Does this person really “deserve” healthcare?
By: Margaret E. McCahill, M.D.
I have been practicing medicine for over 30 years and about 90% of the patients I have cared for live in poverty and have no health care insurance – it has been my great privilege to be able to serve in organizations that provide care to those persons, and in the course of my work, I have seen a lot of fear in the eyes of my patients. Let me share one typical patient’s story…It is raining heavily and the Mobile Health Clinic (MHC) is set up in a church parking lot with a team of eager health care trainees and faculty, ready to provide the best care they can to those who have no other access to care. The next person to be seen in the MHC is a 46 year old woman, single mother and sole support of herself and her three teenage children, who works at three part-time jobs as an in-home health aide. She is trembling a little, and her eyes well up as I enter the room with the second-year resident physician and the medical student, who have already talked with her before I come in now, to see her as her attending physician. We’ll call her Ms. Worker, and she is scared. She has a very strong family history of colon cancer, she’s a former heavy smoker, she has a long history of poor dietary habits, and she knows she has signs and symptoms that could be colon cancer. She has no health care insurance; she has not been able to afford to see a physician in many years – for most people, having no health care insurance means they have no access to health care. Ms. Worker has come to see us today because her pastor told her about our free services, and she is scared, for good reason. After verifying her history and physical examination, I am also worried that she likely has cancer.
As we talk about the importance of getting some tests done as soon as possible, including a colonoscopy, the tears now flow in earnest. In our free mobile clinic, we will provide some laboratory tests free of charge, but the cost of a colonoscopy for someone who must pay cash will be more than two months of her wages, and she says, “How will I pay my rent? How will I feed my kids? I just can’t do the colonoscopy!” But, we explain, for your children’s sake, you can’t not do it either… Ms. Worker is in a position of deciding between a test that can help identify what she needs done next in order to save her life, or provide food and shelter for her children – she cannot do both. And if the test confirms cancer (it did), the next steps are unimaginably expensive for a person with no health care insurance. Little wonder that the most common cause of personal bankruptcy is health care costs.(1.) Ms. Worker has had her symptoms for many months and she delayed coming to see a health care provider because she could not pay for it. This delay could cost her dearly. During this delay, her cancer may have spread such that life-saving treatment may not be effective. We all wish she had come in much, much earlier, but the fear of cost kept her from getting the care she needs.If it matters to anyone (it did not matter to us), Ms. Worker is model United States citizen. She was born and raised in California, she has an Associate of Arts degree from a San Diego Community College, she works 60-to-70 hours a week at 3 part-time jobs, she pays her taxes, and she and the children were abandoned by an abusive husband – she is not a lazy ne’er-do-well. She works very hard and is doing the best she can to get by. But Ms. Worker cannot afford to pay for health care insurance, and with her family history, smoking history and current symptoms, even if she tried to sign up for health care insurance now, she would be “rated” as high risk and be charged an annual rate that even the well-to-do would feel as a big pinch in their budget – Ms. Worker simply cannot do that. So, here we have a devoted mother raising three teens by herself, who provides loving care to the frail elderly that she cares for in their homes as part of her three jobs, who pays her bills and her taxes, does not abuse any substances or commit any crimes, who is in fact a very good person. However, because she is poor Ms. Worker is on course to die soon of something that, if diagnosed and treated early enough (as it would be in the well-insured and/or wealthy person), would most likely allow her to enjoy good health for decades to come. Her frail health will likely result in her having to stop providing care to those in need, and her early death will thrust dependent children on public support. No one wins by the fact that this woman does not have access to health care, repeat, no one wins. Everyone loses, what happens to this woman affects every one of us – as John O’Donohue said, “No one ever knows what divine narrative God may be writing with the crooked lines of someone’s struggles…We are all in the same drama, but no one has seen the script.”(2.) Yes, we are all in the same drama of life. What impacts this one woman impacts us all – but by American standards, does she really deserve healthcare? After all, she didn’t get insurance, and she can’t pay for her care – in the United States that means she’s out of luck.
