By Barbara Casper, M.D.
Louisville Courier-Journal, September 20, 2018
I am a physician who has spent my entire 32-year career caring for uninsured and underinsured patients ā 20 of those in Kentucky. I have written editorials in the past supporting the ACA as well as the Medicaid expansion and I feel that I need to respond to an editorial published in this paper written by Jordan Harris.
First of all, Mr. Harris points out in his editorial that 1.4 million of our neighbors are poor enough to qualify for Medicaid. That is simply stunning ā it means that 1.4 million people are living below 127 percent of the poverty level inner state. As someone who cares for many of these patients, I can tell you that the idea that these folks are taking advantage of the system is simply untrue. Are there a few “able-bodied” people who have chosen not to work and therefore qualify for Medicaid? Yes there are. However, the vast majority of our patients work in jobs that do not provide employer-based insurance, have disabilities that have taken them out of the workforce or are caring for aging parents and children. In addition more and more of my patients are caring for their grandchildren as the children’s parents are suffering in the current opioid use crisis.
Secondly we cannot afford to let these folks lose their insurance. The cost of medical care does continue to increase but taking insurance away from patients will not decrease that cost, but will shift it. Patients will continue to get sick. We have to make a decision as a society whether we are OK with patients dying because they cannot afford lifesaving treatment or if we are willing to absorb that cost. It is also much more cost-effective to treat illnesses earlier rather than when the disease has progressed. Let me give you a real-life example.
A 50-year-old man has a screening colonoscopy as recommended for his age. A 1 cm polyp is found in his rectal area and is removed and has no evidence of cancer. Because he had a polyp, he has a repeat colonoscopy every five years for the next 10 years and thankfully has no further polyps. The cost of the initial colonoscopy with biopsy is $2,145 and the subsequent colonoscopies are $1,905 each for a total cost over 10 years of $5,955.
By contrast his brother does not have insurance and cannot afford to pay for a screening colonoscopy. Five years later he develops rectal cancer requiring a resection and a colostomy. He also undergoes chemotherapy and radiation treatment. The cost of the colon resection alone can be up to $38,000. The cost of chemotherapy and radiation treatment will be equally if not more expensive. I am not an accountant but it seems much more cost-effective to allow people to have recommended treatments and preventive care. This does not even take into account the pain and suffering for our patient now with a colostomy.
The only way taking Medicaid away from the patient is cost effective is if we allow them to die. People die from lack of insurance. Unfortunately, I have personally experienced situations where patients delay treatment due to concerns of cost and seek care when there is little we can offer. I hope we will not, as a society, get to the point that this is acceptable.
Which brings me to Mr. Harris’ second point. He posits that conservatives are uncomfortable with a “welfare” state. He cites studies which do not show cost-effectiveness of the expansion of Medicaid. I can provide equally compelling evidence from the literature that shows that since the implementation of the ACA and Medicaid expansion, there have been fewer ED visits, increased primary care visits and improved compliance with medications in Kentucky. My own experience corroborates this. It will take years to prove the benefits of management of chronic medical conditions such as diabetes and hypertension. However, I have witnessed improved BP and diabetes control in my patients who now have access to medications and other resources. As a physician I am confident we are making a difference.
I also believe it is time to have an honest discussion about the role of government in our lives. I find it interesting that conservatives decree government intervening when people need help with health care, housing, etc., but have no issue with telling me who I can love or what I can do with my body. It is true that the cost of health care has skyrocketed but taking insurance away from people will NOT change that cost. Please be clear that very few people could afford to pay for health care with the assistance of insurance, whether employer-based or Medicare or Medicaid. The absolute best solution would be to have a single payer system ā Medicare for all. Until we, as a country, decide we need to provide essential medical care to all citizens, we cannot afford to dismantle the Medicaid expansion.
Dr. Barbara R. Casper is a professor at the University of Louisville School of Medicine.
