Every now and then I am talking about health care issues with a friend from a place like Canada, or Australia, or the UK, and I toss off a reference to something completely normal to me and my friend reacts with shock and horror. ‘It’s not really like that, you must be exaggerating. That would be…ridiculous. No country would actually do that.’ It’s a reminder to me that things I view as utterly routine are really not, and that despite documentaries and other discussions about the problems with the health care system in the US, many people are really not aware of the depths of the problems here.
If you cannot afford health care in this country, you do not receive it.
This is a complicated thing, and a simplistic statement that is not quite completely accurate. For people with low incomes, it’s possible to go on government benefits to get assistance with some health care costs. Things like vision and dental are not covered, though; if you get a bad cavity it could very well turn into septicaemia, but you still won’t get treatment for it unless you can afford to pay out of pocket. And government benefits come with some significant problems. There are some doctors who refuse to take them, and hospitals tend to toe the line when it comes to limits on things like procedures and hospital stays. If you need a particular service and it is not available through your benefits, you do not get it.
Yes, emergency rooms in the United States are required to provide care to people who are medically unstable. We do not actually leave people writhing at the side of the road with multiple broken limbs after car accidents. There is an obligation to stabilize the patient and address the pressing medical issues. That does not necessarily mean the patient receives complete treatment, though. Patients can be discharged when they are not fully well because they are ‘stable,’ even though doctors and hospitals are well aware that they need more care, probably a longer hospitalisation, access to medications.
I have doctor friends who tell me on a regular basis about their frequent fliers, the patients with no money and no insurance who come into emergency, get treated, get discharged, and show up again almost immediately because they decompensate. The doctors and hospitals have performed their duties, and even when doctors want to keep patients longer because they clearly need it, they may be forced to discharge by policy. You don’t want a non revenue patient taking up a bed. The emergent problem is over, kick that patient back onto the street.
Even though this is more costly in the long run because it results in situations where people who need followup care and treatment don’t get it, get sick, get emergency treatment, and enter a hamster wheel of treatments, growing worse and worse over time. Perhaps the most striking example can be seen in the handling of mental illness, where patients receive intermittent care, get much, much worse over time, are in and out of hospitals and treatment centres. If they received continuity of care, and attention, and caring, focused treatment, they could go from ‘stabilised after an emergency’ to ‘stable, period.’
If I need emergency treatment, I can get it. The hospital will hound me for payments for the rest of my life, but I will get basic treatment. The followup care for that treatment is fundamentally inaccessible because I cannot pay up front. I know first hand about how this works: I have a locked finger because when I was a child, I severed a tendon. My father couldn’t afford treatment beyond the very basic irrigation of the wound and stitches to close it. The severed tendon snapped back into my hand, and the window for surgery passed, and now I can’t move my right pinkie.
This is normal to me. It is utterly routine. Of course I cannot afford some of the medications I need and must pick and choose, must balance them out in the hopes of striking that fine line between taking them just enough to stay healthy, and slipping up and getting sick because I tried to stretch them too far. Of course people can’t go to the doctor when they are sick. Of course people cannot expect follow up treatment and continuity of care. This is normal to me. People dying because they cannot access health care are normal to me.
I’m not saying I like it, but this is the world I am living in, and I am always jarred when I encounter a world where that is not the case. A world, for example, where prescriptions cost a fraction of the amount they do here, even before government health care plans shave the price down, where people can buy things that I cannot afford for $5, sometimes over the counter, even. I am shocked when I encounter a world where people assume that if they go to a hospital for emergency treatment, they will stay until they are better, not just stable, they will receive followup care like rehabilitation if they need it, they will be able to access the medications they need.
I live in a world where transplant patients are dropped from government benefits because they stabilise after transplant, so they can no longer afford their anti-rejection medications, so they get sick, and have to go back on the transplant list because the donor organ is rejecting.
And this seems perfectly normal to me, even as the rational part of my brain asks how on earth this policy could be in any way reasonable, sensible, or cost efficient.