America; Heal Thyself III

 Third Part in a Series

"Just go to an emergency room"

“People have access to health care in America.  After all just go to an emergency room.”  George W. Bush

Mitt Romney recently echoed Mr. Bush in a 60 Minutes interview. If you have a heart attack “you go to the hospital, you get treated, you get care, and it’s paid for, either by charity, the government or by the hospital.”

“Just go to the emergency room” is a great plan if you have a heart attack, break a limb, have a stroke or get shot. That’s what every rational person does because the emergency room is there for critical conditions that require immediate attention. 

When I broke my ankle in the spring of 2011, I went to the Kaiser Permanente ER in Walnut Creek, CA. The ER doctors had x-rays done and then put a temporary plaster splint on my leg from the ankle to the knee. The good folks at the ER made an appointment for me to go to that medical center’s orthopedics department a couple of days later.  There I was seen by a podiatrist and a knee specialist (to be sure that my swollen knee wasn’t an issue).  The splint was removed and replaced by a small cast on my ankle.  They also made sure that there was no soft tissue damage to the joint.  The new cast was replaced again a few weeks later.  When the cast came off I was fitted for a walking boot.  When I was having trouble walking I was referred to a physical therapist who worked with me for several months.  When I was still having problems nearly a year later an MRI was done to determine if there was some damage that hadn’t been spotted earlier.  After more aggressive exercise was prescribed by the therapist my ankle was finally back to normal.  I got all of this post-emergency room care because I’m covered by an HMO.  I followed to the letter the good advice given by Romney and Bush but going to emergency was one step in many that took place over a 13 month period.  I wonder; at what stage does the care that I got cease to exist for someone without coverage?  I imagine that at six weeks the cast comes off, the patient gets some exercise bands and an instructional flyer and then is sent on his way.  If you end up walking with a limp, have pain, or your foot just hangs there at an odd angle I suppose that, to use the vernacular of the day; it sucks for you.

And what suggestion do Messrs. Bush, Perry and Romney have for all of those non-urgent needs?  You know those mundane things; from a persistent cough to the vision that’s a little blurry; that ominous looking lump that wasn’t there a week ago and that abscessed tooth that you bathe in cheap whiskey to get you through the night. The CDC reported that; About 40 percent of uninsured persons in comparison with 16 percent of insured persons reported an unmet need… Health insurance status played a key role in an individual’s decision to delay seeking medical care. Uninsured persons were dramatically more likely to delay care (29 percent) than persons with public health insurance (12 percent) or persons with private insurance (8 percent).

Farmhand Sidney Lawhorn went to the University of Virginia ER for a toothache when the dentist who pulled his tooth was on vacation.  ”I go through a dental clinic, which is kind of cheap, and that's one reason why he don't have nobody filling in for him," Lawhorn explained.  A USAToday article explained that dental visits are the fifth-most-common reason for a visit to the UVA Medical Center.  Lawhorn has no medical or dental insurance so he visits the ER, “whenever something happens.”  On a previous occasion he brought his wife Shannon to the same ER for a migraine.  So due to his circumstances, Mr. Lawhorn waits for hours in an emergency room, impacts the staff that should be taking care of the gunshot wounds, strokes and heart attacks and costs the system more than if he had been able to have primary care under an insurance plan.

And what about those folks who were getting treatment for a chronic condition and then suddenly lose their coverage? An acquaintance worked for a company that phased out all health coverage.  A single mom with a chronic medical condition requiring prescriptions, she had to make the choice between food and shelter and trying to buy health insurance.  She ended up with no coverage and in her circumstance the ER was about as useful to her as the local pizza parlor.  What does the person with diabetes do?  Wait until things start falling apart?  A foot with no sensation?  A failing kidney?

And what of the yearly checkups and well child visits?  These aren’t services that are provided by emergency rooms but they are services that can keep people from having to visit the emergency room. Again from the CDC; Between 2009 and 2010, 9.6% of children between the ages of 6 and 17 who had insurance coverage did not visit a doctor or clinic within a 12 month period.  That percentage jumps to 37.3% of uninsured children.

