As crises go, medical insurance is not a very sexy one. It's not that no one talks about the 43.6 million uninsured, skyrocketing drug costs, emergency rooms crammed with patients in search of routine care or the 18,000 Americans who, according to the Institute of Medicine, die each year for lack of care. Every politician has a stump speech and a plan--usually a rather complicated one. (Insert your Kerry joke here if you must, but give the man credit--at least he'll cover most people.) The simple solution would be a single-payer system like Canada's, a mantra the left has been humming for decades, but where's the big, irate, energetic movement for it? Health coverage doesn't seem to bring out the fire-breathers, like, oh, gay marriage or "partial-birth" abortion or whether "under God" belongs in the Pledge of Allegiance.
Why is that? Maybe we've been living this way so long that we've just accepted it, like the housing crisis. Maybe the kinds of people who are uninsured are the sort voters are all too used to ignoring. Maybe people don't want to pay for universal coverage (even though they tell pollsters they're willing). And maybe the political classes, who have good coverage and money and tend to live in places with lots of specialists and state-of-the-art hospitals, fear they'd have to stand in line under a Canadian-style system, as the New York Times is always warning them they would.
While wonks debate, the crisis deepens. Dr. Michele Barry, who directs tropical medicine at Yale Medical School, sent me her notes on three patients she saw within a single week recently at Yale-New Haven Hospital:
An Italian-American man in his early 50s who moved from Florida to New Haven to let his wife die up near her family in Maine. He went 250,000 dollars in debt trying to self-pay for care for his wife, who was diagnosed with cervical cancer over a year ago. He was admitted to my service with hyperkalemia (high potassium) due to using expensive medicines he could get for free from pharmaceutical donations--these were inappropriate for his kidney problems, which were caused by diabetes. He could not even afford the long-acting insulin we wanted to give him. His reply to my telling him he might die if we didn't treat his potassium was: "Doc, maybe that's for the better."
A 38-year-old auto mechanic who was admitted in narcotic withdrawal. A year ago, he was the victim of a freak accident when a clutch released and a car rolled back into him. He developed back pain which subsequently caused him to seek several neurosurgical opinions, but nothing was done because he couldn't afford follow-up appointments. He became addicted to the OxyContin the doctors prescribed. Unemployed, disabled and out of money due to medical costs of imaging and doctors, he lost his home and was forced to move to a motel and file for bankruptcy. He came into the hospital when he could not afford his motel room or any more narcotics and thus started to withdraw.
A 40-year-old black woman from North Carolina who came into my service with hypertensive emergency (escalating blood pressure) and heart failure. She had stopped taking any blood pressure medicines in order to save for her husband's kidney transplant. Due to her prolonged non-treatment, she developed irreversible heart damage.
As these tragic stories show, health insurance is about more than treating an immediate illness. Lack of insurance can precipitate an avalanche of trouble: job loss, debt, bankruptcy, more illness, inappropriate charity treatment that worsens the original problem, prescription drug addiction, homelessness. The crisis doesn't even have to be yours: Mr. N.'s diabetes and Ms. W.'s hypertension--common, manageable conditions--became life-threatening because they skimped on their own medicine to help a spouse with an even bigger problem. In the case of Mr. N.'s wife, her fatal illness was itself possibly related to lack of preventive care because she didn't have health insurance: Cervical cancer is usually curable if caught early on by regular Pap smears.
Critics complain about the cost of universal coverage, but if you think of those 43.6 million uninsured as embedded in families, you have to count the privations endured by everyone in them as part of the true cost of the status quo. More money for a parent's doctor means less for the children's dentist--or summer camp, or college fund. Untreated or inadequately treated illness means stress and anxiety for the whole family. When a patient goes bankrupt, like Mr. M.--and healthcare costs are involved in 50 percent of bankruptcies, which have risen 400 percent in the past twenty-five years--the whole family suffers. Conservatives are always worrying about divorce--what about divorce as triggered by the financial and emotional stresses of uninsured illness? Maybe universal coverage could be sold as a family value.
Dr. Barry, who moves mountains for her patients, is doing all that one doctor can do. She was able to arrange donated drugs for Ms. W. and Mr. N., as a temporary stopgap. But what will happen to them down the road? As for Mr. M., she writes, "We gave him a long-acting morphine compound--not OxyContin!--for his pain and are trying to find him a surgeon who will accept state insurance. Not one orthopedic in our area does this. He was last seen living in a shelter in town."
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Clarification: Many, many readers objected to my claim in my last column that the money from the breast-cancer postage stamp goes to the Defense Department. I should have phrased it more carefully: The DoD receives 30 percent of the stamp revenues--for medical research into breast cancer, not, as some thought I implied, cluster bombs and homemade sado-porn. (Seventy percent goes to the National Institutes of Health.) Several letter writers argued that this funding is a good thing. Maybe so, but it nonetheless illustrates my general point: that the military is extending its tentacles deep into civilian life, often without our being aware of it.