White Coat Underground

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.

Comments

#1 Tony P
February 3, 2009

I’m hoping you also emailed this case description to your representatives, the house speaker, etc. They need to know the real effects of not having adequate coverage.
#2 CyberLizard
February 3, 2009

My takeaway from this is that I need to get to the doctor. My lungs feel like the ones pictured on the left. I’m not looking forward to the nasty taste of those damn Proventil inhalers. Hopefully the new CFC-free ones will be less disgusting.

We’ll see what my insurance does as far as covering the inhalers. I think it’s something like 85%? Fortunately my current meds are only costing around $4/month.
#3 Comrade PhysioProf
February 3, 2009

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.

Dude, she’s poor. Don’t you know that poor people are lazy and morally flawed, and government handouts to poor people just keeps them poor and drains resources from hard-working decent real Americans like Rush Limbaugh?
#4 PalMD
February 3, 2009

Of course, you could argue that this illness should further motivate her to get a better job.

If she could breathe.
#5 D. C. Sessions
February 3, 2009

Dude, she’s poor. Don’t you know that poor people are lazy and morally flawed, and government handouts to poor people just keeps them poor and drains resources from hard-working decent real Americans like Rush Limbaugh?

Wrong rant.

If she were on assistance, she wouldn’t have the same problems. It’s the people who actually work hardest for a living in the USA who have the worst health care; the bottom-rung poor are actually better off.

And, yes, I know people who basically gave up working because they couldn’t afford the lack of health care. Putting in 50-plus hour weeks at a physically demanding job was a net money-loser for their families.

Yeah, I know: wrong audience. I don’t know whether playing bookend to CPP bothers him or me more.
#6 Abel Pharmboy
February 3, 2009

Brother Doc, I just had a similar conversation with my pulmonologist last week. I have mild asthma made worse by seasonal allergies and have worried about this increased cost of CFC-free albuterol. For God’s sake, the damn stuff is generic and I am certain that the CFC to HFA formulation didn’t triple the cost. There are also very inexpensive inhaled steroids and I’m learning that the long-acting beta2-agonists will be restricted to those with COPD because of increased risk of bronchospasm in folks like me with regular old asthma.

Your next to last pgh absolutely needs to be heard by policymakers, far beyond our, god forbid, humanitarian concerns. An inhaler going from $10 to $30 is going to cost the system thousands of dollars.

I’m really grateful to you for writing this compelling post but please tell me where to line up to support a single-payer system to help this woman beyond sending her $30.
#7 Stephanie Z
February 3, 2009

D. C., you don’t think the litany against the poor really stops with a job, do you? The tune just changes slightly: If they were smart and motivated enough, they’d improve themselves so they could get real jobs….
#8 Igor
February 3, 2009

A very compelling story, and I agree with D.C. Sessions (notice how this woman is employed and uninsured). I am similarly affected by the abysmal state of health care system in this country. After seven years of schooling my loans are overwhelming so that I can’t afford health insurance (which my employer doesn’t provide). I was under a misguided impression that since I’m young and don’t engage in risky or unhealthy behavior I could manage for a short period of time. Recently, a 4 hr stay at ER (fortunately nothing too serious) ended up costing me eight grand. After seven years of post secondary education and gainful employment at 50-60 hrs per week some are incredulous that I don’t have health insurance. Unfortunately, no health insurance or inadequate health insurance is a fate of too many people that I know who are similarly situated.
#9 D. C. Sessions
February 3, 2009

Recently, a 4 hr stay at ER (fortunately nothing too serious) ended up costing me eight grand.

IANAL, so fair warning applies.

However, having recently had my own brush with ER (distal tibial fracture) I was utterly amazed at the “discount” that my insurance got — it was close to 4:1. I am also informed (you may need to verify this) that there is little-known Federal case law that hospitals can’t force the uninsured to subsidize the insured by this kind of differential pricing — which means that for all I know you might be able to save $6000 that you can’t afford by quoting obscure law at them.

The lawyer may be cheaper than the hospital, anyway.

