Wednesday, May 2, 2012

No heart, or no brain?


It's been a while - things have been busy lately.

I'm in an economic frame of mind today, so I'll share an experience I had last month.  I'd be interested to hear your thoughts on this particular situation.  Medicine is so saturated with absurd economic policy that it's my default when I don't know what else to write about.

I had a 40 year old M who presented to the ED two months ago because he didn't feel well.  Why didn't he go to his PCP first?  Because he didn't have one.  Why didn't he have one?  Because he didn't have insurance.  Why didn't he have insurance?  Because he was in the country illegally.  Very common dilemma across the US these days.

Routine blood works reveals a BUN of 90 and serum creatinine of 10.  In English - he had kidney failure.  Further workup told us that this was not an acute problem, but one that had been slowly brewing for years without him knowing it.  Thorough investigation failed to uncover the cause of renal failure - could have been one of a bazillion things.  He was discharged home as there was no indication for starting dialysis at the time.  He was given a list of clinics to follow up at, but failed to do so.   His medical insight was very poor and he felt that dialysis would kill him.

So he presents again to the ED one month after discharge - still not feeling well.  Not unexpected - you can imagine that living without a major organ system might cause some discomfort.  But by this time his renal function had worsened even more - now he was overtly uremic (fancy medical word for his brain now being affected by years of toxins that have been slowly accumulating in his body).  

Once you hit uremia-ville, you're pretty much screwed unless you either start on dialysis or get a kidney transplant.  Transplant takes about 5 years to get on average and is limited to those with insurance, good social support system, and a whole host of other factors.  This gentleman obvious wasn't going to get a new bean.

That leaves dialysis.  Sounds simple enough, right?  Not so fast.  It's incredibly expensive.  

I have no clue how much it really costs to dialyze someone for a year.  I'm not sure anyone really does - the cost can vary tremendously.  A quick google search led me to an article from 2002 that approximated the cost at $66,000 per year.  That was 10 years ago.  Tack on a few extra K and we're probably around $75,000 now.  

Back to the case.  With a clear need for dialysis and without insurance, the hospital is forced to eat the initial cost of his hospitalization (I can hear the administrators groaning).  Since he isn't a citizen, there's no federal insurance that will cover his dialysis (virtually all dialysis patients are covered under Medicare regardless of age, btw).  Likewise, he won't qualify for Medicaid because he isn't a citizen.  

So now he has a dialysis catheter and clearly needs dialysis three times per week for the rest of his life.  There is no other option to keep him alive.  But no dialysis center will accept him as a patient because they are all for-profit, private companies.  Many of them are public companies whose stock is traded on Wall Street.  Accepting charity patients would be financial suicide.


Now what?  The first solution to pop into your head is the same that came to me - sir, it's time for you to go back to your country of origin.  Maybe they can help you.

But with a wife and kids that have grown up in the states, he was hesitant to even consider the option.  And besides, there's no work back home, and he's not sure he'll get any treatment at all.

Sounds like we need a social worker - anyone want to step up to the plate?

This is where it gets interesting.  Unbeknownst to me, there is apparently a federal emergency insurance program that will provide insurance to certain illegal immigrants.  What?  You're kidding, right?  Nope.  I don't know much about it, but there is some program out there that, with the assistance of the social worker, he applied for.  Apparently it takes a while to get approved, so unfortunately I'm going to leave you hanging because I don't know the rest of the story.

In the meantime, the patient was instructed to return to the emergency department three times per week to get dialysis.  Tack it on his bill - he doesn't care.  He'll never be able to afford 1/100th of it.  Whichever hospital he chooses to go to gets stuck eating the bill - potentially three times per week for the rest of his life.  And recall it's not cheap - somewhere in the ballpark of $75K per year (probably more when done at the hospital).  

