CompetetiveHe worked as a logger. He was cutting down a large tree and the chainsaw kicked back. When it did it broke his leg at the femur. As an independent contractor, he had no workman’s’ compensation, or disability. He went to pay cash for the treatment of his leg but discovered that the needed surgery cost much more than he had. He went to a free clinic which put him in a long leg cast. He did not have the money for a follow-up visit but fully intended to follow-up in 8 weeks to have the cast removed. Unfortunately, before the follow-up visit, he threw a blood clot into his lungs and died.

I cared for a similar patient several years ago in rural Alabama. He did not get a blood clot and die, due to no special ability on my part.

Alabama has opted out of the Medicaid expansion. Their excuse was two-fold. One was that by accepting the expansion, Alabamians would obligate themselves to paying for care that folks should be paying for themselves. Secondly, the belief seems to be that, if the state is unwilling to deliver such care, others (charitable physicians, hospitals, generally nice people) would provide the care for free or even that people just don’t need the care. I guess we will find out if this is true.

A person having a heart attack can call 911 regardless of their ability to pay and they will have their artery unblocked.  A bill will be generated and, though the person’s life will be saved, they will end up $100,000 or more in debt. A person with a sub-acute illness will not be given the opportunity to access healthcare. He or she will not be given an appointment and though care will be delivered in the emergency department, it will be directed at the acute illness (in this case the broken leg) and not preventing the subsequent illness (in this care having an operation leading to early mobilization and preventing a blood clot to the lungs).

One of the key components of the Affordable Care Act was the ability for those who were working poor to obtain care through Medicaid. An article in Health Affairs, using modeling, identifies the consequences of not accepting the expansion.

Based on recent data from the Oregon Health Insurance Experiment, we predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses…Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage.

The authors project between 7,000 and 17,000 will die annually due to a lack of Medicaid coverage, including  up to 500 people in Alabama. Governor Bentley of Alabama, a dermatologist, in his state of the state speech earlier this month expressed dismay that Medicaid  served no useful purpose other than to “bring people to a state of dependency on government.”

To quote one of the commenters on the article in health affairs:

As a physician who has taken care of thousands of Medicaid patients in my 35 year medical career, I am acutely aware of the problems we face caring for these people. But they are people, not statistics, and deserve care. I am reminded of John Kerry’s famous question to the Senate Foreign Relations Committee in 1971, and how we might ask today, “How do you ask a person to be the last to die for a failed policy?”