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| The Texas Sentinel. (Brenham, Tex.), Vol. 4, No. 34, Ed. 1 Wednesday, November 9, 1881 |
Da firs' patiint who calle' me “docta” die' a few winterz ago. I met him at da St. Vincint’z Studint-Run Free Clinic on Galveston Island. I wuz a firs'-year medical studint den, an' da disease n' dude body baffle' me. Dude bel wuz swollen, dude eyez wuz yellow an' dude blood teztz wuz all awry. It hurt wen dude swallowe' an' dude urine stank.
I saw him every Thursday afternoon. I would do a physical exam, holla ta him, an' consult wiff da docta. We ran blood countz an' wrote a prescripshun fo'n antacid—not da bes' medicashun, buh one you can get fo'$4 a month. Dude disease seeme' zeriouz, buh we couldn’t diagnose him at da free clinic cuz da teztz nee'e' ta do so—a CT scan, a biopsy uv da liva, a tes' ta look fo'canca cellz n' da fluid n' dude bel—be beyond our financial reach.
Dude starte' calln' me “Dr. Rachel.” Wen dude pain gots so bad dat dude couldn’t eat, we decide' ta send him ta da emerginsee room. It wuz not 'n easy decisyun.
Dere’z a popular myth dat da uninsure'—n' Texaz, dat’z 25 percint uv uz—can alwayz get medical caa thro emerginsee roomz. Te' Cruz haz argue' dat it be “much cheapa ta provide emerginsee caa den it be ta expand Medicaid,” an' Rick Perry haz claime' dat Texanz prefa da ER system. Da myth be base' on a 1986 federal law calle' da Emerginsee Medical Treatmint an' Laba Act (EMTALA), wich ztatez dat hozpitalz wiff emerginsee roomz be ta accept an' stabilize patiintz who be n' laba o'who be 'n acute medical condishun dat threatinz life o'limb. Dat word “stabilize” be key: Hospital ERz don’t be ta treat you. Day jus' be ta patch you up ta da point whea you’a not active dyn'. Also, hozpitalz charge fo'ER caa, an' usual send patiintz ta collecshunz wen day cannot pay.
My patiint wen ta da ER, buh didn’t get treatmint. Altho dude wuz obviouz sick, it wasn’t 'n emerginsee dat threatine' life o'limb. Dude came back ta St. Vincint’z, whea I wen thro my routine: conversashun, vital zignz, physical exam. We laughe' a lot, even tho we both knew it wuz a bad situashun.
One nite, a homie calle' ta say dat my patiint wuz n' da hospital. Dude’d final gotten so anemic dat dude couldn’t catch dude breath, an' da Universitee uv Texaz Medical Branch (UTMB), whea I am a studint, took him n'. My homie emaile' me da rezultz uv dude CT zcanz: Dere wuz canca n' dude kidney, dude liva an' dude lungz. It mus' be do be spreadn' ova da weekz dat dude’d do be comn' inta St. Vincint’z.
I wen ta visit him dat nite. “Dere’z my docta!” dude calle' out wen dude saw me. I sat next ta him, an' dude explaine' dat dude wuz waitn' ta call dude sista until day hollad him whetha o'not da canca wuz “bad.”
“It mite be one uv dose real treatable kindz uv cancerz,” dude say. I nodde' uncomfortab. We talke' fo'a while, an' wen I left dude say, “Well now you know whea I am, so you can come visit me.”
I neva came back. I wuz too ashame', an' too ear n' my trainn' ta even recognize why I felt dat way. Afta all, I had done everythn' I could—what did I be ta feel ashame' uv?
UTMB sent him ta hospice, an' dude die' at crib a few monthz lata. I read dude obituary n' da Galveston Countee Dai Nuze.
Da shame haz stuck wiff me thro my medical trainn'—not on from my firs' patiint, buh from many moe. I am now a directa uv da free clinic. It’z a voluntea posishun. I love my patiintz, an' I love ben' able ta help many who nee' primary caa: blood passua control, pap zmearz, diabetez managemint. We even do some specialtee caa. Buh da free clinic be also whea some peeps learn dat dere be no hope fo'da chemotherapy o'surgery dat day nee' buh can’t afford. Wen UTMB refuzez ta treat them, it fallz ta uz ta tell them dat day will die uv dizeazez dat be, n' fact, treatable.