I'm a bit conflicted on this emergency insurance program that he may or may not qualify for.  If this really exists (and I'm told it really does), I'm not sure how I feel about it.  Am I glad that this relatively young, poor, hardworking man who happens to have been born in another country is able remain alive?  Absolutely.  Am I happy that there are 45 million Americans without insurance in this country who get passed over in order to fund this guy?  Not at all.  

It seems a bit ironic to cover foreign nationals when American citizens without insurance declare bankruptcy every day.  It's the leading cause of bankruptcy in America.  I have idea if this is accurate, but I like the graphic.

10 Leading Causes of Bankruptcy

If this example isn't enough to get you thinking, I've got more.

Ever thought about prisoners?  They are provided healthcare at your expense for the entire duration of their incarceration.  But when they get released from jail, their coverage stops, right?  Not in my state - I learned this year (courtesy of a colleague of mine who had a patient that was just released from prison) that we provide care for one freaking year after they are released!  I can't provide any credible source of information regarding this, but I'm using it anyway to prove my point!

And how about terrorists?  I know that I shouldn't use Michael Moore as a source for, well, anything, but I was a bit shocked to find out that we provide full medical service to prisoners housed at Guantanamo Bay.  Wtf?  Again, I'm all about being humane, but really?  Shouldn't they have to work for it like everyone else?

Let me get this straight.  We let 45 million people in this country go without insurance while providing coverage for illegal immigrants and prisoners.  I understand that even we stopped providing this coverage that we still wouldn't have enough money to cover the 45 million uninsured, but it's at least a start.

Then again, many of these undocumented citizens work much harder than many of us in this country and contribute in a very positive way to our society.  Any who disagrees with this is blinded by his myopic partisan view of the world.  My experience has been that they work hard and want what we all of do - a peaceful, successful life.  

This case has caused me to think a lot about these issues over the past month.  I still don't know where I stand.  

It reminds me of a quote often attributed to Winston Churchill.  "Show me a young Conservative," he said, "and I'll show you someone with no heart. Show me an old Liberal and I'll show you someone with no brains."

I guess those in the middle are entitled to waft a bit on these things.  And that's exactly what I do.  I wish I had an answer, but I clearly don't.  Even if I did, I'm not sure it would change anything.  We've proven to be a fiscally reactionary nation that waits until impending disaster before anything gets changed.  I'd rather enjoy my life than waste it ramming my head against a wall.

I guess I'll continue to sit back in the peanut gallery and watch how these things play out.  And in the meantime I'll continue to try to do the right thing - whatever that really means.


  1. The Answer, part 2 of 2

    ok now that we've created a glimpse of a holistically reformed america, here's how the answer plays out:

    with a national sales tax, the national health care, the immigration reform, and redirected funds from anti-terrorism and counter-narcotics, the pool of money is much greater to work with. everybody, including illegal immigrants and tourists contribute to the U.S. system through the national sales tax.

    health care prices are fixed to keep costs in control, and the prices are updated every year. this does in theory limit the revenue of doctors and hospitals, but administrative costs drop significantly, and more time can be spent on earning money through caring vice processing paperwork and claims. with this, there is also more incentive for doctors to keep their patients healthy than to do countless procedures to just keep them breathing.

    meanwhile, the "war on unsustainability" creates a plethora of jobs, ranging from low low income to high income, that are regionalized so that jobs are spread all throughout the country. there are labor jobs for the least skilled, like rummaging through landfills to snatch up recyclable waste products. with the legalization of drugs, you have to accept up front that there may be an increase of population with destructive addictions that can burden a society. the approach here is if you legalize drugs, you must invest more in rehabilitation, education, and opportunities for even the worst addicts to still contribute.

    the "war against unsustainability" may not be profitable or ironically speaking, financially self-sustainable for america for many many years. but that's not the point. just like how the war on terror and the war on drugs is not inherently profitable or sustainable from a financial perspective, it should be a conscious investment by the government. so inefficiencies and growth pains in developing sustainable green energy must be accepted up front, and not compared to the costs of oil or unsafe nuclear energy from a cost perspective.

