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.
Jennifer Gunter MD, FRCS(C), FACOG, DABPM, ABPMR (pain)