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Treating the Uninsured

Question: What happens when a potential patient lacks health insurance and won’t be able to pay for treatment?

Atul Gawande: Well, there's lots of things you do from a practical point of view. Your secretary learns how to say questions like, well, maybe you should call the social work department first, before we book this appointment; or hmm, the schedule looks really full. All of those things are honestly practical things doctors do. Second, many of the larger hospitals, like my own, have a free care pool, and will have people apply to it so that they can get their care, but there are delays built into that, and you see that happen. The next thing, though, is that when you're committed to the idea that look, I want to help anybody I can coming in the door, you still have the questions of how to arrange for their care and manage it.

I can't tell you how dramatically my practice changed when the Massachusetts health reform went through. We went from being a state with about 12 percent uninsured -- and that was about the percentage of my patients who could not pay for my treatments, and I would forgo the surgery costs, and the hospital would eat the medical bills, but you'd still have to figure out how are they going to pay for outpatient chemotherapy, certain kinds of radiation treatments, things like that. And it was a nightmare over and over again. And when the reform bill came through -- well, let me put it this way: it's been two years, and I've not had a patient in those circumstances from my state since then. And it's -- you almost don't notice that you used to grapple with these issues all the time.

Question: What ethical dilemmas have you faced as a doctor?

Atul Gawande: I face ethical dilemmas all the time. They're routine. The 19-year-old patient who sticks in my mind because right before the Massachusetts health reform came through, I'd seen her, and she had a metastatic thyroid cancer. Her cancer had really spread widely. We did the surgery, and then it turned out that she needed chemotherapy and radiation, but her insurance coverage ran out. She only had a -- she had a $75,000 cap on her policy, and she didn't want me to tell her parents about her condition, because she knew they would try to find a way to pay for all of this. That is a kind of ethical dilemma. It seemed to me a no-brainer; I called her parents. And sure enough, you know, they got a second mortgage on their house, they found a way to make damn well sure their daughter got the treatment she needed.

But you have everything ranging from someone who doesn't want to leave the hospital; they are in the hospital, and they're better, but you know, they're just -- they -- things are kind of a mess at home, and they'd love a couple extra days in the hospital even though it's $2,000 a day. How do you grapple with that? Do you kick them out? How do you kick them out? Or do you just say, well, you know, this is my patient. What they -- they're the customer; what they say goes. And you can't -- you find moral questions are a daily part of what you do as a physician, and part of what makes it so interesting.

St. Vincent's Hospital, in New York City, loses $1,000,000 a day in caring for the homeless and uninsured. As the doctor and author explains, the question of treating such patients is one of contemporary medicine's most difficult ethical dilemmas.

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