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M. Gregg Bloche, M.D., J.D.

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'Obamacare' and the Life and Death of Brian Anders

Posted: 10/23/2012 3:41 pm

If you don't have health insurance, will you still get the medical care you need? A silly question, you're probably thinking: The answer is obvious -- agonizingly so for the nearly 50 million Americans without coverage.

But in the war against "Obamacare," what's obvious has become fair game for obfuscation. Consider candidate Romney's claim, on 60 Minutes several weeks back, that "we do provide care for people who don't have insurance." "Different states," he said, "have different ways of providing for that care ... Some provide that care through clinics; some provide that care through emergency rooms." Insurance, he said, is just one "model."

How does Romney's emergency-room "model" (which he dismissed when he was governor of Massachusetts) measure up against medical coverage for all? Consider the life and death of Brian Anders, Vietnam vet, PTSD sufferer, and champion for the homeless, who was often homeless himself. I'm grateful to my friend Suzanne Turner for alerting me to Brian's story and to his caregivers for sharing the clinical details that follow.

Brian became a legend in Washington D.C.'s shelters and an inspiration to activists nationwide for his campaigns to organize the city's homeless to speak up for themselves. He energized those who live in the streets to take to the streets to fight for opportunity. His successes included Congressional passage of the 1987 McKinney-Vento Homeless Assistance Act, which funded primary-care clinics, training programs, and transitional housing.

But he was without health insurance -- and hadn't seen a primary-care doctor for years -- when, last June, at age 58, he walked into the emergency room at George Washington University Hospital, complaining of weight loss, stomach pain, diarrhea, and rectal bleeding. The doctors treated Brian's situation as an emergency, admitted him, and ordered up a panoply of pricey tests. A colonoscopy found a large tumor. A biopsy confirmed colon cancer. Chest and abdominal CT scans revealed that tumor cells had spread to his lungs and kidneys.

Doctors told Brian they had nothing to offer aside from pain relief and perhaps a few weeks to wind up his affairs. Six days after his hospital admission, he was discharged to a shelter, where he spent a night before winning admission to Christ House, a refuge for homeless people with serious illness. A few days later, he made his final move, to Joseph's House, Washington's only hospice for the homeless. On August 12, he turned 59. Sixteen days later, he was dead.

Christ House and Joseph House are remarkable places -- reminders of what faith, at its best, can offer at a time when intolerance is too often religion's public face. But they don't come close to addressing the needs of Washington's homeless sick and dying.

That both made space for Brian made him a rare exception. Homeless men and women more typically die on the streets or in shelters. Emergency departments don't meet the needs of people who are too sick for rescue-oriented care to make a difference.

Nor do emergency departments provide the tests, treatments, and personalized follow-up that are the stuff of routine clinical practice -- practice that prevents or delays the onset of illnesses like the one that killed Brian. Deaths from colon cancer should be rare. Colon tumors begin as small, benign growths, easy to spot and to snip away through a colonoscope. It takes years for these growths to become malignant, then to spread.

That's why screening colonoscopies when we turn 50 are standard. Medical consensus holds that they're necessary. Health insurers cover them accordingly. Had Brian undergone one within a few years of turning 50, he'd almost certainly be alive today.

But emergency rooms don't provide them, nor do they offer other tests and treatments that aren't immediately necessary to preserve life or limb -- or to determine whether there's an emergency. Federal law requires hospitals to treat and screen for emergencies without regard to ability to pay, on pain of losing their eligibility for Medicare payments. Most states impose similar obligations, variously enforced. But hospitals needn't (and typically don't) provide care that's necessary but not emergent -- unless the proverbial "wallet biopsy" proves that a patient can pay.

So unless you're insured -- or wealthy enough to write a check for your five- or six-figure hospital bill -- care that isn't so urgent as to be required by law is unlikely to be available to you. There are exceptions -- some doctors and hospitals still adhere to the fading ethic of charity. But if you can't pay, don't expect a screening colonoscopy or mammogram that might save your life -- or treatment for high blood pressure or other chronic conditions that might shorten it. And don't expect coordinated care for asthma, Alzheimer's, breast cancer, or other illnesses that don't imminently threaten life or limb.

Do expect to die younger. Mounting evidence supports the common-sense conclusion that health insurance extends lives and improves people's sense of physical and mental wellbeing. In a widely-publicized 2002 report, the Institute of Medicine estimated that 18,000 Americans a year die prematurely because they lack medical coverage. More recent estimates are higher, reflecting the rising numbers of uninsured.

Mitt Romney gets it. Six years ago, he told a Chamber of Commerce audience that emergency rooms aren't the answer. "An insured individual," he said, "is more likely to go to a primary care physician or a clinic to get evaluated for their conditions and to get early treatment, to get pharmaceutical treatment, as opposed to showing up in the emergency room where the treatment is more expensive and less effective."

So why is Romney now a pitchman for the emergency room "model"? The answer is pretty simple. Many who oppose public action to provide coverage for all are squeamish about their stance's Dickensian implications. Denying medicine's life-prolonging potential to millions because they can't pay is strong stuff, even if done to defend "freedom" against "big government" or "European socialism." Better to hide the ball and to warn ominously of a "government takeover of health care."

Brian Anders' life and death underscore the cruel consequences of doing so. The claim that people without insurance get the care they need is a fig leaf over the belief that their lives have lesser value. This belief is the ugly, unspoken premise behind the canard that the Affordable Care Act is an assault on American freedom.

Most of us are much closer than we think to becoming Brian Anders. If you live on a salary and haven't saved or inherited a fortune, you're a few months of unemployment (or a pre-existing condition plus a job change) away from dependence on emergency rooms and the charity of strangers. Unless you're wealthy, in other words, opposition to the Affordable Care Act is an existential gamble -- a gamble millions will lose (should they become ill) if voters force a retreat from the act's commitment to coverage for all.

The fate of "Obamacare" is thus the biggest medical decision Americans now face. What we do in the voting booth in two weeks will have a larger impact on our nation's health than the choices we make in the hospital or doctor's office. We'll also make a powerful statement -- to ourselves and to the world -- about whether our life chances when we're ill should depend on our ability to pay.

 

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