payer system was instituted it would become controlled by the government thereby associating it with socialism. It seems the word socialism is the main factor that many Republicans bring up about a single payer system. In the United States there already is a single payer system that is called Medicare, Medicaid and the U.S. military’s “Tri-Care. It seems if one says something to kind about single-payer and there is a Republican around ready to brand you a “socialist”.

    If the mandate in the a Affordable Care Act is repealed it should radicalize Democrats on the health care issue because of the way the U.S. Supreme Court is stacked against Democrats that will in turn will move the Democrats toward the single payer system that will in time lead to the U.S. Congress to pass single payer legislation. The Republicans seem to be hoping that if they fight hard enough the Democrats will eventually give up and move on to something else. But, this is where they are wrong. Many Republicans say they favor universal coverage, but seem unable to every come up with a workable plan. The Democrats see universal care as a right and will not give up on this issue till universal care for all Americans is achieved. If the Affordable Care Act is struck-down only the Democrats will have a viable plan for universal coverage, and will be even less likeable to Republicans than the Affordable Care Act enacted in 2010. And absent of another viable proposal the Democrats will eventually get their way and Medicare for all will become a reality and the Law of the land

    Posted by William A. Perry | March 31, 2012, 9:03 am
    • Sorry, Mr. Perry, but you have inappropriate expectations about the Democrats.
      — Obama literally shouted his support in 2003 at a public meeting during a talk he was giving. He never took the lead in 2008-2010.
      — The Democratic Party platform, established every 4 years (next one August 2012, as far as I know), makes it very clear that they are AGAINST universal health care … by being FOR the continued use of health insurance companies. You can read the words about private health insurance options and health insurance companies in both the 2004 and 2008 party platforms here …
      http://www.medicareforall.org/pages/Democratic_Party

      Note: this is where a reader of this realizes that NEITHER one of the major political parties is supporting the will of the people, as very well documented in the Popular Support section of the Single-Payer Support Monitor
      http://www.medicareforall.org/pages/Monitor_Popular_Support
      Tip: at least select the first link at that web page to see the chart. From there you could select the link to the Massachusetts web page, where 67% of a QUARTER OF A MILLION AMERICANS (255,213) voted at the ballot box for single-payer health care.

      Regarding socialized medicine see an Answer here: http://www.mforall.org/p/830#socmed

      And .. if you go to that answer I suggest that you check out each of the 3 links provided to more information.

      SHOUT THESE TWO POINTS TO THE ROOFTOPS
      PEOPLE POWER TOPIC —- Based on the extremely low lack of support in the U.S. Senate (maximum of around 5%) and the very low lack of support in the U.S. House (maximum around 18 to 20% … less than 90 out of 435) THIS TOPIC IS NOT A POLITICAL ISSUE IN THE UNITED STATES. And, although there are continual attempts to tear down what other countries have, it is not a political issue in other free-market counties either, because the PEOPLE in those countries LIKE their health care. Therefore, it is sometimes political suicide to be in opposition to health care for all.

      – Bob the Health and Health Care Advocate

      Posted by Bob Haiducek | March 31, 2012, 12:25 pm
    • (a continuation of my comments)

      SECOND POINT TO SHOUT TO THE ROOFTOPS
      PEOPLE EDUCATION TOPIC — Since this is very much a people power topic, the need is for education of the American public. We are getting ready for that education, which needs to be done by as many Americans as possible, one-on-one contacts preferred.

      ———————————————–

      Your words “the only wealthy industrialized nation that does not …” certainly caught my eye. That was the accurate statement in the past. I said and wrote something similar to that for a long time. But now it is ALL free-market countries. The two poor ones within the OECD free-market countries (Mexico and Turkey) have been implementing universal health care. So … now … all those people who had been writing that ALL other industrialized / free-market countries have universal health care are CORRECT. But it has now gone way beyond that. One can now call that Phase 1. More countries have been implementing it as a kind of Phase 2 toward a world full of health care for all systems.
      http://www.medicareforall.org/pages/World_View#worldactivity

      But I want you to know that we can and will get single-payer health care, improved Medicare for All, and that it will be the best in the world.
      http://www.medicareforall.org/pages/Best

      We need to start by people knowing what the subject is. Trust me, they do not. We are part of a tiny choir among today’s estimate of 313,279,000 people in the United States.
      Talk to someone — but please use your time wisely. Contact people who themselves or their families are directly impacted — or someone who VERY clearly cares. Don’t bother with the rest, but I don’t have room here to fully explain why.
      http://www.medicareforall.org/pages/Explanation
      http://www.medicareforall.org/pages/Answers

      – Bob the Health and Health Care Advocate

      Posted by Bob Haiducek | March 31, 2012, 12:48 pm
  9. Is there a name & address you can share so people who really care about this woman can contribute money to help her?