In over 30 years of practicing medicine, I’ve seen many wonderful changes in health care. Stunning progress has been made in the prevention of many illnesses, the treatment of others, and what is now on the horizon for some of our most devastating disorders, such as cancer, Alzheimer’s Disease, heart disease, etc., is exciting and will not only extend, but greatly improve the lives of millions. It is awe-inspiring and comforting to know these advances are coming along… if you can afford them.But maybe there is hope for the many millions like Ms. Worker… in 2006, the State of Massachusetts enacted “An Act Providing Access to Affordable, Quality, Accountable Health Care,” sometimes informally referred to as “RomneyCare,” with the goal of assuring that all of the residents of Massachusetts had access to health care. It takes years to implement something like this and work out all the kinks, but it seems that Governor Romney’s vision was an excellent one, and it serves as a model for other states and indeed, for the nation. In 2010, President Obama signed into Federal law the “Affordable Care Act” (ACA), sometimes informally referred to as “ObamaCare,” which is patterned after the Massachusetts health care act in most ways. The ACA is not yet fully implemented, but millions of Americans are very pleased with all of the features that have already started, such as requirements that insurance companies cover those with pre-existing conditions; requirements that college students may remain on parents’ insurance coverage until age 26; the limitation on how much profit insurance companies can squeeze out of our health care dollars, and the impact of the ACA on overall health care costs, moving them in a downward direction. No one is completely happy with the ACA – on May 16, 2013, the U.S. House of Representatives voted to overturn the ACA – for the 37th time. Liberals are not happy with the ACA because many of them feel, “it did not go far enough” to provide health care to everyone and control costs at the same time. I agree the ACA is not perfect, but it’s probably the best start that could be accomplished by a U.S. Congress that has rendered itself impotent by virtue of self-inflicted crises and refusal to compromise when needed, so that very little positive work ever gets done. So, we do have the ACA as a first step and in 2014, more provisions of the ACA will become active. There is a great deal of political posturing over this – with the President and colleagues mounting a campaign to point out the ACA’s merits and encourage enrollment for the uninsured, and the opposition vowing to do everything they can to stop it. There seems to be a great deal of fear in some political circles that the ACA will in fact be a great success, just as its predecessor continues to be in Massachusetts. If the ACA is successful, how do we, as a people, as the human family, make any sense of the battle against the ACA? It is, after all, our society’s best attempt so far to provide care to millions who don’t have access, and to attempt to rein in health care costs at the same time. No credible alternative to Governor Romney’s plan has been offered, and the opposition just votes repeatedly to repeal the ACA, to deny health care access to the poor. It makes one wonder if those who oppose the ACA truly believe that all persons are created equal, and do they believe that all persons have a basic right to health care?
Countless speakers and writers have paraphrased Mahatma Ghandi’s well known aphorism, “A nation’s greatness is measured by how it treats its weakest members.” Just a few of them are:
Pearl S. Buck: “…for the test of a civilization is the way that it cares for its helpless members.”
Hubert H. Humphrey: “…the moral test of government is how that government treats those who are in the dawn of life, the children, those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped.”
Samuel Johnson: “A decent provision for the poor is the true test of civilization.”
Cardinal Roger Mahoney: “Any society, any nation, is judged on the basis of how it treats its weakest members – the last, the least, the littlest.”
Many wise voices tell us we need to do better, but I come back to Ms. Worker… in just a few months, under the ACA, she will be able to enroll in health care insurance for her and her children, in spite of her pre-existing conditions, and at a cost she can afford. Indeed, her costs will be subsidized by government funds, and that is the moral decision that we, as a human family, will make – to care for her even though she cannot pay for that care. The United States is the only industrialized nation that does not provide health care to all of its citizens, including the poor. Although the ACA is not perfect, hopefully it will be a first step in remedying that situation, for Ms. Worker, and for the tens of thousands of people for whom I have personally provided health care, who live in poverty and cannot afford to pay for health care or insurance. I hope we will at least give the ACA a fair trial, without sabotaging it, for the sake of the poor, and for the sake of our nation.
(1.) Brill, S. “Bitter Pill: why medical bills are killing us.” Time Magazine. March 4, 2013.
(2.) O’Donohue, J. Eternal Echoes: Celtic Reflections on Our Yearning to Belong. 2000. HarperCollins Publishers: New York, NY.
Dr. McCahill is a Family Physician and a Psychiatrist, Board Certified in both medical specialties. She is a Physician/Psychiatrist Consultant to USD Wellness Services; an Adjunct Clinical Professor in the USD Hahn School of Nursing and Health Science; a Health Sciences Clinical Professor of Family Medicine and Psychiatry (retired and now voluntary) at UCSD School of Medicine, and she received the Medical Board of California’s “Physician Humanitarian Award” in 2008 for her work as Medical Director at St. Vincent de Paul Village Family Health Center.
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