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

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.

 

Comments

[DestinationsUnknown]

Workman's Compensation Insurance

Do you think Workman's Compensation Insurance is strictly for your income – a percentage at that?

Think again.

Rationing is exactly what you receive from Workman's Compensation Insurance. Are people aware of the process one endures when an accident occurs at work? Do you think you just go the doctor or hospital then take care of the finances?

Workman's Compensation Insurance dictates your health care from that accident- period. Before you see a doctor, the insurance company has to approve -

Just ask any HR department across the country how they handle work comp accidents.

[iblogleft]

Thank you for a great read. Truth is, we already ration health care, and most of the rationing is in end on life care. Our babies die at a rate just lower than Liberia (27th in industrial nations) but our aged get to live as long as money can provide. It makes no sense.

[JDM73]

You're absolutely right, Sarah--health care couldn't be rationed much more than it already is. My left leg is slowly withering (just as my father's did) from chronic venous insufficiency, and I've begged for anything--surgery, physical therapy--that might actually help. "Not right now," my GP said. When, then? "When it gets worse." I don't want it to get worse, for god's sake. At times the pain is unbearable; I'm only 36 and I don't want to live this way.

[weatherwaxx]

Thank you! I can't tell you how many friends and family I know who have been blown off by doctors working in "managed" care systems. . . or 'mangled' care systems, as they're known to those who have to live with them.

America's medical system is horribly broken. I wish all the doctors in the country were as intelligent and realistic as you are. For-profit medical care is NEVER going to be in a patient's best interest.

[Rhymenoceros]

Good post, and quite true. But the people who make this argument don't actually care about whether health care is rationed for the have-nots. They are worried that if the people who aren't currently receiving sufficient care get more, they won't get as much. Basically, they A) don't know how to share, and B) assume a situation in which resources are scarce.

[Idytme]

You seem like a great, caring doctor. I would probably want you as my physician. Yet, your focus here is a genetic test, that if someone who is insured probably shouldn't do it on the insurer's dime, as if the test was +, could ruin their chances for health insurance in the future.
Everything that is done with insurance is a permanent record. I knew someone who sold insurance who would laugh that "people told their doctors everything". There is a big difference between just getting added to a company's insurance and having to get it for your own. I know someone who was prescribed an anti-anxiety pill for fear of flying and was then later denied insurance because of that prescription. And then when he told his doctor about it the doctor said, yah - that has happened before with my patients. If he knew that ahead of time, couldn't he have advised his patient to fill that prescription without using his insurance?
People without insurance don't even go to the doctor. They don't fill prescriptions which aren't immediate. Doctors many times are ignorant to the price of drugs and give them the "latest" rather than the cheapest. The difference between an extended release and regular can be significant.
With all due respect, a genetic test is the least of the problems of the uninsured.

[sunnydee07]

Good luck to you all as you navigate this health care reform crisis in the US. I am more grateful than ever for my universal health coverage (yes, sorry - I'm Canadian). Apart from the obvious advantages of a single payer system, and the lack of stress (at least I won't lose my house if I'm sick), one of the reasons why our system is guarded so strongly by our citizens is because we believe that ALL our citizens are deserving of basic health care. Your access to health care should NEVER be determined by your income level or ability to pay. I understand that our two countries have some very different approaches to how we build our countries and societies but the US "survival of the fittest" mentality when it comes to this issue just smacks of a lack of care and concern for one's neighbours. The reform battle you have coming is a huge one - the big pharma and insurance lobbies are formidable opponents and their disinformation campaign about the single payer system has been outrageous.

[mitsie]

I am a retired RN certified Risk Manager, and really enjoyed your article.

Our small hospital here was sold about three years ago, and is now for profit. The care is terrible, and the bills are infurating.

In April my husband had a GI virus. He was sent to the hospital by our family DO for two bags of IV for hydration. This D.O. didn't even try to treat him at home and he should have. I had this same virus, same dehydration, but we couldn't afford two of us being admitted. I did as well at home, as he did in the hospital. I asked our DO why he admitted him, and he said "because I am afraid of being sued"

The hospital MD. ordered a litney of unneeded blood work, EKG, chest x ray and cat scan that were not medically necessary for a person being treated for dehydration. My husband ended up with a 38 hour stay, and the hospital bills we received were over $26000.

I audited the medicare statement for the Radiologist who billed for two cat scans, when one was performed. He billed one for scan without dye, and another the next day, with dye. The Radiologist also billed for an abdominal scan and a pelvic scan. This is actually double billing to increase the reimbursement from Medicare. This is fraud if it's done deliberately.

Since when do family practice doctors, not follow their patients in the hospital? This is a problem here.

[singermuse]

You'd think with the looming FEAR of possible rationing, we'd be seeing more protests and people up in arms in places like: the UK, Australia, New Zealand, France, Germany, Canada, and every other industrialized "first world" country. Instead, when asked, the natives seem so much more content, HEALTHIER, they have more disposable income, get far more vacation days (average about 4 weeks, while we get barely 2 if we're lucky, and many people here in the USA get NO vacation days), are more calm, and live longer.
Boy we sure could use some of THAT kind of "rationing"!!

[sunnydee07]

All this fear of rationing is ludicrous. I use the Canadian single payer system and have NEVER been denied access to ANY doctor I want, ANY specialist or ANY clinic I want to visit. The only rationing occurring (in the US) is done by insurance companies who only allow policy holders to visit certain doctors, or hospitals or have certain tests based on what they'll pay for. One of the most disgusting things I've ever heard is the practice of labeling illnesses as "pre-existing" to get out of paying for care - diabolical!

[winchestereast]

maybe try an internist instead of a GP - they have more years training in diagnostis and treatment of multisystem diseases - and are board certified - good luck

[lisakaz2]

Rationed? No kidding. Even when you have insurance, care can be withheld. I couldn't even get my GP to give me the name of an infectious disease doc to look at my lyme disease tests (that I paid for) because "we don't think you have lymes (sic) disease." I had to travel 5 hrs round trip to see docs obtained thru an off-insurance doc recommended to me. And the lack of running that test or treating me for lyme over the last decade perhaps has made my neurological problems at least semi-permanent. I'm hoping I can reverse some of them at least. No, the docs would rather dismiss me with an MS diagnosis and give me nothing but an antidepressant and the name of a counselor so I can "live with it." How nice. They can kiss my ---.

I'd like to see these rethhuugican twits cope with real health issues and have the insurance problems of real Americans versus their Cadillac, pubilc-financed coverage. They got some nerve telling us how great the free market is when they have NO EXPERIENCE WITH IT.

[lisakaz2]

Rationed? No kidding. Even when you have insurance, care can be withheld. I couldn't even get my GP to give me the name of an infectious disease doc to look at my lyme disease tests (that I paid for) because "we don't think you have lymes (sic) disease." I had to travel 5 hrs round trip to see docs obtained thru an off-insurance doc recommended to me. And the lack of running that test or treating me for lyme over the last decade perhaps has made my neurological problems at least semi-permanent. I'm hoping I can reverse some of them at least. No, the docs would rather dismiss me with an MS diagnosis and give me nothing but an antidepressant and the name of a counselor so I can "live with it." How nice. They can kiss my ---.

I'd like to see these rethugican twits cope with real health issues and have the insurance problems of real Americans versus their Cadillac, pubilc-financed coverage. They got some nerve telling us how great the free market is when they have NO EXPERIENCE WITH IT.