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Health Care Rationing? The US Has Been Rationing Care for Years

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Conservative pundits and politicians so quickly jump all over the Democrats' attempts to provide health care for all, bemoaning that any expansion of government programs will lead to health care rationing. Images of middle-aged men standing in line at the local hospital, clutching their chests and popping nitroglycerine pills while waiting endlessly for the artery-cleaning heart operations they need lest they drop dead may come to mind -- in the style of a make-believe Canadian or British 'socialist' health care system -- where basic medical needs are delayed for months or years, as opposed to our shining, efficient, and above all, fair system where, true to our democracy, Americans get the care they need when they need it. I am not sure in which alternate reality these Conservative nay-sayers live, but as a primary care doctor working with uninsured patients, I can assure you that health care has been rationed in the US for years.

Since I completed my internal medicine residency in 1996 and started to work in community health centers in Chicago and Boston, I have seen the plight of my uninsured patients go from bad to worse as fewer people become eligible for Medicaid, county hospitals start to charge for services, and waits for an appointment with me become longer. But as a doctor married to a doctor, I have always had great health insurance coverage, getting all the care I need. How fair is that?

Yesterday, an uninsured woman in her mid-20s came to my clinic for her first visit with me and her annual Pap test. In discussing her concerns -- she is currently healthy -- it turns out she has a strong family history of early breast cancer. Both her mother and her maternal aunt were diagnosed with pre-menopausal breast cancer, and this young woman was naturally concerned about her own risks. As a doctor, I talked about her concerns and her risks and her rather limited options, given her lack of health insurance. But as a patient and another human, I could naturally relate. I too have a strong family history cancer history.

My mother died of ovarian cancer about 23 years ago, and age 57, and my brother, now 50, was diagnosed with advanced colon cancer at age 41. He had a rocky course at first, but his tumor responded to chemotherapy, and he is now in complete remission. When he was first diagnosed, I knew that I needed to get a colonoscopy, the best test to detect colon cancer and pre-cancerous polyps. The wait for a routine colonoscopy can take months, but I found a doctor willing to add me to her schedule within a few weeks. Certainly my private insurance did not hurt my chances for getting the test I needed quickly.

I have also undergone intensive genetic counseling and screening for 2 family cancer syndromes: hereditary breast and ovarian cancer and HNPCC, or Lynch syndrome. As a Jewish American of Eastern European ancestry, my mother's ovarian cancer imparts on me a higher risk of having either the BRCA1 or BRCA2 genes. My brother's early colon cancer together with my mother's cancer also increases my risk of having Lynch syndrome, or a set of genes that increase my risk for colon, ovarian and uterine cancer. How do I know all of this? Being a doctor does not hurt, but mostly having private insurance has given me access to experts in the field of medical genetics, lot's of helpful counseling, and ultimately, expensive genetic tests. I have been tested for both the BRCA1 and 2 genes and my brother's tumor was tested for the Lynch syndrome genes. All the tests came back negative, and my doctor and her assistant were able to conclude that I do not appear to have a genetic predisposition to the kind of cancers that have struck my family members. I still need routine screening and more frequent colonoscopies than the general population, but my private health insurance pays for it (well 80% -- that's another story), and so I can get the care I need.

But what about my patient? I was able to refer her for a mammogram, and unless the looming Illinois budget catastrophe cuts the free mammogram programs offered here, she will be able to get a mammogram now and hopefully, periodically, but that is only a small amount of the care she truly needs. I did refer her for genetic counseling which would most likely lead to genetic testing because I need to practice income-blind care, but will she really get genetic testing? I doubt it. As a single mom, currently unemployed and struggling a bit, I doubt she could pay the $3000 or so out-of-pocket for the test to determine if she does have the BRCA1 and 2 genes that put her at a higher risk for early, potentially deadly breast cancer. Without insurance, she probably will forgo not only the genetic testing, but also the frequent breast MRIs or even preventive mastectomy that a medical geneticist would possibly recommend, if her genetic testing revealed a risky set of genes. I told her to try to get a job that would give her health insurance and hope the federal government can provide health insurance for all soon. Until then, she might as well keep her fingers crossed. I know I will.

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