On American Healthcare Crises

A woman suffers from peripheral artery disease. She knows something is wrong with her left foot and is checked into a hospital. By how and why she is checked into the hospital that she is, is not known. It’s discovered that the low blood flow to her feet has caused need for some digits to be amputated. As part of diagnostical prerequisite, necessity, or whatever you want to call it, a mass in her lung is also discovered. It’s malignant and has metastasized (cancer with ‘mets’ = spreading). She is 55 years old, lives alone, and has family who live out of state. For all intents and purposes the patient is alone in the city and state she currently calls home.

She has worked her entire life but was recently laid off from her job, subsequently losing her health insurance. Luckily for her she collects about $1,000 a month in unemployment benefits; this has allowed her to maintain her home and a small quality of life.

The unemployment the patient collects renders her ‘over assets’ and ineligible for the state and national medical programs (AKA: Medicaid). And, the hospital she is currently checked into is out of her county of residence. This is a big deal for a patient who has no insurance. In many major cities ‘county’ hospitals exist in order to act as a safety net for provision of medical and psychiatric needs for all of their ‘county’ residents, regardless of things like ability to pay or legal U.S. status. In other words if you are an illegal immigrant, have no insurance, are dirt poor, and live in that county…you WILL be treated to the fullest extent (this varies from state to state, etc.). There is a dignity factor that plays into this hospital philosophy. For this patient, however, a large gray line is produced by which she falls into.

The patient’s toes are amputated, at no cost to the pt. This is an issue, medically and politically, identified as an emergent need; life threatening and easily fixed in the acute setting. Unfortunately for her, her cancer is not. She is stage 4 and requires chemotherapy and possibly radiation. These treatments are expensive, and could have an indefinite timeline. They also require a lot of follow up care in an out-patient setting, such as primary care needs, specialists, tests, labs, medication, and other treatments (let’s face it, without insurance even the wealthiest cannot afford this kind of medical care). And, because ethically speaking a patient cannot be left dangling, all of this care, cost included, will be the responsibility of the hospital system that starts the care in the first place.

If only the patient had been taken to her county of residence’s hospital she may be eligible to receive the care she needs to fight her illness. But she wasn’t. Despite all efforts on the parts of the physicians and social workers currently treating this patient, her county’s hospital declines to accept a transfer of this patient. Why should they? This patient is expensive. And, currently she is being well cared for at another hospital. Regrettably, (and I cannot stress the regret enough) her current hospital cannot begin or provide the treatment needed for her cancer because this is not identified as an emergent need. “This can be treated in an out-patient setting…” The patient’s only option is to remain in the hospital until her symptoms are managed enough for her to safely return home. The current hospital is under no obligation, and is philosophically critical of, providing on-going care to out of county patients. This has nothing to do with the will or desire to care for this patient, but everything to do with the funding.

Every hospital has the opportunity to receive funds from the state to treat uninsured patients whom are unable to pay for their care. All county and most non-profit hospitals do receive these funds. Of course these funds are capitated… meaning, that there is a limit to the amount of money the state will provide the hospital, but no limit to how much treatment the hospitals are expected to give (or how many patients land on the hospitals’ door steps). The difference = millions of dollars. Ultimately, some hospitals are more willing to continue to provide care in these situations than others. So, patients come from far and wide to the locations known for providing the treatment needed, leaving some hospitals saturated with expensive patients whom they will not be paid for. When other hospitals are asked to take these patients back, there, again, is no obligation to accommodate.

Meanwhile our patient is stabilized, discharged home, and days later she is re-admitted to the same out of county hospital. Her illness is progressing and causing more symptoms. Again, the current hospital will treat the patient’s acute, or immediate needs. She will then be discharged home, again, in hopes of eventually accessing in county care. But, because this hospital cannot logistically, realistically, or feasibly keep its doors open if it takes on the responsibility of the entire state’s uninsured population, it cannot provide possible life sustaining/saving treatment to this patient. We must “share the wealth…”

In all things, it is the patient that ultimately suffers here. She will continue to get sicker and sicker. The patient WILL lose her life to cancer. Even with treatment she may only gain one extra year of life. The injustice in this is that this patient is not allowed the same fighting chance that you or I would be, OR of a wealthier, better insured person. Understandably cancer is a horribly hopeless diagnosis; but a cancer diagnosis for this patient means even less hope.

Who then takes responsibility for this patient’s life?

Sobering truth....

Post my 2011 return to the Old Lady Next Door last week, I re-read through all of my past posts. In doing so I found that a consistent sad theme throughout was obvious: death, lost love, depression, loneliness, absent families, sickness, nursing homes, etc. I thought on this awhile and resolved to include more positive and uplifting posts in the future. But that’s easier said than done. Because let’s face it, people with good retirement plans, financial security, safe homes, good health, and present and supportive families… don’t need social workers. That’s not the reason my profession exists. The need for a social worker comes with the absence of one or more of the above listed provisions. So for the sake of honesty and transparency, the Old Lady Next Door will continue to reflect a sense of sadness, as is needed. Not to be received as a buzz kill, but I hope, rather, a sobering truth.

On that note, one of my old high school friends recently posted a link on my Facebook wall and commented “this seems like it might be right up your alley.” It was a link to The Julie Project by Darcy Padilla (http://www.darcypadilla.com/thejulieproject/intro.html). Padilla is a photographer who followed a woman named Julie, a homeless mother with HIV, for nearly 2 decades. Talk about a sobering truth, this photo project speaks to, nay proclaims issues that often go well hidden in our society… issues that the mainstream middle class may have nothing to do with, least of all understand. Julie was born to a teen mother and was sexually abused during childhood by her step-father. The Julie Project explores her ensuing life of homeless shelters, drug addiction, disease and the loss of 5 of her total 6 children to child protective services. The emotion of this woman’s short lived life is palpable.

