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Dead Man Walking

“Shocked” wouldn't be accurate, since we were accustomed to our uninsured patients'

receiving inadequate medical care. “Saddened” wasn't right, either, only pecking at the

edge of our response. And “disheartened” just smacked of victimhood. After hearing this

story, we were neither shocked nor saddened nor disheartened. We were simply appalled.

We met Tommy Davis in our hospital's clinic for indigent persons in March 2013 (the

name and date have been changed to protect the patient's privacy). He and his wife had

been chronically uninsured despite working full-time jobs and were now facing

disastrous consequences.

The week before this appointment, Mr. Davis had come to our emergency department

with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had

cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with

a diagnosis of metastatic colon cancer.

The year before, he'd had similar symptoms and visited a primary care physician, who

had taken a cursory history, told Mr. Davis he'd need insurance to be adequately

evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and

ineligible for Kentucky Medicaid, however, he'd simply used enemas until he was unable

to defecate. By the time of his emergency department evaluation, he had a fully

obstructed colon and widespread disease and chose to forgo treatment.

Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an

evaluation. As his wife sobbed next to him in our examination room, he recounted his

months of weight loss, the unbearable pain of his bowel movements, and his gnawing

suspicion that he had cancer. “If we'd found it sooner,” he contended, “it would have

made a difference. But now I'm just a dead man walking.”

For many of our patients, poverty alone limits access to care. We recently saw a man with

AIDS and a full-body rash who couldn't afford bus fare to a dermatology appointment.

We sometimes pay for our patients' medications because they are unable to cover even a

$4 copayment. But a fair number of our patients — the medical “have-nots” — are

denied basic services simply because they lack insurance, and our country's response to

this problem has, at times, seemed toothless.

In our clinic, uninsured patients frequently find necessary care unobtainable. An obese

60-year-old woman with symptoms and signs of congestive heart failure was recently

evaluated in the clinic. She couldn't afford the echocardiogram and evaluation for

ischemic heart disease that most internists would have ordered, so furosemide treatment

was initiated and adjusted to relieve her symptoms. This past spring, our colleagues saw a

woman with a newly discovered lung nodule that was highly suspicious for cancer. She

was referred to a thoracic surgeon, but he insisted that she first have a PET scan — a test

for which she couldn't possibly pay.

However unconscionable we may find the story of Mr. Davis, a U.S. citizen who will die

because he was uninsured, the literature suggests that it's a common tale. A 2009 study

revealed a direct correlation between lack of insurance and increased mortality and

suggested that nearly 45,000 American adults die each year because they have no medical

coverage.1 And although we can't confidently argue that Mr. Davis would have survived

had he been insured, research suggests that possibility; formerly uninsured adults given

access to Oregon Medicaid were more likely than those who remained uninsured to have

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Dead Man Walking “Shocked” wouldn't be accurate, since we were accustomed to our uninsured patients' receiving inadequate medical care. “Saddened” wasn't right, either, only pecking at the edge of our response. And “disheartened” just smacked of victimhood. After hearing this story, we were neither shocked nor saddened nor disheartened. We were simply appalled. We met Tommy Davis in our hospital's clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient's privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences. The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer. The year before, he'd had similar symptoms and visited a primary care physician, who had taken a cursory history, told Mr. Davis he'd need insurance to be adequately evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and ...
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