    Posted by Harry | March 31, 2012, 9:09 am
  10. This is terrible. Sadly many of my fellow Americans are brainwashed to believe single payer is the worst thing ever.
    Did anyone see the Youtube video of the Republican debate where the crowd CHEERED at the idea of a hypothetical man dying because he lacked health insurance? Sick and mean.

    Posted by Sharon M. | March 31, 2012, 10:47 am
    • The saddest part is that it was not a hypothetical situation for one of the candidates. The candidate’s friend had died uninsured and left his family in $400,000 of medical debt: http://tinyurl.com/7szqq7q

      Posted by J | March 31, 2012, 1:33 pm
  11. I wish for all folks opposed to universal health care to lose their job (and therefore their insurance), and then get cancer. If I lived around Washington, DC, I’d go up to and tell those selfish, idiotic protesters myself.

    Posted by swampwiz | March 31, 2012, 12:03 pm
  12. While I agree the point that the US Healthcare delivery system is the most effed-up of the first world nations, I disagree that this mis-mash bill is a step in the right direction. Nor do I agree that it’s this…or nothing. All this bill does is to enfranchise the biggest problem with the delivery system, namely abusive “health insurance” companies.

    While this bill was the right wing’s wet dream a few years ago and in some ways mimics the German system, it essentially compels the individual to purchase the world’s most defective product in exchange for a promise that those who have been most cruel in US Healthcare delivery system will do better in the future. We have seen those promises before…and we have seen them broken before.

    The US “healthcare insurance” companies play the role of a wife beater in front of cops who promises to never to do it again…and like the pummeled wife, the supporters of this bill accept this promise at face value…and I stand like a cop, who knows these promises will be broken and the wife will be beaten again and again…until she ends up as a murder victim. This bill will be modified in time, at some point you will be forced to purchase “health insurance” that has all the shortcomings of today’s model…with no hope of real reform.

    Fortunately, the right wing on the Supreme Court is too stupid to realize this is a divinely sent golden parachute for all the present evil doers in the US Healthcare delivery system. That combined with Kennedy questioning the wholly unique proposition of citizens being compelled to purchase a privately held defective product/promise on constitutional grounds this bill may be pushed back for a new bill that expands Medicare into a base insurance program.

    Posted by S Brennan | March 31, 2012, 1:49 pm
  13. Here are clarifications about my posts at this web page.

    #1 — About the importance of education.

    Some activists like to “shout” out the fact that American people want this:
    health care for all, single-payer health care, improved Medicare for All, universal health care.

    That obviously would indicate or imply that no particular emphasis on education is required. Nothing could be farther from the truth, as “they” say.

    Why do I communicate a graph that over half of Americans want it, and also share that Americans do not know what the subject is?

    Because both items are factual.

    A) Responding to a well-timed survey that is appropriately worded will get positive answers.

    B) People being surveyed do not necessarily fully understood nor have a highest degree of support when faced with the subject in a one-on-one conversation. I’ve been on multiple national conference calls (for multiple organizations) over the last few years where single-payer activists communicate this: they go to people “on the street” or anyplace and find that most people are not aware. My latest check on this was making contacts in a drive across 7 states during which literally nobody I contacted had heard of this topic.

    Last but not least, the “over half of Americans” in support can, in a flash of multi-million-dollar advertising, turn that into about 80% against.
    http://www.medicareforall.org/pages/Media

    What is at that Media web page must be kept in mind. Education is critical, not just important.

    #2 — We (Medicare for All Teams) are not ready yet.

    I find this particular blog page as especially good or else I would not have spent time posting comments. The benefits to the Medicare for All Teams is that some web pages were refined as part of my providing the comments. We make refinements over time as we work to finish the final projects. Posting comments forces us to make certain that the linked web pages are in good shape.

    Thus, I am promoting what you can do on your own to be on the ground floor of what needs to occur. However, an active promotion among the masses is NOT ready to occur, at least not from our perspective.

    – Bob the Health and Health Care Advocate

    Posted by Bob Haiducek | March 31, 2012, 1:53 pm

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