Hey, you people who don't want to pay for other people's stuff...read...

A physician’s response to Jimmy Kimmel’s monologue
JONATHAN KOHLER, MD | POLICY | MAY 13, 2017

Jimmy Kimmel recently delivered a 13-minute monologue that transfixed the nation.  He told the story of how his newborn son, Billy, was diagnosed with a potentially fatal cardiac anomaly, tetralogy of Fallot, and had undergone emergency surgery. He painted the picture of a sick child and a terrified family, who have the benefit of excellent care that ends well. He complimented the nurses and physicians who had cared for Billy, and encouraged donations to the hospital.

Most importantly, Mr. Kimmel put a face on the importance of health insurance and the inhumanity of not providing it to those who need it most: those with pre-existing conditions.  He suggested that without good insurance, Billy would have been abandoned by the health care system. It was a moving story, that was immediately viral on the internet.  It was also not completely accurate. And the way that it’s wrong tells us a lot about what’s wrong with the health care debate today.

There’s a strange anomaly about the American view of health care. We are nice people who don’t like to pay for other people’s stuff.  We don’t want to pay for everyone to have health care, but we won’t abide the consequences of people not having access to care. That means that the reality of Billy Kimmel’s care — or any baby born with a surgical emergency, or for that matter anyone who presents to an emergency room — is that health care providers will take care of them. It’s what we do. But it keeps the implications of not having health care hidden.


What if people who didn’t have health insurance and couldn’t afford care simply didn’t get it? What if emergency rooms demanded proof of insurance or a credit card at the door? What if hospitals didn’t provide millions of dollars in charity care? What if people without health care actually died on the sidewalks outside hospitals, in plain view of the people who don’t agree with making health insurance available to all?  My bet: We’d have universal health care immediately.

Instead, we have a safety net. Hospitals do provide emergency care, and charity care. There are free clinics and GoFundMe campaigns. Uninsured people who are sick spend down their savings, lose their homes, and declare bankruptcy. Then, impoverished and unemployable, they qualify for Medicaid and get some measure of care.  They do this out of sight. We can tell ourselves that our fellow citizens are getting care.  But it is care that comes at an extraordinary cost — lost productivity, lost hospital revenue, and ultimately lives lost in quieter, subtler ways.

Because the reality is that not having health insurance doesn’t mean that the Billys of the world die on the street. Instead, they die of poverty. They take health care system down with them, because physicians and the hospitals they work for are committed to — and mandated to — care for people regardless of ability to pay. This preserves the illusion that health care is a luxury; that, as George W. Bush famously said, people can always just go to the emergency room. But it doesn’t keep people healthy and productive. Driving people into bankruptcy and ER visits for chronic conditions costs more to our society than any health insurance plan.

How do we fix it? We cannot let people die in the streets, in full view of the voters, martyrs to the fundamental inequity of our society. But we can tell the stories of the people hurt by the health care system as it exists now and as it seems destined to change under the new administration. We need to tell the stories of 1,000 Billys. Not the ones with famous, millionaire parents, but the ones we see in our clinics every day whose parents face the choice of keeping a low paying job or losing it to qualify for government assistance, or whose mortgages are three months late in the face of crippling bills. Without names and faces, affordable health insurance is just another entitlement, given — and taken away — by a government whose own access to insurance is never in doubt.

Jonathan Kohler is a pediatric surgeon.

Jonathan Emerson Kohler
Yesterday at 5:47pm

To my doctor friends:

As a physician, I often forget how much I know. But there are things that remind me just how different our own experience as doctors is from those who don’t spend their days and nights taking care of the ill.

I do a lot of work for television, helping writers and directors to create medically plausible stories and scenes. I used to get worried that I might get the dose of a rare medication wrong, or use the wrong instrument when staging a complex operation I don’t normally do myself. Then writers would come to me and ask, “how many lungs do people have?” or “what’s the name of the leg bone?”

Recently, I married a business litigation lawyer. When I come home and describe a standard, boring day at the office, she gets a look of startled amazement and says, “you did WHAT to a baby?”

It all seems pretty normal, though. Of course we spend our days seeing people at their most vulnerable -- their clothes off, their scars exposed. Of course I take children from their parents arms, put them under general anesthetic, and open them up. Of course I sometimes have to tell those parents their child didn’t survive, despite our best efforts to save them from any number of traumas. Or that the cancer has spread. Or that their newborn baby will require a lifetime of care. This is what we do. It’s our normal. But to those who do not do it, it’s not just extraordinary, it’s unfathomable.

Now is the time for us to make people fathom, though. Because the Senate is about to pass a bill that will take $800 billion out of Medicaid, which pays for the medical care of almost 50% of children. Which pays for prenatal care, childbirth, cancer care, surgery, home nursing, total parenteral nutrition (TPN) – all the things our patients need to survive, and even thrive, with debilitating medical conditions. 22 million patients will lose their insurance, according to the CBO. To us, those patients have names. We’ve looked into their eyes, their family’s eyes. We’ve cared for them, and know them.

To most people, the people we know as our patients are numbers on a page – vague abstractions impossible to really conceive. What is 800 billion? What is 22 million? What’s an essential benefit? People don’t know what that means. How can they? But they can understand Joey with cerebral palsy, Susie with neuroblastoma, Jorge who got run over by a tractor. These are the real people to whom loss of Medicaid means loss of houses and jobs, desperate GoFundMe drives, bankruptcies and ultimately, in many cases, early death [http://www.kevinmd.com/…/physicians-response-jimmy-kimmels-…].

We need to explain that without Medicaid funding, small, rural hospitals will close.

That large academic safety net hospitals will strain to provide care that people need while not receiving the money necessary to provide that care. Some conservative politicians, like Senator Ron Johnson (R-WI), think this is a good thing – that making people pay for their own healthcare will drive down healthcare costs. He points to the example of laser surgery for eyes, which got cheaper when it stopped being covered by insurance [https://www.nytimes.com/…/opi…/senate-health-care-bill.html…]. But there’s a critical difference, that we as physicians understand and he does not, between elective surgery to stop wearing glasses, and care for a childhood cancer – care that, even if steeply discounted, would bankrupt all but the wealthiest and most assiduous savers.

We know what that looks like. We know that it’s wrong. We owe it to our patients to treat them not just in the clinic, the wards, and the operating room, but by advocating for them to politicians who, if they knew what we know, could never do what they’re doing.