Recently I was seeing a patient who had been out of his diabetes medications for almost six months. His sugar was in the toxic range, and now we were scrambling to ameliorate some of the damage. His clinical case was a mess, with a host of complications that didn’t have to be. In his case, it was the abrupt death of a family member and the subsequent legal battles and emotional stress that pulled him out of medical care, but I’ve seen countless similar health catastrophes when something traumatic happens in a person’s life. (Before the Affordable Care Act was passed, this also happened for patients who lost a job and with it, health insurance and health care.)
As a physician working in a safety-net hospital, every day I see the effects of inconsistent health care. When patients get “lost to follow-up”—whether from loss of insurance, or from unexpected family or financial crisis—their health status plummets. Insulin prescriptions run out. Mammograms are missed. Psychiatric care is forfeited. Cardiac medications are halved, then quartered to make them last. Blood pressures snakes skyward, unnoticed. The emergency room becomes the default site of health care but only accessed when crisis level is reached.
Oftentimes the damage wrought by these gaps and this inconsistent access is permanent. Untreated blood pressure can lead to irreversible kidney damage. Neglected diabetes can lead to foot ulcers that don’t heal and end in amputation. Gaps in chemotherapy can allow cancer to get an edge that is never bested. Untreated depression can lead to suicide. Regretfully, we’ve seen these all.
The GOP’s plan is not a paean to stability. It removes the basic premise that everyone needs to be covered by health insurance. Without this requirement—the baseline needed to maximally spread out risk—costs can only go up. Higher prices for older Americans in the form of reduced tax credits plus cuts to Medicaid mean that the poor and the elderly will be most affected, and potentially millions will find health insurance out of their reach. These segments of the population already suffer a disproportionate share of the illness burden and will be hardest hit by disruptions in medical care.
Those who do try to re-enter the insurance market after a two-month break can be slapped with a 30 percent surcharge—a fine likely to discourage anyone who is already struggling to pay for health care (and a fine that serves only to enrich the insurance companies, not assist the government in subsidizing medical coverage for others). This is a setup for widespread disruption of medical care, with the gravest consequences falling upon the sickest people.
As I sat with my patient, painstakingly trying to reconstruct his medical care, I thought about the ramifications of his situation multiplied times millions. How can it be that our government can so capriciously cast its citizens to the wind? Would we ever imagine removing police protection from a random segment of our society? Fire protection? Road repair?
Since the election, many Americans have felt anxious about their access to health care. Women are requesting IUDs in record numbers, which is a depressing statement on the reproductive care they expect to receive. They worry about no longer having access to birth control, abortion services, even a doctor.
When was the last time that a president of the United States deliberately put so many Americans in harm’s way?
It’s encouraging to hear that some Republican members of Congress are having second thoughts about the charging locomotive of repeal. (Republican governors, who actually have to govern, are leading this refreshing nod to reality.) The precipitous dearth of town-hall meetings suggests that members of Congress don’t have good answers for their constituents who are suddenly realizing that ACA repeal will have grave corporeal consequences.
Trump’s recent observation—“Nobody knew health care could be so complicated”—has been called the understatement of the year. Yes of course health care is complicated. That’s why everyone who’s ever undertaken to change it has found themselves in a yearslong quagmire attempting to jigger hundreds of disparate pieces together without breaking the bank or losing their minds.
But there’s also something that’s very simple about health care: If you take it away, our fellow citizens will suffer. People will get sick. People will die. The new GOP plan will exacerbate this. This is not only contrary to the Hippocratic oath, it’s also contrary to the presidential oath of office.