As for /me, I’m seriously embarrassed by being employed, well-paid, in a job that I can do with my leg elevated at home — and paying much less thereby than the roofers who work way harder and can’t afford to miss work.
#10 Dianne
February 3, 2009

Among other things, this case demonstrates why health care in the US is the most expensive in the world. (And not only the most expensive but the most expensive in terms of public money spent.) The US healthcare system provides only emergency care for people without means of paying. But emergency care is the most expensive care and the need for it can often be prevented relatively cheaply with outpatient medications and occasional followup–which is, however, beyond the means of peole without insurance.

Basically, the US should do one of two things if it wants to decrease health care costs: 1. Implement universal health care. It could be modelled on the lines of the German system (multiple competing public and private systems) or the Canadian (single payer period end of story) or some other way entirely. As long as everyone’s covered for all medically necessary procedures, health care costs would go down. 2. Get bloody minded about it and allow people to die in front of ERs if they can’t pay-or can’t prove that they can pay. I add the second because anyone advocating option 2 should be aware that if it were in use and they were to, for example, get hit by a car while jogging and don’t have their health insurance card with them then they would be left to die of potentially treatable trauma.

I favor option 1, for obvious reasons. And non-obvious reasons. I find being unable to treat patients to the best of my ability and knowledge because they can’t afford the medication or therapy I believe to be best one of the most stressful events that can occur in clinical medicine. (And remember that I’m comparing it to telling people that we have no further options for treating their disease and that they are going to die soon. That’s not easy either but at least it isn’t a huge injustice except in the universal sense.)
#11 Igor
February 3, 2009

D.C.,

IAAL and as such feel slightly ashamed to have you refer me to an obscure federal law. The reason I can manage is because I am a lawyer, so while I currently have my financial constraints, knowledge of law and the ability to write annoying letters helps. The downside is that I have virtually no federal insurance litigation experience, nor is it prudent for any lawyer to represent himself or herself.
#12 ERV
February 3, 2009

Now I feel bad because I needed an inhaler after a vicious cold, and the PA got me a free sample… and now Ive got ~80 hits leftover I dont need…

Our physicians assistants are great about getting us free stuff, when they can. You arent alone in your frustrations, Pal
#13 D. C. Sessions
February 3, 2009

The downside is that I have virtually no federal insurance litigation experience, nor is it prudent for any lawyer to represent himself or herself.

“… fool for a client.” Check.

However, professional courtesy and all that — you may still find that for $6k you can have a colleague spend an hour or two negotiating.
#14 Igor
February 3, 2009

D.C.

My thoughts exactly. And I’m glad some people recognize that not even an attorney (or at least any attorney worth his or her salt) would want to litigate pro se.

On a different note, and returning to the original topic, I still remember PAL’s article regarding Diabetes and the costly nature of testing strips. A good friend of mine who at a very young age became type I diabetic went through a lengthy battle with his insurer.

As much as I’m against the notion, there is a point at which anecdotal evidence is pervasive and consistent enough to motivate a serious inquiry. Perhaps what works in Canada (which isn’t much better than us) or in Britain will not work in U.S., and we should stop looking to those countries for an answer, but instead search for our own.
#15 Dianne
February 3, 2009

Igor, you aren’t actually trying to pay that bill are you? Because most hospitals work under the expectation that self-pay=no pay. They write the costs they’ll have to eat for taking care of uninsured patients into the budget at the beginning of the year. What are they going to do, repossess your health?

Perhaps what works in Canada (which isn’t much better than us) or in Britain will not work in U.S., and we should stop looking to those countries for an answer, but instead search for our own.

