When I first met my patient, I didn’t know why he’d been vomiting. It turned out to be for the worst reason.
He’d been losing weight and energy for months. He’d occasionally seen blood in the toilet. Now he was unable to defecate: A tumor in his bowel had grown so large it stopped stool from passing through.
When I looked to review his last colonoscopy, he said he’d never had one. His father had died of colon cancer, but my patient didn’t have insurance or a doctor, and he hadn’t been screened. Although millions of Americans have gained health insurance in recent years, he was one of millions more who remain uncovered.
I wondered whether his fate could have been prevented. Could we have caught his cancer earlier? Would insurance coverage have prevented a bad outcome?
Lack of insurance
As doctors, we see such tragedies every day. We see how a lack of health insurance exacerbates illness and suffering. And research supports our experience.
Twenty percent of uninsured adults say they’ve gone without the care they need in the past year, compared with just 3 percent of insured patients. The uninsured are three times as likely to forgo prescribed medications because of cost and are less likely to receive preventive care or have chronic conditions treated. Uninsured patients are more likely to receive medical care only after their cancer has spread. They’re less likely to receive surgery and radiation, and are more likely to die.
In my own practice, I’ve prescribed one medication to treat an uninsured patient’s blood clot knowing a different one would work better but costs too much. I’ve accepted medical risks I wouldn’t otherwise accept when a patient asks for discharge because he’s footing the bill for every night in the hospital. I’ve cared for an unconscious woman with psychiatric illness who’d cut her wrists after being unable to see a doctor for medications to stabilize her mood.
Affordable Care Act
Health coverage substantially affects whether people are able to get the care they need. And the Affordable Care Act, though far from perfect, was an important vehicle for getting more Americans covered: The uninsured rate fell from nearly 16 percent in 2007 to less than 10 percent in 2015 – the lowest level in history.
The law has its problems. Critics rightfully point out that premiums are rising in the individual market and that many insurers have constricted provider networks to control costs.
But high premiums, while problematic, are better than the alternative: no coverage. And while we rail against potential death spirals in the insurance marketplaces, we ignore existing death spirals many patients face today: If they’re not well enough to work, they lose insurance. And if they lose insurance, they won’t be well enough to work.
Right to health care
Almost all developed countries recognize health care as a right – that access to medical care for all people comes first, before cost controls or even quality improvement. In America, we’ve made no such commitment. The result is a system that underperforms on all measures.
As a physician, I am not particularly concerned with battles between conservatives and liberals. I don’t care whether we use free-market principles or government programs to ensure that patients get the care they need. But our current conversations are so frustrating because they overlook an essential reality I contend with every day: People are hurting. Today. Tonight. Tomorrow and yesterday.
As doctors, we work nights and weekends because human illness and human suffering aren’t restricted to working hours. I’m there because they’re there. My patients can’t wait for policies that appeal to this political lobby or that political base. Any lapse in insurance coverage affects the care they get – or don’t get – right now. Their medical urgency strips them of the luxury to waffle, obstruct and pontificate – and recognizing their humanity should strip lawmakers of that luxury, too.
Congressional leaders and the president-elect have vowed to overturn the Affordable Care Act, which, despite its imperfections, gave 22 million Americans greater health security. As a physician and a citizen, I ask only this of the new Congress and next administration: Whatever path you choose – whether to repeal, replace or refine the ACA – pledge that no patient who has health insurance today will lose it tomorrow. Promise that during your tenure, at worst, the ranks of the uninsured will not grow. And, at best, that we accelerate progress toward a country that recognizes health inequity as shameful injustice – one that, as the president-elect himself has said, won’t let its people “die in the streets.”
Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.