Swollen, throbbing, and pale purple, Beatrice’s left leg looked less like a limb and more like an oversized, striated eggplant.* But her breathing—or lack thereof—is what caught my attention first.
Beatrice was suffering from deep vein thrombosis, a condition that occurs when blood flowing through veins in the calf and thigh unexpectedly clots and obstructs the flow of blood to the rest of the body. Left untreated, the clot can dislodge and travel to blood vessels in the lungs—known as a pulmonary embolism. There’s a risk of sudden death.
The doctors dissolved the clots and stabilized her. Beatrice was clinically safe for now. The anxiety spreading over her face told me a different story.
Beatrice had been feeling throbbing pains in her leg for the past week. Afraid of the cost of urgent care, she hoped the pain would pass with time. Beatrice and her two children were constantly moving apartments every few months, and her Medicaid renewal paperwork had accidentally been sent to an old address, leaving her without coverage. Without insurance, she had been forced to choose between her rent and her leg. For the sake of her family, she had chosen her rent. Now she feared she no longer had a choice.
A college volunteer at a Phoenix hospital, I stood on the sidelines watching in shock. I hoped to explore the practice of medicine, the doctor-patient relationships, and the miracles of treatment. Instead I discovered patients more frightened by dollars than disease. It was 2012.
In 2011, following the worst financial crisis since the Great Depression, then–Arizona Gov. Janet Brewer cut the state’s Medicaid funding and froze enrollment. Arizona blocked new enrollment in Medicaid and only allowed existing enrollees to continue receiving benefits if their income remained below the federal poverty line and they turned in their annual renewal paperwork on time. A family that received a raise that lifted their income even slightly above the poverty line lost Medicaid coverage permanently, even if their income dropped below the line again the following year.
Between 2011 and 2013, 150,000 adults on Medicaid in Arizona, nearly two-thirds of the childless adults in the program, lost coverage. Over those months I spent at the hospital, many of the patients presented their own horror stories after losing Medicaid.
A farmworker had his right foot amputated, lost to gangrene because he had been putting bandages on ulcers on the bottom of his feet to avoid paying for clinic visits. A truck driver with Type I diabetes was driving across the border to Mexico every other week to buy insulin, a life-or-death drug, because he could no longer afford the price in the U.S. The last patient I saw in the hospital was a landscaper who showed up with his hand shattered from a construction accident and wrapped in duct tape. He hoped his simple fix meant he wouldn’t need, or have to pay, for a cast.
The Senate’s health care bill freezes Medicaid enrollment, preventing new poor families from signing up. We’ll know more after it receives a score from the Congressional Budget Office next week, but it is also likely to cut Medicaid funding by hundreds of billions of dollars. Like Arizona’s 2011 freeze, if a patient goes off Medicaid, she’s barred from re-enrolling in later years, regardless of her financial or medical status. In particular, the federal cap on Medicaid spending will place more financial pressure on the states to rein in costs. The end result is that, like Arizona, more states will be forced to restrict Medicaid eligibility, cap enrollment, and cut health benefits. The Congressional Budget Office estimated that 14 million Americans would lose Medicaid coverage over the next 10 years under the House GOP bill. Now that we’ve seen it, the Senate version of the bill doesn’t offer a much different result.
Congress can—and should—learn from Arizona’s mistake. The U.S. health care system faces significant challenges. Rising premiums, high deductibles, and fewer insurers to choose from each year have been both difficult and frustrating for Americans to manage. But Arizona knows, better than any other state or the federal government, the catastrophic effects of taking health care coverage away from people entirely.
Arizona expanded Medicaid coverage in 2013 following the implementation of the Affordable Care Act. Commenting on Arizona’s decision to expand Medicaid, Brewer said “It saved lives, it insured more people, it brought money into the state, it kept rural hospitals from being closed down. And today there are tens of thousands of people that are very, very grateful.”
I don’t know what happened to Beatrice, but as Congress votes on a radical restructuring of Medicaid, I can’t help but remember her and the many others I met in that Phoenix hospital whose lives might now hang in the balance of a single vote.
Whether we choose to provide care via public insurance, market forces, or a combination of both is irrelevant if we forget the true purpose of health care coverage. What I care about most as an aspiring surgeon is that my patients have the peace of mind that, regardless of their incomes, locations, or medical conditions, they won’t have to decide between their health or their homes. If the Senate passes this bill, more Americans are likely to have to face that impossible choice.
*For privacy, I’ve changed Beatrice’s name and personal details. (Return.)