She sat on the exam table looking tired an cranky. Otherwise there wasn’t much to note about her appearance—not young, but not old; not thin, but not fat; she didn’t smell of smoke or have pet hair on her clothes. A glance at her demographics sheet confirmed that she was middle-aged, domiciled, and employed—and uninsured. But why tired and cranky?
She’s been wheezing for weeks and this was her second visit to the doctor for the same problem. She has been using her short acting inhaler every few hours, with some temporary relief, but she’s run out. It’s hard for her to sleep at night. In short, she’s miserable.
On the previous visit, she had been given a prescription for a short course of oral steroids in addition to her inhaler. She improved, but when the steroids wore off, she was miserable again.
She has “severe persistent asthma“. Thankfully, we’ve learned a lot about asthma over the last couple of decades, so I’ll summarize (briefly) what is going on in her lungs.
The effects of asthma on the airways involves complex actions of the immune system, but for simplicity’s sake we can think of it as an “early” and “late” reaction. The early reaction involves an immediate tightening of the airways, causing wheezing, and can often be relieved by “rescue” inhalers, such as albuterol. But the late reaction is much more troublesome. It involves chronic inflammation of the airways, with swelling and mucus build-up causing the airways to become more narrow. The swelling lasts a long time, and can become permanent. If you have narrower airways, the next time you have an attack and they tighten up, they close even further, making for a more dangerous situation. Any rational approach to asthma involves treating the airway spasm and the inflammation.
So, recently, thanks to environmental concerns, all inhalers had to do away with CFCs. Unfortunately, this pushed the average price of a rescue inhaler from 10 bucks to 30 bucks. Still, it’s sort of do-able. But what my patient really needs is inhaled steroids, and probably inhaled long-acting beta agonists (LABAs). They are best prescribed in combination, as LABAs can make you feel significantly better, but when prescribed without the steroid, they can increase mortality. There are no generic inhaled steroids, LABAs, or combinations (which are quite convenient).
So we started filling out “mercy” forms, which get sent to the drug companies. The drug companies will often give them drugs at a steep discount if the patient can’t afford them. But it takes a while. My patient needs drugs yesterday.
What are the consequences of her not being able to afford these medications? She is likely to end up in an ER and eventually in the hospital. She is also likely to end up on oral steroids, which will cause weight gain, hypertension, diabetes, osteoporosis, gastric ulcers, etc.
What the hell am I supposed to do for this woman? She needs medications that she cannot afford, and she needs them now. If she doesn’t get them, she will get sicker, and in addition to the human cost, she’ll cost the system hundreds of thousands of dollars.
Anyone who is still arguing against a single-payer system has to answer to this woman. It makes no sense from a human-rights perspective, a moral perspective, or an economic perspective to continue rationing health care by knowingly preventing poor people from getting good care.