Condemning The Poor To Death In Texas

(This image is from the website of The Brownsville Herald.)

The state of Texas has the highest rate of people without health insurance of any state in this nation -- somewhere between 25% and 27% of the state's population (more than one out of every four people). The 2010 census showed the state's population was about 25.2 million, meaning that more than 6.3 million Texans are uninsured.

Of that huge number of uninsured, the most vulnerable are the poor -- because they have no way to access the preventative care that could save their lives. And in fact, about 9,000 Texans die every year from treatable diseases -- diseases that could have been cured if they had been caught in time through adequate preventative care. They die because the GOP leadership in Austin has refused to expand Medicaid, even though the federal government would have paid for all of that expansion for ten years (and 90% after that ten year period).

For me, these numbers are shocking -- and the failure of state leaders to do something about it (for purely political reasons) is inexcusable. The Texas Observer has printed an essay from a young medical student named Rachel Pearson. This excellent essay puts a human face on the problem of the uninsured poor in Texas. I am posting the opening paragraphs of her essay below, but I urge you to read the whole thing. It will probably leave you feeling angry and frustrated (as it did me), but it is well worth your time. Ms. Pearson says:

The first patient who called me “doctor” died a few winters ago. I met him at the St. Vincent’s Student-Run Free Clinic on Galveston Island. I was a first-year medical student then, and the disease in his body baffled me. His belly was swollen, his eyes were yellow and his blood tests were all awry. It hurt when he swallowed and his urine stank.

I saw him every Thursday afternoon. I would do a physical exam, talk to him, and consult with the doctor. We ran blood counts and wrote a prescription for an antacid—not the best medication, but one you can get for $4 a month. His disease seemed serious, but we couldn’t diagnose him at the free clinic because the tests needed to do so—a CT scan, a biopsy of the liver, a test to look for cancer cells in the fluid in his belly—are beyond our financial reach.

He started calling me “Dr. Rachel.” When his pain got so bad that he couldn’t eat, we decided to send him to the emergency room. It was not an easy decision.

There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.

My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.

One night, a friend called to say that my patient was in the hospital. He’d finally gotten so anemic that he couldn’t catch his breath, and the University of Texas Medical Branch (UTMB), where I am a student, took him in. My friend emailed me the results of his CT scans: There was cancer in his kidney, his liver and his lungs. It must have been spreading over the weeks that he’d been coming into St. Vincent’s.

I went to visit him that night. “There’s my doctor!” he called out when he saw me. I sat next to him, and he explained that he was waiting to call his sister until they told him whether or not the cancer was “bad.”

“It might be one of those real treatable kinds of cancers,” he said. I nodded uncomfortably. We talked for a while, and when I left he said, “Well now you know where I am, so you can come visit me.”

I never came back. I was too ashamed, and too early in my training to even recognize why I felt that way. After all, I had done everything I could—what did I have to feel ashamed of?

UTMB sent him to hospice, and he died at home a few months later. I read his obituary in the Galveston County Daily News.

The shame has stuck with me through my medical training—not only from my first patient, but from many more. I am now a director of the free clinic. It’s a volunteer position. I love my patients, and I love being able to help many who need primary care: blood pressure control, pap smears, diabetes management. We even do some specialty care. But the free clinic is also where some people learn that there is no hope for the chemotherapy or surgery that they need but can’t afford. When UTMB refuses to treat them, it falls to us to tell them that they will die of diseases that are, in fact, treatable.