Copyright 1999 Plain Dealer Publishing Co.
The
Plain Dealer
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December 19, 1999 Sunday, FINAL / ALL
SECTION: FORUM OPINION & IDEAS; Pg. 1G
LENGTH: 980 words
HEADLINE:
HEALING ON A BUDGET;
THE UNINSURED AND THEIR DOCTORS
STRUGGLE
BYLINE: By Wendy Johnson, M.D.
BODY:
The uninsured are in vogue
again, and none too soon. During the past few years of neglect, the problem of
access to health care may have faded from the political
consciousness, but it has only grown worse for the burgeoning number of people
(nearly 45 million at last count) who struggle daily to take care of themselves
and their families in an increasingly hostile system.
Those of us who
treat the uninsured or underinsured have been forced to become
specialists in a niche of medicine with few medicines or tests and almost no
high-tech studies. We become experts in getting a few precious drops for our
patients from the sea of medical technology surrounding them, but denied to
them. Often we are faced with problems about which we can do very little. There
was the pregnant woman who thought she just had the flu and waited until she
couldn't eat or drink to come into the hospital because she couldn't afford the
bill for a doctor's visit. She miscarried from an overwhelming infection. A
young mother with a sudden onset of intractable headaches, nausea and vomiting
had to choose between paying the rent and paying for a CAT scan of her brain to
rule out the possibility of a tumor. I worry about the Nicaraguan immigrant who
could not afford a mammogram to investigate an ominous mass in her breast and
the 35-year-old man with diabetes who doesn't have the money to pay for critical
blood testing to monitor his illness.
Simply by living in poverty, these
patients share increased risk for infectious diseases, asthma and complications
of chronic illness. I wonder what happens to the patients who don't even make it
into my office. They are reflected in the statistics: the higher infant
mortality rates and shorter life expectancies in the poorest neighborhoods.
There are no formal residencies for this "specialty." Many of us did our
training in primary care, internal medicine, family practice or pediatrics. We
found residencies in inner cities and rural areas which would teach us the
combination of social work, political advocacy and medicine that we need to care
for our patients in a terribly flawed system. We learn which are the cheapest
antibiotics and blood-pressure medications and we often write a prescription
based on cost rather than on more medically respectable grounds like efficacy or
side-effect profiles. We learn to pare down to the essentials, judiciously
narrowing our diagnostic studies to a vital, affordable few.
We practice
at public hospitals or community health centers, which attempt to provide
"charity care" to the uninsured, at least those lucky enough to live near such
increasingly rare and overburdened institutions. But even in the
cobbled-together network of hospitals and clinics that serve the uninsured,
people fall through the cracks. Some live far from the facilities and have no
transportation. Some are immigrants, both with and without legal status, whom we
allow to do our hardest labor while we deny them access to basic health care.
Some have problems like drug addiction or mental illness for which accessible
treatments are even scarcer than for other medical problems.
Of course,
I don't like to practice medicine this way: spending an hour on the phone to
find mental health services for a patient; begging free samples from drug
company representatives; calling specialists to find one who will allow patients
to pay off their bill at $10 a month. It certainly isn't what I was taught in
medical school, where we heard the virtues of high-tech medicine extolled at
every opportunity. But because of the growing recognition of our two-tiered
practice of medicine, we now have our own professional society, the Association
of Clinicians of the Underserved, and our own medical journal, The Journal of
Poor, Underserved and Indigent Medicine. Demand for our services is growing as
the nation's policy-makers show little interest in taking on the lobbyists who
represent the interests of private HMOs and insurance companies.
Until
recently, the only nod in the general direction of health care reform was the
contentious Patient's Bill of Rights. It grants no rights to most of my
patients. No amount of tinkering will cure the terminal ills of the for-profit
medicine industry. Of all the presidential candidates, only Bill Bradley has
come close to offering a proposal for universal coverage, and his idea does
little to address the growing power of corporate CEOs in deciding what our
health-care system will look like in the future.
In this era of
unprecedented prosperity and federal budget surpluses, we must do more. Two
simple ideas could be enacted right now. First, at the state level, expand
Medicaid to cover all those living on wages up to 200 percent of the poverty
level. This expansion would provide care to whole families instead of covering
children and neglecting their parents. The windfall that the states are now
experiencing from welfare reform and tobacco settlements could be used to fund
this expansion. Second, go beyond President Bill Clinton's Medicare proposal.
Add a meaningful prescription drug benefit to the Medicare program and lower the
eligibility age to 55. We should be expanding programs that work rather than
fiddling with systems which benefit no one but the wealthy executives and
investors in the medical-industrial complex.
These incremental changes
should be only the first step down the road to seriously reforming the health
care system so that it works for people, not for profit. Perhaps because
politicians on the state and federal level are so beholden to health industry
lobbyists there is little serious discussion of substantive reforms.
Unfortunately, for the foreseeable future, it looks like those of us trained to
practice underserved medicine will have no shortage of patients, taking care of
those that for-profit medicine rejects.
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December 20, 1999 
