Pre-existing

I've been doing this medicine thing for a long time. I got my degree waaaaaay back in the 1900's (1997, that is) and finished my residency in 2000. I've worked in family practice clinics, hospitals, ER's, urgent cares, and specialist clinics. I've taken all manner of health insurance, including Medicare and Medicaid, as well as cash pay. Now I happen to be in a direct primary care practice, where we file no insurance. That's not really the point, but I want people to understand that this isn't a field I'm unfamiliar with.

In watching the healthcare debate for the last several months, in evaluating the Trumpcare plan (which should really be called Ryancare or Wealthcare, but that's not the point), I keep coming back to something I was taught during my earliest years in this career.

One day, as a student in a rural family medicine clinic, I was evaluating a 7 year old boy brought in by his parents because of a cough he had off and on for about 6 months. Whenever he would run at school or when he was really working hard with his dad doing chores on their farm, he would have to stop and cough. He didn't wheeze, he would just cough. It got worse when it was cold out, when he was in a dusty environment, or when he exercised.

On presenting the boy's history and exam to my preceptor, like you do when you're a 3rd year medical student, I said that his differential diagnosis included allergies, infection or, most likely, asthma. My preceptor agreed with me that the boy likely had mild or at the very least exercise induced asthma (this was before the current categorizations for asthma like mild, moderate, severe and intermittent vs. persistent were developed).

As I was dictating his note for the chart, my preceptor stopped me as I got to the "assessment" aspect of the note. He said to me, "Hey, when you do that note, don't say that he has asthma. Say that he has reactive airway disease."

So, I did as I was told. We gave him his inhalers and instructions for limiting his cough and shortness of breath with exercise and away he went.

I went back to my preceptor at the end of that office day and asked why he did not want me to put the boy's diagnosis in his chart. The answer has been with me ever since:

"Because if you diagnose him with asthma, even if he grows out of it and never has another problem with it for the rest of his life, he won't be able to get insurance because of a pre-existing condition."

I was stunned. That boy had asthma. He should have had an asthma action plan at school. He should have been wearing a medic-alert bracelet. He should have had a rescue inhaler available to him (which we did give him). Sure, his symptoms were mild, he only really coughed when he exercised, but he had limited his activities at school and play because of it. But we didn't give him that diagnosis because it could potentially hurt him in the long run by denying him access to health insurance or care.

Fast forward now nearly 20 years. A 30 year old man comes to my office wearing a drug store brace on his wrist. He has his previous records from his orthopedist from 2010, where he had a fracture and dislocation of his wrist that required surgery. Because of that injury to his dominant hand (he worked in cabinetry), he was unable to work for about 6 months. Because it didn't happen on the job, it wasn't covered by Workman's Compensation, and because NC is a right to work state, he was fired. When he was fired, he lost his medical insurance. Because he couldn't afford the rehab, he was unable to finish his rehab for his wrist after surgery, and stopped going to physical therapy. He wore his $20 wrist brace and kind of just limped along, doing whatever work he could and trying to get by. He got a job in 2014 with a company that offered healthcare benefits. Because he had insurance now for the first time in 4 years, he asked for a referral to an orthopedist to get his wrist looked at (it continued to give him pain nearly constantly). We referred him, and the orthopedist recommended surgery to remove some hardware that had become loose.

When he was scheduling his surgery, the patient discovered that his insurance company was not going to cover his wrist, because it was a pre-existing condition. When he returned to my office about 3 months after the initial referral, he was telling me how disappointed he was that not only could he not get his surgery, but now he had over $500 in outstanding bills for orthopedist visits that his insurance was refusing to pay. At that point, I reminded him that in 2014, the ACA rules regarding pre-existing conditions took effect and that he should call his insurance company.

About a week later, he called the office to thank me. He had called Blue Cross and after asking for supervisor after supervisor, finally spoke with someone who had "some sort of authority." He asked if the plan was ACA compliant, and when he was told that it was, he reminded them about the law regarding pre-existing conditions. Within seconds, he said, the BCBS representative he was talking to on the phone said that yes, of course it was covered and, oh, I see you don't have the correct insurance card, let me send you another one, and yes, I'll make sure that the outstanding bill you have with the orthopedist gets paid. Within a month, he had his surgery.

I share these 2 patient stories because they are a tale of two eras in my career. I spent the first 14 years of my medical career being very cautious about which diagnosis codes I listed for patients to get their care, so that they would not lose their access to care in the future. I would carefully word my notes so that I wasn't technically lying or committing fraud, but so that patients wouldn't be punished for their health histories. That all changed in 2014 with the ACA. Not only could patients not be denied coverage if they had a gap (a change in jobs, for example), but they could not be charged more for those conditions. The problem with that first patient I told you about is that when someone sees or hears that their kid has "reactive airway disease" instead of asthma, they may not take his symptoms seriously. Nothing relieved me more than knowing that in 2014, I didn't have to be creative with my documentation, implying a diagnosis but not stating it outright.

The bill passed by the House of Representatives this week no longer protects people with those conditions. They claim that it does, but what it really does is allow insurance companies to charge more for those conditions. In some cases, up to $30,000 more per year for a prior cancer diagnosis (imagine if you had a skin cancer removed in your 40's, recovered completely but were now obligated to pay more for your care for the next 25 years).

Not one single doctor's organization supported this bill, but members of Congress held up the doctor patient relationship as the winner in this bill. Patients don't win when they can't afford their care. Doctors don't win when their patients forgo care because of cost or lack of coverage.

Look, I now work in direct primary care, I do not accept insurance. I should secretly be delighted that patients will opt out of insurance that costs too much and I may get a surge in my number of patients. But I'm not delighted. I'm disgusted.

Hey, President Trump, Speaker Ryan! Physicians aren't asking you to gut the coverage for their patients, and they don't support this bill. Stop pretending like you're trying to help us out here. You're not on my side. I'm one of those docs who makes under 6 figures a year, so I don't even get a bonus tax cut here. So, please, stop speaking for physicians, we can speak for ourselves. And more importantly, we can advocate for our patients. Maybe instead of claiming you're doing this for us, you should listen to us instead.