I told my high school friend that I appreciated his post but that The Julie Project was hardcore social work... not the kind I’ve ever actually worked in. I did, however, study this kind of thing during my degrees via text books and case studies. The Julie Project illustrates gaps in our society and in social justice. It also magnifies the polarity of wealth and disparity in our society. Regardless of where anyone stands politically or socioeconomically, lives like Julie’s exist, they are tangible and worst of all they are changeable. Remember in my last post (All You Need is Love) I stated “it makes me wonder if I will ever suffer that way too” in regards to the suffering I see in my work. I guess that is one of my attractions to social work, the fact that I cannot answer the question “why not me?” Why is it someone else that is subjected to such a degraded existences and not me? I guess one of the harder parts of social work is having a foundation and understanding into things like the vicious cycle of poverty and other marginalized aspects of society that perpetuate suffering. Some parts are unexplainable and perhaps nothing can be done to change them… but not all.

One more time for good measure: http://www.darcypadilla.com/thejulieproject/intro.html

All you need is love...

Welcome 2011! I realize the Old Lady Next Door has been MIA for several months… what can I say? The usual excuses I guess… busy, holidays, can’t think of anything to write about. So here goes… I want to introduce you to a few of my current, and some past, clients. The names have been changed to protect the innocent.

Tonight I’ll tell you about Mikey. Mikey is a 91 year old man who lives at an assisted living facility. Not one of those fancy facilities either… the one Mikey lives at does not have chandelier lighting, or room service. It’s old, it smells weird, the carpet throughout desperately needs replacing, the staff speak very little English, and around the same corner I turn every time to get to Mikey’s room is a mentally ill woman who sits talking to herself and screams at me as I pass… every time!

Mikey has lived here as long as I’ve known him. He spends his days in his recliner chair in his tiny room because he has lost most of his vision, he cannot hear well, can't walk, he suffers from chronic pain, and, well, he just doesn’t care to do anything else. His am/fm radio stays close where he keeps it tuned to the country station. I usually have to turn this down when I visit with him. I always ask, “Mikey, how is your appetite? How have you been sleeping? Anything new?” His answers are always the same “I’m not very hungry… I get up about 4 times a night to use the bathroom… nope, nothing’s new.”

Mikey was married for over 70 years. He met and married his wife at the age of 17… she was only 16. They never had any children, which they later learned was because of some inabilities on Mikey’s behalf. I remember when Mikey had recounted for me the conversation he had with his wife after they learned that Mikey was the one unable to have children: “..well, I told her I relieved her of me… told her to go on down to the court house and get a divorce… so she could marry someone else and have children.” Mikey was a lifelong farmer with little education and a serious stutter; conversations like this only magnified these facts. The coddling side of me wants to ooh and ahh at his stories like he is a child (he IS pretty cute). But the social worker in me reminds me that this man has lived 4 and a half times longer than me, has seen and lived things that I have no idea about, and whether he says it or not he demands my respect. Anyway, Mikey sounded downright honest when he spoke about offering his wife a divorce, but she refused. I think the phrase “don’t be stupid” had been used at Mikey in his wife’s rebuttal all those years ago… at least that is how I imagine it. Mikey’s wife has been dead for a few years now. I am not sure how she died, but I know that Mikey told me, on every visit for the first few months after meeting him, that he too wished he was dead so he could see her again. He would tell me how lonely he was, and how much he missed her. How after 70 years with a person it's impossible to experience life with out them. These were the kinds of conversations that had me running home to my own husband and demanding that I die first because I could not stand the thought of being left in my own misery like Mikey. This kind of projection is a hard thing to separate from in my line of work… how could it not be? Seeing someone like Mikey suffering the way he does makes me wonder if I will ever suffer that way too. It’s like the opposite of seeing someone win the lottery… you buy the ticket every week because who knows, that could be you one day!

Mikey’s nephew is his medical and financial power of attorney and he helps Mikey manage his finances, make medical decisions, and maintains communication with Mikey’s care providers. His nephew and I at one time attempted to help Mikey move to a nicer assisted living facility with a nicer environment, more attentive staff, better services, and, where we thought he might be happier. Mikey refused. He didn’t want to mess with the hassle of moving. So he stayed in that same recliner chair day in and day out with his country music and his hasty statements about wishing he was dead.

I’ve continued to see and visit with Mikey for over a year and a half now. Recently, I learned that Mikey had met someone (wink wink). In fact, that someone was another one of my clients! She lived in the same building and had met Mikey in the hallway one day while helping to push him in his wheel chair. As it turns out, Maggie too is a widow… and a caregiver at heart. Maggie is 85 years old, has all her own teeth and is still able to walk (these are serious points of interest between the elderly… believe you me!). Maggie attached to Mikey’s neediness like flies on honey. Before I knew it Maggie was making arrangements to have Mikey moved into her room. I did the responsible social work thing and contacted each Maggie and Mikey’s families to ensure all parties were on board with the couple living together. And, when I spoke to Mikey, although I definitely got the sense that Maggie drove him a little nuts at times, he did state “she keeps me company.”

Today, Maggie is in the hospital after a surgery, and Mikey is desperately awaiting her return. I think he’s been reminded of the loneliness from last month, and the years since his wife’s death, before Maggie came into the picture. I am nearly certain that Mikey is still waiting to die so that he can see his wife again… but at least now he has someone to wait with him.