This week’s issue of the New England Journal of Medicine has a perspective piece by a doctor from Kentucky, describing the changes wrought by Obamacare in its first year. The doctor, Michael Stillman, is writing from a clinic serving a relatively poor area with limited health access: 60% of the doctor’s patients had no health insurance in the year before Obamacare’s introduction. It’s a short but quite powerful piece, and worth reading if one wants to get a sense of the transformative effect of Obamacare for the working poor. Dr. Stillman writes:

Last year, I encountered a patient with widely metastatic colon cancer whose diagnosis had been delayed because of lack of health insurance. He had clearly become ill at the wrong moment in our commonwealth’s history. Before Kentucky Governor Steve Beshear decided to implement the Affordable Care Act (ACA) and accept federal funding for Medicaid expansion, the 60% of my clinic patients and 650,000 Kentuckians who lacked health insurance received disjointed and disastrous care. They could be seen in subsidized facilities and be charged for their visits on a sliding scale, but they were asked to pay in advance for most diagnostic tests and consultations. Many of them avoided routine and preventive care — and worried that a medical emergency would leave them bankrupt.

This describes a pretty terrible situation in the world’s richest nation, and something that could hardly be imagined in any other developed nation. Dr. Stillman’s first sentence in this paragraph has a reference to another perspective he wrote last year, Dead Man Walking, in which he describes the case of this patient with colon cancer in more detail:

We met Tommy Davis in our hospital’s clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient’s privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences.

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening’s end he’d been sent home with a diagnosis of metastatic colon cancer.

The year before, he’d had similar symptoms and visited a primary care physician, who had taken a cursory history, told Mr. Davis he’d need insurance to be adequately evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and ineligible for Kentucky Medicaid, however, he’d simply used enemas until he was unable to defecate. By the time of his emergency department evaluation, he had a fully obstructed colon and widespread disease and chose to forgo treatment.

This is not the fate that should be allotted to the working poor. Obamacare will change this situation for a large number of Americans: in Mr. Davis’s case, Obamacare made him eligible for Medicaid, so had Obamacare been passed just a little earlier he might have been able to diagnose and treat his cancer earlier; or at the very least, would not have used up all his life savings on a mere diagnosis. The author reports that in Kentucky Obamacare has expanded access to 430,000 previously-uninsured Americans, and the same process is being repeated across the country. The Obama administration itself is forecasting a total of 9 million people will gain health insurance through the ACA, and I earlier reported on the first assessments of its impact from the Commonwealth Fund. Although most of the rest of the world agrees that Obamacare is flawed and doesn’t go far enough towards universal health coverage, this is still a huge achievement and any politician who opposes it, or any pundit like Michael Cannon who deploys disingenuous arguments to destroy it on ideological grounds should be seen as the wrecker and low-life that they are. Responsible politicians of any political stripe should be focusing on improving it, not destroying it, but sadly this is not the way the American political system seems to work.

Dr. Stillman finishes his article with this little observation:

I was once uncomfortable discussing politics with my patients, but now I routinely ask them if they are registered to vote and remind them that certain candidates do not support the legislation from which they have so palpably benefitted.

This little sentence should have Republicans and other opponents of Obamacare worried. If they can’t destroy it in the Supreme Court soon, they’re going to have to hoodwink 9 million Americans at the next election. The fact that they would even consider such a reckless and destructive policy is a depressing indictment of the cruelty and shortsightedness of the modern Republican party. I hope their intransigence on this issue destroys them at the next election, and Obamacare survives to be improved and consolidated, rather than dismantled and discredited. For where will the working poor be without it?

Advertisements