Last month’s somewhat surprising Supreme Court ruling to essentially
uphold the Affordable Care Act has left us wondering what to expect
next. While the emphasis of the ruling rested on whether the ‘individual
mandate‘ could be ruled a legal tax – something both sides of Congress
disagreed with for different reasons – the overlooked aspect of the
ruling is its impact on healthcare for the poor.
Steve Lopez, a columnist for the L.A. Times, recently reported a classic
tale of medical care sticker shock. A man brought his daughter to an
emergency department, wanting to check to see if she had appendicitis.
She didn’t. The bill for answering that question was almost $5,000.
She was rail thin and her deeply wrinkled face reflected the years she
had spent sucking on her “cancer sticks”, as she called her cigarettes. I
had seen Dorothy many times before in the ED. She had trained so many
residents on the nuisances of end stage COPD. The 60/60 rule for
intubation, PO2 below 60 or PCO2 above 60 just didn’t apply to her any
One of the primary expectations from the passage of the Affordable Care
Act was that fewer people would go to the nation’s emergency departments
rather than their primary physicians, thereby reducing the overall cost
of health care.
After sitting for hours reading the transcript of the Supreme Court oral
arguments on the constitutionality of the Affordable Care Act, I had
worked up quite an appetite. “It’s about time you came to eat,” my wife
said as I came into the dining room. “What have you been doing?” she
said without hiding her annoyance. “You know we have the grandkids for
“Of course, health care is a right,” my young friend said with a
disdainful twist of her face and a shudder that seemed to shake off the
unthinkable. “You are a doctor,” she added, reminding me of what I had
done for thirty years. “ Surely you agree that health care is a basic
Have you ever gotten a chance to see how one of your ‘one in a million’
cases turned out? You know, the gunshot to the chest that got opened in
the ED and actually lived? In emergency medicine, unless you work in an
academic center doing research, most of our cases are lost to any long
term follow up. But that doesn’t keep us from wondering just how things
I don’t often get calls from thoracic surgeons asking for my help. But
this was a unique circumstance. His son, a first year student at the
U.S. Naval Academy (a plebe as we call them) was going through his first
baptism by fire. He was concerned that his son was hitting a breaking
point, so he reached out for my help.
It’s a simple question. Given a specific set of facts concerning the
presentation of a patient in the ED, what would the reasonably prudent
physician do? Or stated more specifically, was an emergency physician’s
actions in response to a given set of facts reasonable? This is the
“standard of care” against which the physician’s actions will be judged
in a case of alleged negligence.
As I arrived to work I saw that the parking lot and the waiting room were packed. This is not supposed to happen at this place. “I’m getting too old for this,” I mumbled to myself as I dropped
my 2am lunch in the frig and grabbed a handful of charts. I’d raced
through an hour of charts before it dawned on me that they were filling
the rack as fast as I could empty it.