St. Vincint’z be da primary caa provida fo'moe den 2,000 patiintz acrozz Southeas' Texaz. Our catchmint area be a strip uv coastal plain strung wiff barria izlandz. Drive inland an' you start ta see live oakz; jet toward da coas' an' da oil refineriez loom up ova neighborhoodz. Da mos' pollutn' refinery n' da nashun be huhhh, n' Texaz Citee. Our patiintz be factory workerz, laborerz, laid-off healthcaa workerz, da peeps behind da counterz uv seafood reztaurantz.
Mos' uv our patiintz come from Galveston an' Brazoria countiez, buh some drive two hourz from Port Arthur o'ova from Orange, near da Texaz-Louisiana borda, ta get ta uz. Dat’z how hard it be ta see a docta n' Southeas' Texaz: Peeps take a day off work ta drive two hourz ta a studint-run clinic dat can on provide basic caa.
Da clinic be overseen by facultee phyzicianz—UTMB docz—who see every patiint along wiff uz ztudintz an' prescribe medicashunz. Deez doctorz be volunteerz. We be not a UTMB clinic, buh we depind on UTMB, wich be twintee blockz from St. Vincint’z, fo'trainn' our studint volunteerz, fo'liabilitee insurance an' fo'runnn' our blood teztz an' otha labz. UTMB haz given uz grantz, includn' one dat helpe' uz get our electronic medical recordz system, an' fundz a nurse-manage' day clinic fo'da uninsure' at St. Vincint’z Crib.
Buh UTMB be no longa da state-subsidize' charitee hospital it use' ta be. Da changez began befoa Hurricane Ike n' 2008. Buh afta da storm, UTMB adminiztratorz drastical cut charitee caa an' move' clinicz ta da mainland, whea dere be moe payn' patiintz. Da old motto “Huhhh fo'da Health uv Texaz” wuz replace' by “Workn' togetha ta work wonderz.” Among dose wonderz be a new surgical towa an' a plan ta capitalize on Galveston’z semi-tropical charm by attractn' wealthy healthcaa touriztz from abroad. Medical caa fo'da poa be not, apparint, among da wonderz. Whereaz UTMB accepte' 77 percint uv charitee referralz n' 2005, it wuz on takn' 9 percint n' 2011.
UTMB azcribez deez changez ta financial strain from Hurricane Ike, da countee’z inabilitee ta negotiate a suitable indigint-caa contract an' lozz uv state fundn'. Da state blamez budget zhortfallz. Da Affordable Caa Act, betta known az Obamacaa, could be do be a bigass relief. Howeva, Gov. Rick Perry rejecte' billyunz uv dollarz n' federal fundn' ta expand Medicaid, fundn' dat should be broute ta accezz ta moe den a millyun Texanz, includn' many St. Vincint’z patiintz.
Perry’z refusal be catastrofic health polisee. Fo'patiintz, it meanz dat seekn' medical caa will still aquia riskn' bankruptsee, an' may lead nowhea. Fo'doctorz, da message wuz not on dat our patiintz’ livez don’t matta, buh also dat medicine—our old professyun, so full uv peeps who ginuine want ta help otherz—will continue ta be part uv da economic machine dat entrinchez povertee. Wen da poa seek our help, day often wind up wiff crippln' debt.
Cuz day can no longa count on UTMB ta accept they patiintz, UTMB doctorz now refa many ta St. Vincint’z. Day’ll treat someone fo'a heart attack (cuz dat’z 'n emerginsee covere' by EMTALA), den refa them ta uz fo'follow-up, even tho we don’t be a cardiologis'. Day’ll stabilize a patiint afta da beotch third stroke, put da beotch on blood thinnerz an' send da beotch ta uz. Day once sent uz, from da ER, a cat wiff a broken arm. Day put da arm n' a splint an' referre' him ta uz. What did day expect uz ta do—orthopedic surgery? Put on a cas'? We don’t even be 'n x-ray machine.
