Sunday, May 21, 2017


A few weeks ago I was awakened by a 2 a.m. call from the ED regarding a case of pneumoperitoneum.  I barely recall the specifics of the conversation, but I vaguely remember snippets of phrases, words that light the fires and compel immediate action: "free air, tender all over, hypotension".  I donned some old scrubs and quickly drove in to the hospital.

The patient wasn't much older than me.  He looked healthy, had a robust build.  No other medical problems.  But his vitals were perilously unstable.  Heart rate 120's.  Blood pressure 70 systolic despite several liters of fluid.  The CT showed air under the diaphragm and inflammatory changes in the pelvis consistent with acute perforated diverticulitis.  And he certainly had peritonitis on exam.  I didn't have much of a choice.  He needed an emergency operation.

An hour later I had washed him out, resected the colon with the gaping hole, and fashioned an end colostomy.  Primary anastomosis was not a consideration given the degree of contamination and pressor sustained systolics in the 80's.  We call it the Hartmann's procedure; an old school operation that is not used as often as it once was.  We found that it isn't always so easy to reverse a colostomy (70% success rate) and the procedure itself can result in significant morbidity.  Nowadays we find we can treat many cases of perforated diverticulitis medically with antibiotics alone.  Primary anastomosis is performed even on unprepped bowel in cases of mild contamination and hemodynamic stability.  Sometimes you can even get away with just laparoscopically washing out the pelvis, placing some drains, and bringing the patient back later on, for definitive one stage surgery, once the sepsis clears.  Lots of options.  But there is still a role for the Hartmann's procedure.  Four or five times a year I find myself resorting to it, even still.

The guy did well.  Got better, cleared the sepsis, started eating.  Right before discharge, I received a call from the case manager.  She told me she would not be able to arrange for a wound vac or home health care assistance, as I had requested, because the patient lacked any health insurance.

I must say, I have received far fewer phone calls of this nature since 2008.  Obamacare (in all its iterations, not just the exchanges but the Medicaid expansion as well) has certainly reduced the number of "self pay" cases I have seen.   And this simply makes statistical sense.  The number of uninsured since the passage of the ACA has fallen from 50 million to around 20 million (which is still embarrassingly too high!)

I told them to discharge the guy home with wound care and colostomy instructions and some bags of extra dressing supplies and to see me in the office in a week.  There isn't much else you can do in this situation.

The first thing he asked me in the office was, as expected: "doc, when can you put me back together again?"  Well, it's complicated, I told him.  I had been dreading this moment because it inevitably casts me in the role of villain--- the predatory quid pro quo shyster who financializes the doctor/patient relationship.  You gotta get some insurance, man, I told him.  I do plenty of uncompensated emergency surgery.  I'll be damned if I willingly perform complex elective surgeries without the guarantee I will be remunerated for my services.  In addition, it isn't just about me--- there is an anesthesiologist and the hospital facility that will want to bill for services.  I could do the procedure gratis, but he would still get a bill for 20 grand or more.

And the guy was not some street urchin or derelict.  He owned his own landscaping business.  He worked 60 or so hours a week.  He was married and had children.  By all metrics, he was an upstanding, contributory member of his community.  But he didn't have any health insurance.  And the reason is because he was able to choose not to have health insurance.

There is a mandate built into Obamacare, but it is a fairly weak one.  The cost of not having insurance often was cheaper than the cost of purchasing a plan on the open market.  Furthermore, the Trump administration, via executive orders, has enacted changes at the IRS that make it easier for people to get away with not paying anything at all.

Outside of government-run, single payer health care systems like the NHS in the UK (i.e., the rest of Western Europe and many countries in Asia), everything hinges on universal participation.  Universal coverage directly correlates with universal participation.  If the pool of patients buying health insurance are only the sick, the critically ill, and those with chronic illnesses, a health care fund will need to pump up premiums in order to ensure financial viability.  You need the young and the healthy on those health care roles in order to justify enforcement of "community rating".

Sadly, I see us starting to slip back into old ways.  AHCA probably has no chance of passing in the Senate.  But there are other ways of eroding the incremental reform brought to Americans under the imperfect auspices of Obamacare.  Executive orders to "decrease regulations" are one such seemingly anodyne way of accomplishing this.  Simple administrative incompetence and mismanagement is another way to sow doubt in the minds of private insurance companies and impel them to withdraw from markets.

So yeah, we can go back to those "good old days" when 50 million Americans lacked health insurance, when medical bills were the number cause of personal bankruptcy, when a person could be denied reasonably priced insurance due to pre-existing conditions.  It would be just as shameful and inexplicable in the future as it has always been.  The wealthiest, most hegemonic nation in the history of the world, unable to muster the means to care for its own citizens when illness strikes.

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