The wrong card
September 17, 2011
September 17, 2011
Walter maneuvered the empty school bus down the narrow car-lined street on the hard-knock West-side of Chicago when he saw the man pummeling a woman with his fists. Walter slammed the brakes, shoved the gear into park and bolted out the door. It was just the way he was. Walter was a railroad man; a fifty year-old tough guy. He moonlit as bus driver for extra dough. The railroad had good benefits especially the gold-plated health insurance policy he never used. But his life was about to change and he would soon confront the cruel realities of health care in America. Where the health care a man received depended on the health insurance card in his wallet.
Walter bounded towards the fracas and placed himself between the brute and his bloodied victim. Walter never saw the gun. The bullet ripped through his upper chest, shattered his clavicle, collapsed his lung and lodged into the nerve that controlled his right arm.
I met Walter three weeks later in my primary care office after he was discharged from the rehab center at my inner-city hospital. The lung damage from the bullet had worsened his emphysema. He needed oxygen at night. His right arm throbbed in pain and was weakened from the nerve damage. He would never work again despite his many attempts. He would never live without pain. He soon lost his railroad job and the insurance card that came with it. He went from Good Samaritan to No Insurance. He stopped coming to see me because he could not pay.
Months later, I met Walter by the front desk of my office. He needed a refill of his pain medications. He had lost his home and camped on the couches of family members and friends. A deep depression overcame him. He began to drink and contemplated suicide. I convinced Walter to see me and promised to treat him for free. It took six years many letters and phone calls to convince the state to provide Wallace with a Medicaid card.
One would think that once he had a Medicaid card that life would get better. And it did to a degree because he could still see me without shame and get medications. But I was an exception. Walter like many Americans on Medicaid had trouble obtaining specialty care because many specialists refused to take Medicaid. Medicaid was not as desirable as his railroad insurance. And most doctors just refuse to accept it.
The Accountable Care Act will create the opportunity for many other patients like Walter to get on Medicaid. We know that when poor people are given Medicaid they go to the doctor more and they feel better and are less depressed. More women get mammograms when insured and more patients take prescription medications. Walter is living proof of the obvious concept that providing health care to the poor and uninsured is a good idea. But as Walter discovered the Medicaid card did not equate with access. A recent study in the New England Journal of Medicine (June 16, 2011) on access to specialty care in Chicago showed that two thirds of children with Medicaid were turned down by specialists compared to 10% of children with insurance. Walter is a case study of the inequalities of our health system and of the problems to come when more patients swell the Medicaid ranks in the US in 2014. More patients will have cards but what good will these cards be if doctors and hospitals will not accept them.
A better solution- Medicare for All- one payment system for all providers and patients so there can be no cherry picking or denial of patients because of the type of card. It is fair, it preserves choice and it will end some of the more egregious inequalities in health care that plague the most expensive health care system. So the next patient like Walter can get the health care he deserves.
Why I Wrote "County: Life, Death and Politics at Chicago’s Public Hospital"
Many people have asked me why I wrote “County.” I wrote “County” (a memoir, social history of Cook County Hospital and a reflection on race, poverty and health care in America) because I am shocked by the gaps in health care that have only worsened in the past thirty years in the US. I wrote “County” because what keeps me up at night is the fact that African-American men on the south side of Chicago (it’s only slightly better in Detroit and Harlem) will die eight years earlier than a white man. And half of the premature deaths in these men are from heart disease and cancer- preventable and treatable. I wrote “County” because I am pained that African-American women in that city have twice the death rate from breast cancer than white women and it does not have to be. I wrote “County” because when one examines the problem of racial health disparity in America the chronic underfunding and lack of coordination of the public hospital and private safety net sector in the US is a clear contributing factor. I wrote “County” to make the case for a fair health care system, one that does not discriminate by race, ethnicity, insurance status or residence.
I went to Cook County Hospital as a 25 year old doctor-in-training to fight for the life and the rebuilding of this iconic public institution. It was a fight that brought young doctors and nurses head to head with a corrupt political establishment that would have preferred to have County close or remain in chronic dysfunction. In the course of this struggle we not only got a new hospital rebuilt, but developed a network of community health centers and innovative public health and treatment programs that became national models for the respectful delivery of care to the underserved. But it was not enough.
Despite these achievements, the chronic underfunding of our nation’s public hospitals and other safety net providers leave many out with disastrous health consequences. It’s just that the demand for services outstrips the capacity. I have come to believe that a system of care that sends the poor and uninsured to one set of institutions and the wealthy and insured to another is unfair, likely to provide unequal results and a contributing factor in the premature deaths our nation’s uninsured experience. Only a payment system such as “Medicare-for-all” that allows all US residents freedom to choose public or private institutions to receive their care has the chance to lessen the gaps between the insured and uninsured, rich and poor, white and non-whites.
“County” tells the story of young doctors like me who decided to take a stand for health equity by coming to this renowned public hospital and who stayed on to continue the fight for fairness that should have been available to patients as a simple condition of their humanity. I tell the story through my experiences, through the stories of my patients and through the stories of political fights and demonstrations for fair funding.
The goal of this blog is to share my perspectives on health care in Chicago and the nation linked to the release of my book COUNTY, Life, Death and Politics at Chicago’s Public Hospital. This book was thirty years in the making. It began when, as a young physician at Cook County Hospital in Chicago, I was struck by how little the public knew about health care delivery and the great gaps in access to care and quality that existed. After seventeen years at Cook County Hospital, I moved to Mount Sinai Hospital in the Lawndale community where I gained a deeper understanding of how structural forces of poverty, joblessness and institutional racism contributed to ill health. I began to write this book in 1995 as a way to digest my experience of the prior twenty seven years delivering care to the medically underserved in Chicago. It reflects my perspective of health care disparity, poverty, racism and quality. As I sit on the Cook County Health & Hospitals System (CCHHS) Board for the past three years, I am struck how the problems we faced thirty years ago have yet to be resolved. A few disclosures: The opinions here are mine alone and do not reflect the opinions of my employer, Rush University Medical Center where I am Chief Medical Officer nor those of the CCHHS where I am a board member. I am a proponent of single payer healthcare and this conviction has been forged over thirty years starting as a medical student and reinforced during my stints at County and Mount Sinai. I welcome your comments and thoughts to my ideas.