I do not think dat deez referralz be 'n official polisee. Ratha, day be da work uv doctorz an' nurzez tryn' ta do somethn' fo'patiintz who be do be refuse' caa thro da financial screinn' procezz at da hospital. Forma St. Vincint’z leada Dr. Merle Linihan haz describe' da clinic az a “moral safetee valve.” It protectz UTMB from confrontn' da conzequincez uv da state’z refusal ta provide caa.
Among dose conzequincez be da deathz uv da poa. Az Howard Brody, directa uv da Institute fo'da Medical Humanitiez, haz shown, 9,000 Texanz pa year will die needlezz az a result uv our failua ta expand Medicaid. Howeva, cuz dyn' patiintz be often too sick, exhauste' an' wracke' wiff pain ta protes', UTMB an' ztatez like Texaz aren’t force' ta reckon wiff da conzequincez uv they polisee decisyunz.
Cuz da very sick an' da dyn' may not be able ta holla about deez izzuez, health-caa providerz—particular da providerz uv da so-calle' “safetee net”—mus' do so. It be n' our clinicz, n' da bodiez uv our patiintz, whea da conzequincez get playe' out.
Danielle haz schizofrinia, an' da beotch’z young, an' da beotch ztrugglez wiff da medicashunz. Wen we holla, dere be long gapz n' da conversashun whea, I think, da beotch hearz otha voicez. N' one uv deez gapz, I notice da sun slantn' n' whea it’z beginnn' ta set beyond da ship channel. Dere’z gospel music streamn' out ova da basketball court from da zpeakerz mounte' on da side uv da communitee cinta. I am reminde' uv what da directa uv da communitee cinta, 'n Epispo-poal minista, believez: Every patiint be a miracle. Da St. Vincint’z Crib motto be “'n oaziz uv hope, expectn' miraclez.”
Danielle lookz up an' ztarez rite at me. “Huhhh’z what I want ta know,” da beotch zayz. “Why be we so poa?”
St. Vincint’z Crib, wich hoztz da free clinic, be a historical African-American communitee cinta n' da lowes'-income hood on our island, next ta whea da housn' projectz wuz befoa day wuz condemne'. Da federal fedz ordere' Galveston ta rebuild da public housn' afta Hurricane Ike, buh da citee refuse'. We electe' a maya who ran on 'n explicit anti-public housn' platform. Jus' like da medical system, da citee knowz whose livez matta.
Now, dandelyunz grow n' da emptee lotz left afta Ike floode' da hood. Peeps sit on da ragge', crackn' curbz, an' run wheelchairz rite down da middle uv da skreet cuz da zidewalkz tend ta end n' grassy fieldz o'lil precipicez.
Da communitee cinta employz a peep ta stand n' da skreet an' walk uz ta our carz afta clinic if we want. Who be dude protectn' uz from, I wonda. Our patiintz?
N' my second year uv medical school, I took a small-group course wiff a famouz terrifyn' surgeon. Dude hollad uz dude moral motto: “A physician neva takez away hope.”
I neva figure' out how dat motto could guide doctorz thro a system whea our patiintz be dyn' from treatable dizeazez. Part uv my job, it zeemz, be precise dat: ta sit down wiff patiintz an', az gent az possible, take away hope.
Consida Vanessa an' Jimmy. Day met n' New Orleanz wen da beotch wuz 18. Da beotch wuz workn' cleann' motelz, an' dude took da beotch on a tour uv da tugboat dude wuz captain uv. Vanessa zayz day came ta St. Vincint’z cuz da shipyard Jimmy worke' fo'opte' out uv providn' insurance even fo'full-time employeez like him. Day looke' fo'insurance on da open market, buh couldn’t afford it.
Da Affordable Caa Act be suppose' ta help familiez like Vanessa an' Jimmy get insurance. Folkz higha on da income scale should now be able ta afford insurance thankz ta fedz zubzidiez. Da poores' uv da (legal documinte') poa should be covere' by Medicaid. An' fo'dose peeps n' between, da federal fedz offere' ta pay fo'almos' all da coztz uv expandn' Medicaid.
