Dear Secretary Price,
This week I acquired a new pre-existing condition. In a sane world I should just be able to say I have pneumonia, but America is teetering on insanity when it comes to health care and I, like many, am worried about affordable access to health care and it is now your job to reassure me.
Last week I felt ill. High fever and terrible muscle aches. I missed two days of clinic, which you must know is very unusual for a doctor. I suppose it’s a combination of feeling our illnesses are somehow different (in the same way we surgeons think we are naturally sterile, you know?!), thinking we are being a hypochondriac unless body parts are falling off, decades of learning to suck it up, not wanting to leave patients hanging who may have taken time off work for appointments or surgery, and the fear of the work tsunami that awaits us if we miss a few days.
I figured I had an abbreviated version of the flu and so 48 hours post fever I went back. I was okay, but not myself. I trudged through several days and then started feeling really ill again. And then I started coughing like I had consumption.
Just some kind of post influenza airway irritation I told myself. I’m sure you’ve diagnosed yourself many times too and as an orthopedic surgeon I bet your pulmonary acumen is as good as mine! So I lay in bed and coughed and coughed and coughed and just kept thinking I would get better. I didn’t go to the doctor when I should have because of stupidity and ego. I can endure a lot, although I’m not sure that skill will be of much use except perhaps in an apocalypse. I once took two buses (I needed to get a transfer) and walked four blocks with a ruptured spleen because my fear of getting in trouble for rupturing my spleen was greater than the pain of my acute abdomen. That is another story, but it is a good example of how fear can make you suck up a lot. I suspect fear is why many people don’t seek care when they are ill. Fear they will get a dreaded diagnosis or fear of the cost. Fear of the doctor or fear of needles or maybe even fear that immigration authorities may be loitering around medical buildings. There was a time pre-affordable care act when patients would ask me not to enter a diagnosis because they feared pre-existing conditions. Maybe you also heard about that fear?
Finally I went to the doctor. Mostly because I didn’t want my gravestone to say She knew she was sick, but was too stupid and stubborn to go. My doctor was very nice. He heard some crackles (not good). Stood back a little as I almost deposited a lung lobe in his lap and sent me off for a chest x-ray. Verdict, pneumonia. Antibiotics. Inhalers. Stay off work you foolish woman.
And then my nice doctor said, “You should get the pneumonia vaccine when you’re feeling better.”
“Why?” I asked, feeling a little pissy and maybe like he wasn’t so nice after all as I have always associated that vaccine with the, ahem, elderly. True I wasn’t looking my best, but still! I like to think I am a relatively well-preserved 50.
“Well, the biggest right factor for pneumonia is having a history of pneumonia,” he replied.
Whether it is pneumonia or chlamydia or osteoarthritis or high blood pressure in pregnancy or a heart attack or cancer as a doctor you know as well as I do that having something once puts you at much higher risk of having it a second time. It is a great actuarial summary of behavioral, genetic, and environmental risk, which is of course why it is of value to insurers.
So now I guess I have another pre-existing condition. I had a nephrectomy as a result of my splenic rupture (it really is a great story, if we meet one day I’ll tell you), but even though I have never once had kidney problems in the 39 years I have lived with one kidney I am “at risk.” Makes you wonder how pre-exiting conditions might affect living kidney donation?
Will your ACA replacement protect those with pre-existing conditions? Your Empowering Patients First Act of 2015 doesn’t really help to quell my fears. By the way, it’s not just me I’m worried about. My kids both have health issues that hit pretty much every organ system and I worry about my friends, my own patients, and everyone else. Your plan, section 221, says if you have a gap in coverage for 18 months then an insurer can impose pre-existing condition exclusions for up to 18 months and then raise your premiums up to 50% for up to three years. Here’s the section in case you forgot:
People will have gaps in coverage. They may not be empowered enough to navigate the system. They may think the coverage offered through work is too expensive and then when they finally realize what the open market has to offer they are stuck with nothing. They may lose their job and not be able to afford insurance because they have nothing left after they have paid for rent and food. Maybe they studied abroad for two years?
I imagine someone with pneumonia coughing and gasping like I was and not going in to be seen because they knew it wouldn’t be covered and a chest x-ray and doctor’s visit and antibiotics and inhalers, which they desperately need, will be $400 or more. Maybe they are currently uninsured and are terrified of a preexisting condition. You know as well as I do what happens when bacterial pneumonia is left untreated. It’s never good, it’s bad, really bad, or deadly. Not a very pro-life game of Russian roulette, is it?
That as a physician you can even entertain the idea of preexisting conditions really frightens me. I can see how a non physician who has never been ill and has a heart two sizes too small doesn’t understand, but as a doctor you know that the point of pre-existing conditions is to prevent expensive, sick people from getting health care. I’m also curious how that fits with your pro “life” agenda?
So Dr. Price you are now secretary of Health and Human Services and tasked with dismantling the ACA. It is your job to tell me if I have to worry about having another pre-existing condition or if I can just focus on getting better from my pneumonia?
I eagerly await your reply.
Sincerely,
Jennifer Gunter MD, FRCS(C), FACOG, DABPM, ABPMR (pain)
Dr. Jen Gunter 
I’m very sad for our country. It feels like any progress we’ve made to help those in need is disappearing. A friend of mine died from pneumonia at the age of 21 because she put off going to a doctor since she couldn’t afford it and didn’t have insurance from her retail job. She would be 35 today. The ACA gave me some hope that a tragedy like hers wouldn’t happen again but now our government leaders are taking us right back to those days. I cry when I think about it.
Sorry to hear this 😦
Hopefully the system doesn’t get too much worse in the short-term, and better in the medium-term.