In a CNN opinion piece last May Professor Aaron E. Carroll of the Indiana University School of Medicine wrote: “If they (politicians) are saying that we have universal access if we're acutely having a heart attack, then I suppose there's truth to that as well. But there's no such access for lipid panels, stress tests or prescriptions for cholesterol medications that might help you avoid the heart attack in the first place.”

“You can't get preventive care in the emergency department. You can't get screened for a host of disorders. You can't get treatment for your depression there or really for any chronic mental disorders. You can't get help with your child's autism, ADHD or developmental delay.”

I wonder if George Bush or Rick Perry or Mitt Romney have ever had to wait in an emergency room.  Sit for hours in a crowded room with people in misery; complaining and moaning; children coughing; couples arguing; a television on the wall showing Dr. Phil analyzing his latest freak show du jour or Judge Judy arbitrating two societal losers.  I recall going to the ER at Kaiser in Vallejo, California.  I was in atrial fibrillation.  The place was packed and a triage nurse verified my condition.  There was no place to put me but the waiting room.  Hours later, still waiting to be seen my heart kicked itself back into gear.  I told the nurse that I would be leaving and she had a doctor quickly verify that my heart was back to normal.  An apology from the doctor and he sent me on my way.

The emergency room at Highland Hospital was where I went to check on a friend who had been admitted.  I had no idea such a place existed in America.  An overflowing waiting room, people staking out a patch of floor to sit for hours, some of the more fortunate in chairs, dozing, staring at nothing in particular, some in various stages of pain.  It looked like a place that never emptied; one patient would leave the treatment area to be replaced by one of the waiting crowd who’s place would be filled by someone off the street.  Doubtless there were many without financial means seeking their last recourse.  It’s a  place that Romney, Bush and Perry have never seen.  It’s a place that they would deny exists in America.  And indeed it doesn’t exist in their America; unless there was a photo op involved they would never deign to set foot in a county general. But it’s the place where they would have a parent take a child to get a prescription for cough medicine. 

Remote Area Clinic Sacramento CA.

Every year or so another, this can’t be America scene is played out in Oakland.  A group of health care professionals called the Remote Area Medical Foundation sets up a free clinic at the Oakland Coliseum for people who can’t afford basic services. Patients stand in line overnight for free health care, dental care and eye care. As many as 3000 people are seen over three days. One doctor described it to the local CBS affiliate as being “kind of like a MASH unit.” “You’re here and you look up and there’s 50 people waiting in line, and you’re working away. And an hour later, you look up and there’s another 50 in line."  When I first heard about this clinic I was astounded.  Is this America or is this Somalia?  A similar event has taken place at Sacramento's Cal Expo Center.  I’m certain that this is also a place that Romney, Bush and Perry have never seen.  It’s yet another place that they would deny exists in the America that they know.  In their Norman Rockwellian fantasy, Americans don't wait overnight in the outdoors to receive basic medical services at a football stadium. 

And then there’s that looney insinuation by Mitt Romney that through some voodoo economics emergency room care goes unpaid for; "you get care, and it’s paid for, either by charity, the government or by the hospital.” In your next visit to the ER you will likely find a nurse on your left plumbing a juicy vein and a staff member on your right asking for your credit card number.  In his CNN piece Dr. Carroll explains that many hospitals use aggressive debt collection methods to collect on unpaid bills.  In one case a family of four living below the poverty line but still unable to qualify for Medicaid was sued by a hospital in Ohio.

What happens if the hospital fails to collect or the patient simply can’t pay? The American Hospital Association reported that in 2010 hospitals lost nearly $40 billion in unpaid bills.  In 2008, Bay Area Hospital in Coos Bay, Oregon reported $9.3 million in bad debts.  Said the hospital’s vice president of finances, Tim Salisbury; “If someone is living on the street, it’s hard to send them a bill,” 

And so a hospital being a business, it does what businesses have always done when people don’t pay for goods and services.  It raises rates and charges patients with commercial insurance more than the cost of the service.

A physician who commented on my first post in this series eloquently summed up the notion of ER as healthcare; Instead of quality prevention, we accept inadequate piece-meal. It is sad, cruel, and decidedly unchristian.