As a physician who had been in practice for many years, I remember the hardships suffered by many of my elderly patients prior to the initiation of Medicare in 1965. During that time, I was forced to sit painfully by as many unfortunate sufferers lamented that, even though they desperately needed to be hospitalized or needed expensive tests and additional services, they had only received small monthly social security payments with or without a small pension that barely kept them at a subsistence level. In short, that situation afforded not only insufficient medical care, but threatened their financial security during their so-called “golden years.” Then, in 1965, something abruptly and miraculously changed the landscape—the advent of Medicare. Suddenly our elderly could receive a standard level of medical care, which included, among others, diagnostic tests and hospitalizations. Simultaneously, the financial burden was lifted from both the patients and physicians, because we were no longer confronted with agonizing daily decisions about how we could provide decent medical care on a shoestring budget without threatening our patients’ health or survival. Although Medicare is not an ideal solution, it has persisted for many years, and its success is supported by the huge numbers of senior citizens that cry out against any threats to this form of insurance that periodically arise in the political arena.
Now history seems to be repeating itself, for our focus has been sharpened by recent editorials written by two physicians, appearing in the well-respected New England Journal of Medicine (November 20, 2014). One of these, entitled “Civil Disobedience and Physicians—Protesting the Blockade of Medicaid,” was written by C. van der Horst, MD. In his communication, he stated that, with the anticipated passage of the Affordable Care Act, he would no longer need to worry about, among other issues, patients’ affording necessary medications, preventive care services and hospitalizations; moreover, “providing contraceptives free of charge would decrease the number of unwanted pregnancies that shackle teen mothers to unrelenting poverty.” He went on to quote reliable data that demonstrated that, up to the present date, 23 to 28 million Americans have gained access to health insurance through insurance exchanges, Medicaid expansions, and allowing children to remain on their parents policies until the age of 26, and no longer excluding those with pre-existing conditions. And these changes have resulted in a well-documented reduction of mortality. But then his hopes were dashed by a law passed in North Carolina, his home State, blocking Medicaid expansion. In addition, many other states, including Indiana, have decided not to expand Medicaid, even though the federal government is bearing 100% of the costs for the first 3 years and never less than 90% thereafter. Those decisions have left 5 million Americans—most of them the working poor, with incomes below the federal poverty level—in the “Medicaid gap,” i.e. bereft of decent medical care. This is the same type of disadvantaged patients that I had seen so many years ago. Vigorously opposing the state’s decision not to expand Medicaid, Dr. van der Horst interestingly quoted his guiding philosophy taken from Moses Maimonides, the ancient Jewish physician and philosopher, who stated “The eternal providence has appointed me to watch over the life and health of Thy creatures and Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend.”
Thus, over the protests of health care workers, teachers, union workers, immigrants, environmentalists, and people of all races and religions, North Carolina has remained steadfast in this—arguably callous—opposition to such expansion of care.
By contrast, a second editorial in the same journal was written by Michael Stillman, MD, from the state of Kentucky, entitled “The Affordable Care Act, 1 Year Later.” Contrary to expectations and despite objections to the Affordable Care Act by both its senators, Kentucky approved Medicaid expansion and this, as stated by Dr Stillmen, “fundamentally altered our medical practice, allowing us to provide data-driven and thorough care without first considering our patients’ ability to pay.” The decision by Governor Steve Beshear allowed 650,000 Kentuckians to gain access to decent and comprehensive medical care. They had previously lacked health insurance, or at best, were receiving “disjointed and disastrous” care. Previously they could be seen only in subsidized facilities and be charged for visits on a sliding scale, but they were asked to pay in advance for most diagnostic tests and consultations. Many of them had avoided routine and preventive care—and worried that a medical emergency would leave them bankrupt. Not only did this legislation lighten the financial and emotional burden on the group, but it even provided better student physician education, for those doctors in training had previously been forced, against their better judgment, to offer and become accustomed to offering substandard and incomplete care. Now they could provide guideline and evidence-based care. While 23 states have thus far not expanded Medicaid eligibility, Kentucky has moved in the right direction, but Dr. Stillman points out that there remains a need for policy-makers and insurers to provide benefits that are both adequate and fair, which is not always the case. Perhaps he is lobbying for a single payer system?
This country will eventually—and inevitably—support decent medical care for all its constituents. Perhaps the process would be enhanced if our politicians were forced to spend time on the “front lines” of medical care in our clinics and hospitals and actually have dialog with those patients who are most vulnerable and under served.