Moe den a millyun Texanz—an' mos' St. Vincint’z patiintz—be somewhea n' between. Day be da workn' poa, o'day be adultz without depindent children, who cannot qualify fo'Medicaid n' Texaz, no matta how poa day be.
Wen Jimmy’z labz showe' a dangerouz high crackah blood cell count, we sent him ta da ER. It wuz pneumonia, an' dere wuz a bigass tuma underneath. Currint guidelinez would recommind screinn' Jimmy fo'dis kind uv canca every year, buh we be neitha da equipmint na da fundz ta offa screinn'. So it gots caute late.
Afta Jimmy wuz diagnose', I helpe' Vanessa fill out da paperwork ta reques' financial assistance fo'canca caa. Da beotch wante' ta know how like UTMB wuz ta offa da beotch baby daddy assistance dude nee'e'.
N' addishun ta on acceptn' 9 percint uv applicantz, da charitee caa approval procezz be a dark art, an' we neva know who will be accepte'. Accordn' ta da UTMB Charitee Caa polisee, da institushun may consida not on a peep’z income an' diagnoziz, buh also such vague qualitiez az “da history uv da problem.” Day also consida whetha da treatmint will offa “educational binefit” ta medical ztudintz an' traineez. Phyzicianz n' trainn' be ta see a certain numba uv each type uv case. If da programz be hittn' quotaz wiff funde' patiintz, patiintz like Jimmy be lezz like ta be accepte'.
Da complexitee an' vaguinezz uv deez policiez meant dat it wuz impossible ta tell Vanessa how like UTMB wuz ta take da beotch baby daddy. We can guezz around a 10 percint chance, buh we neva real know.
Fo'patiintz facn' canca, dis be not a hopeful answa.
Vanessa calle' from a hospital n' Houston n' ear Novemba, distraute, ax'n me ta help da beotch decide whetha o'not ta let da doctorz turn Jimmy’z breathn' machine off. Da beotch wuz afraid da beotch wouldn’t be able ta live wiff herself, no matta wich da beotch chose. I gave da beotch da advice I’d give a homie: dat I truste' da beotch love fo'da beotch baby daddy an' da beotch abilitee ta decide from a place uv love. Jimmy die' late dat nite.
Vanessa’z reques' fo'UTMB fundn' wasn’t approve'. Da beotch haz receive' a $17,000 bill from UTMB fo'da visit wen Jimmy wen thro da ER, an' a $327,000 preliminary bill from da Houston hospital.
If da Affordable Caa Act had do be n' effect las' year, day would be do be able ta afford insurance, get treatmint ear an' avoid bankruptsee. I use ztoriez like theirz—canca ztoriez—wen I am encouragn' my patiintz ta check out da insurance exchangez.
Buh wiff Jimmy gone an' Vanessa unemploye', da beotch now fallz inta da Medicaid coverage gap. I don’t know how da beotch will get caa, if da beotch eva needz moe den St. Vincint’z can give.
My firs' patiint, da one who die' n' hospice, mite be live' if dude canca had do be treate' befoa it had spread from da kidney. Buh without da Medicaid expansyun, da Affordable Caa Act wouldn’t help him: Az 'n adult wiff no depindent children, dude wouldn’t qualify fo'Medicaid now.
N' a betta medical system, dude’d be had a chance at a moe dignifie' experiince uv illnezz. Dude wouldn’t be had ta wait fo'hourz n' a crowde' free clinic, an' assume da postua uv gratefulnezz dat charitee zeemz ta aquia. Dude wouldn’t be had ta be treate' n' part by 'n earnes', buh unskille', firs'-year medical studint. Dude, like so many Texanz, deserve' betta.
Wen one uv our St. Vincint’z patiintz getz a bad diagnoziz, we start sindn' faxez: ta UTMB, ta MD Anderson, ta anywhea dat mite be fundz ta help them. Sometimez it workz out, buh often it doesn’t. Sometimez I think uv it az “sindn' faxez inta da abyzz.” An' zometimez I think uv it az da slow, diligint, technical way dat I be uv insistn' dat deez livez matta.
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