Your detractor seems to be hung up on the right wing myth of the “freeloader”. We can’t have anyone pulling less than their equal share of the weight! Find me a fainting couch ’cause I got the vapors…
I don’t demand that everyone pull an equal share. Some certainly can’t. I’m saying those that can should pull a fair share if they expect the benefits. And I’m not a right winger, I don’t think I’ve voted for a Republican this century and few before that.
I believe people should be expected to see to their own wellbeing to the extent they are capable of doing so, but that society should help out those who can’t–can’t, not won’t. I have no sympathy for those who want Starbucks rather than health insurance.
Find me a reliable litmus test that can tell me who “can’t” and who “won’t”. I’m not holding my breath. I reckon that you also believe that people who have substance use disorders are guilty of willful misconduct. That paradigm went away with the Dodo bird.
For a good starting point, look at income. What % of (income – poverty line) would the insurance have cost? If that’s too high it’s deemed unavoidable and they aren’t penalized.
This covers the case of the unemployed. (I fully admit the Republicans are wrong about this situation–they have this stupid notion that everyone can get a job if they’ll just take what’s out there. Never mind that the guy who has worked a desk for 20 years has basically zero chance of getting an unskilled job.)
The student who studied abroad was probably covered by some system there–that should count as coverage.
It’s not hard to tell the can’t from the won’t. (Although this will class some working under the table or the like as can’t rather than won’t. So long as it’s only false negatives this isn’t a big issue.)
Excellent Writing. You laid it out, and if you get a reply, it will probably be from some lacky sending a form letter. This post deserves to be more widely circulated. Other than Kevin MD, do you have some other ideas? Grassroots action by patients could turn this around.
I’m the medical director of a community health center in Lawrence, Kansas. I’m sharing Jen’s post with leadership and clinicians at my clinic. We do a fair amount of advocacy at the state house in Topeka so this should get everyone fired up
He’s too much of a coward to reply to you. I’m ashamed that he is a fellow physician.
Usually I agree with you but you partially missed the target here.
*They may think the coverage offered through work is too expensive and then when they finally realize what the open market has to offer they are stuck with nothing.*
That’s exactly who this is aimed at–the person who expects the benefits but doesn’t pay in.
So a policy that punishes people for making misjudgments in long term thinking? Since most people fail at that one way or the other, it’s basically punishing people for being human.
It’s punishing freeloaders. If you don’t deter freeloaders you get buried in them.
I have paid the mandate fines 3 years straight for not having coverage!
The company I worked for had an awful insurance plan. The Representative of the Insurance company, who spoke at an company meeting for my company, said the coverage offered has been affected by Obamacare, in a negative way. She explained what they offered before, and it was an excellent plan until Obamacare crashed and burned it.
Now, we have people in our society who work for a living, hoping for good coverage, getting shafted, because certain other people think that being human is done by screwing over other people, just to help another group of people… who are small in numbers.
There are more people who are, and are still, getting hurt by the ACA, just for the few who receive it off the dime (taxes/fines) of the people, who are the group that is really being hurt by it’s policies.
Until the repeal comes, each year I will be fined to the max now… until I find a better policy that fits my needs and budget.
Repeal Obamacare NOW!
You name of “Model for restoring health” makes me suspect you’re not what you claim. However, on the off chance you are:
You were being lied to. Obamacare did not crash excellent plans. Obamacare crashed plans that were excellent for the small stuff but useless for the big stuff. I don’t think people realized how many such garbage plans were out there, masquerading as good coverage.
Insurance guys are often not honest with the workers. Many years ago the insurance guy tried to exclude my wife by means of various things from the insurance plan at her work. In the end it turned out that she hadn’t been informed of the insurance meeting and wasn’t in the office when it was held. The agent didn’t realize the problem and was trying to cover up his mistake. When my wife finally tracked down his superior all it took was one phone call, she was back on the insurance.
But in this case, it’s not they expect the benefits per se, it’s that they wanted to do their due diligence as a consumer and pick the best plan. I don’t know about your work, but mine has a two-week open enrollment period only, and it doesn’t overlap with the marketplace open enrollment. Once you’ve missed the enrollment period, unless you have a “qualifying event”, you can’t get insurance for a year.
Seems a high penalty to pay to me, plus it kills people, so there’s that too.
Work plans are almost always a better deal than exchange plans. There are legitimate cases for non-coverage but there are too many that go without figuring nothing bad is going to happen.
Are you listening, so-called Doctor Tom Price? I try to explain this to people in other countries who don’t quite comprehend the awfulness of having a pre-existing condition before Obamacare came in, but I think from now on I’ll just point them to this entry on your blog. You’ve laid it all out there in a way I never could.
p.s. I hope you get better really soon. I’ve been hospitalized with bad pneumonia and wouldn’t wish it on anyone.
Hard to believe that in the world’s largest economy people cannot get healthcare. I thought Obama had gone some way to solving that problem but it seems Trump is going to destroy any hopes you might have had. Presumably the poorest in your communities will be the worst affected by Trump’s questionable decisions relating to health. Goodness knows how your education sector is going to survive Trump and the woman who is now in charge of education. Is this how he is going to make America great again – by destroying it from the roots upwards!? I Wouldn’t hold out any great hope for Trump doing anything to solve your problems unless you are rich of course in which case you won’t have too many problems. Indeed, Trump seems to be a master of making already bad problems much, much worse. I really do think he is delusional. And, your words remind me of the inscription of Spike Milligan’s gravestone (Spike was a British comedian). The inscription reads – “I told you I was ill.” Good luck America. I think you are going to need it.
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