    and what do we have in the end? more people pitching in and contributing, reduced costs, less bureaucracy, more caring, less paperwork, cleaner air, more jobs, simpler and more transparent tax codes and government spending, and hopefully less wars and better quality of life for americans. no system is perfect, but it'd be a heck of a lot better than what we're living with now.

    however.....whatever the answer is, whether it's the above possibility or not, it has to be a holistic answer that addresses all of the big problems at once. or else, an individually good proposal or plan, like a solid healthcare reform plan, will crash and burn and be buried forever under the poop of politics. also as a side note, i've only addressed certain chunks of a grand holistic approach...other big topics, like the financial and banking system, weren't included for the sake of this not becoming a 20 part post...

    perhaps it might be best just to move to sweden =).

    1. The Answer, part 1 of 2:

      Fantastic insight on the ground truth doc!

      I say there are 2 answers:
      a) if you're willing to leave the U.S.: move to a small country that has their act more/less together, like Sweden, where the whole country is pretty much united in their core values -- i.e. willing to pay a crapload of taxes to sustain a stabler society as a whole.

      b) if you want to stay in the U.S.: this answer clearly is exponentially more complicated, but it exists. the answer is the entire country's fundamentals need to be retooled in a holistic manner, not just piecemeal, for anything to really work. for example, you can't expect the nation's health care to improve with only an awesome health care proposal. it has to be part of bigger picture that includes education reform, jobs reform, american industry reform, immigration reform and tax reform. heck, i'll throw in illegal drug law reform in there as well.

      just as an example (it may not be the true answer, but it's sufficient for purposes of discussion)
      -- let's say america abandoned its currently wickedly complicated tax code and went to a simpler herman cain-esque code with 3 flat taxes: corporate income tax, personal income tax, and national sales tax. there are no tax breaks for having children, and no tax deductions period. government assistance to groups in need is still provided, but just not through the tax code. there is also a tax rebate given back to every registered u.s. citizen that equals the tax burden of a person in poverty. for example, if the poverty line is an annual income of $18000, and the person would hypothetically pay $2000 in taxes, everybody gets $2000 back. this is inherently progressive, as $2000 means much more to you the poorer you are and less to you the richer you are, but everyone gets it except for the people who are not u.s. citizens residing in america.
      -- at the same time, let's say america discarded medicare/medicaid and combined everything into one national healthcare system that every citizen had to contribute to, whether they're healthy or not. insurance companies would not be permitted to discriminate off of health history, and prices would be regulated. yup, a little anti-free market, but let's accept it for now.
      -- let's say the government decides to go all-out on a new mission. instead of the war on drugs and the war on terror, it creates a mission of the "war against unsustainability." the focus becomes making america a country that is self sustainable, particularly in terms of green energy and raw materials consumption. counter-terrorism and defense budgets are decreased, but not to the extent where america cannot defend itself and is not the most powerful military nation in the world.
      -- let's say recreational drugs are legalized and all of the money spent towards the counter-narcotics mission is redirected towards the "war against unsustainability."
      -- immigration laws are both stricter and more lax. worker visas are more plentiful and straightforward to obtain. immigrant workers must pay into the national healthcare system and flat income tax and national sales tax, and this will cut into their takehome pay. at the same time, there is heavy but fair enforcement of illegal immigration. the theme is, the doors to the states are open, but you gotta play very strictly by the rules, contribute financially to the system, and behave. same goes for the can hire immigrant workers, but follow the rules, and it's not going to be as cheap as it used to be, but probably still cheaper than paying an american citizen.

    2. Thanks for your insight, anonymobio. Either you have put a lot of thought into this beforehand, or you are intoxicated! Your excellent grammar points against intoxication - so you obviously have thought this all through before. I admire your comprehensive plan to change the world - and the optimism with which you present it. You may have budding career in politics. But do not forget that in politics you must be willing to fully commit to things! Committment is key.