I both agree and disagree with this statement. Mostly disagree. We shouldn’t expect to be able to import the Canadian (or any other) health care system wholesale without any tailoring to the specific circumstances of the US (or individual states and counties) but ignoring an example that works at least as well and is far less expensive strikes me as foolhardy. Why reinvent the wheel when you’re living next to the Michelin factory?
#16 Donna B.
February 3, 2009

Having insurance does not automatically equate to getting good healthcare.
#17 Rowan
February 4, 2009

i am currently unemployed and uninsured. i was employed for the last four years at two different employers, neither of which could afford health insurance for employees.

i discovered when i tried to find individual health insurance that due to having asthma i don’t qualify. i could purchase the catastrophic coverage offered by the state for a mere $1500/month.

i couldn’t afford it when employed and i certainly can’t afford it while unemployed.

with the removal of over the counter inhalers from pharmacies as well as the severe limits placed on purchasing the original formulation of sudafed many of us are out of luck (the new formulation causes severe side effects). i can register to purchase twenty four sudafed tablets once every thirty days. at a dosage of one tablet every 4-6 hours, i manage to breathe for eight days.

i am slowly suffocating as i cannot afford to go to a doctor.

i can identify with this woman.
#18 The Perky Skeptic
February 4, 2009

When I was 20 weeks pregnant, I got hit by a slow-moving truck while crossing the street. (Needless to say, I was terrified, but the actual facts of the situation was that he just bumped me and I only got knocked over and skinned my knees and elbows.) The paramedics were called, oxygen was administered both to me and to the driver, who looked even more frightened than I was, and they wanted to take me to the hospital in an ambulance. I was so shaken up I couldn’t even remember my own phone number– they asked, and I couldn’t!– yet I balked at the ambulance because of cost.

The paramedics could see I was in no condition to drive and argued, “Look, if you can’t pay for the ambulance, no one’s going to take you to court over it or anything.”

I took the ambulance. And OF COURSE I paid, because the fact was, losing that money hurt, but I couldn’t stand the idea of ducking out of a bill. But, gah, the pricing system is so unfair, and just thinking that if everyone could just be charged the negotiated insurance company rate instead of the screw-you-self-payor rate, it seems that a lot more bills would get paid.

I hate the idea that some people can’t pay for their inhalers. I cannot think of a worse chronic condition than not being able to breathe.

(By the way, in case you need something to take your mind off the back pain, tag. )
#19 Dianne
February 4, 2009

the PA got me a free sample

Quick rant about free samples: We aren’t allowed to give them out anymore. As far as I can tell, the reasons for this are that the presence of free samples might influence prescribing patterns in ways that are not necessarily consistent with standard of care and that bias might be displayed in deciding who gets the samples. I can see both points in principle, but when faced with a patient who needs drug now, not in 2-6 weeks when the drug companies finally get their act together, it’s not much comfort to think that at least we aren’t giving our samples to one sociodemographic group more often than another.
#20 khan
February 4, 2009

Having insurance does not automatically equate to getting good healthcare.

And your point?
#21 MKandefer
February 4, 2009

“Why reinvent the wheel when you’re living next to the Michelin factory?”

We live next to France? =D
#22 Cheyenne
February 4, 2009

I am an unemployed student in Canada and even though we have a single payer system it still is inadequate to help those who are poor. Each province controls their health care system slightly differently but essentially preventative services are out of reach. I won’t argue that if I break my leg not having an $8,000 bill waiting for me is nice. However I still have to pay for the ambulance, any prescriptions, the cast, and the crutches. Most of which I’d have to go without because I wouldn’t be able to afford it. (I think basic plaster casts are still 100% covered…so there’d be no painkillers, no crutches, and a bus ride home for me).

Our system has been so eroded over the years that the real long term savings for the system (those tied to preventative services like dentistry, wellness programs etc.) are all gone and you have to rely on private insurance to use them as well.

I wish we actually had the guts to provide a real single payer system up here. But for the moment private insurance is still very widespread amongst employers. Most people don’t even know what is covered and what isn’t, and it’s no fun to find out after you get the bill!
#23 Donna B.
February 5, 2009

Having insurance does not automatically equate to getting good healthcare.
And your point? — khan

My point is, as stated, that the best health insurance does not equate to good medical care.

I’ve truly got the best in monetary and referral terms. Tricare Prime is only bested by Medicare with Tricare For Life.

Yet… what I really need is simply not available. Anywhere. For no amount of money. I’ll live with it, and you needn’t worry yourself about it.
#24 Igor
February 5, 2009

What’s that Donna? Posthumous care coverage?