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Monday, October 6, 2014

Ebola -- Or why Medicaid Expansion matters.

Summary:

It seems obvious to me that the Hospital turned away on September 25 2014 Thomas Eric Duncan because of his insurance and because Texas Health Presbyterian Hospital is part of a medical system that refused the Medicaid expansion and doesn't make money from indigent patients. The medicaid expansion matters because it will make a dent in this inequitable and dangerous system. Because that is part of the purpose of medicaid and the medicaid expansion -- to ensure that doctors get paid for treating sick patients, including ones who might be infectious and otherwise make others sick.

Discussion

NBC article titled "Texas Hospital Makes Changes After Patient Turned Away" the Hospital admitted that the Nurse documented his disclosure he'd come from Liberia in the Electronic Medical Record at the Hospital. This puts the lie to the usual official first response of the Hospital that it was "The Nurses Fault" (anyone who knows Doctors, Nurses and Hospitals know that many Doctors always blame Nurses for their inattention, arrogance and mistakes). They admit:

"The nurse who took Thomas Eric Duncan’s medical history did the job correctly, the hospital said. “However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case,” it added."

Thomas E Duncan didn't get treated until his relatives called the CDC and alerted them multiple times. Anyone ask why? Here's what his neighbor said:

"That was the day "I called CDC to get some actions taken, because I was concerned for his life and he wasn't getting the appropriate care," Duncan's nephew, Josephus Weeks, told NBC News on Wednesday night. "I feared other people might also get infected if he wasn't taken care of, and so I called them to ask them why is it a patient that might be suspected of this disease was not getting appropriate care?"

But you have to go outside the major news media to even get the "elephant in the Room" -- Insurance and the fact that Texas is refusing the medicaid expansion and that Hospitals around the country are either turning away patients or closing on account of that:

Charles D. Ellison rightly notes that:

"Did Duncan get initially turned away because he is black and, possibly, uninsured?"

Of course the Supreme Court says racism is dead in the USA and uses that to justify striking down laws intended to stop racist policies. So who wants to talk about this? He continues:

"We may never know for sure and it’s unclear if Duncan had insurance or not (it’s unlikely considering he’s a Liberian national on a U.S. visa)."

It's not hard to find out. A reporter should have asked him, or his relatives. Or the Hospital. But none of them seem to have asked this basic question.

“I was stunned,” Walks told The Root. “You could put [Duncan’s] picture in the dictionary under what you look for when responding to Ebola. How do you miss that guy?”

The Hospital had to notice. But I really don't think they missed this disclosure, what they missed was an even more important set of facts; the hospital wasn't focusing on where he was coming from. The Hospital was focusing on his insurance card and his ability to pay. Anyone who's been to a hospital recently with less than perfect insurance has found that out. In 2010 I went to a hospital after breaking my arm, spent 4 hours in the emergency room, only to be put in a cab to a clinic in Bethesda. Why? They said because they didn't have anyone on the staff who could set a broken arm. That wasn't true, the Hospital didn't have any doctors who would treat my broken arm under my insurance so I rode a cab. I suspect he was sent away because the Hospital didn't want to lose money on Thomas Eric Duncan by treating him under his substandard insurance if he had any. Texas has blocked the medicaid expansion. He likely didn't have insurance and the State wasn't going to reimburse him for the expense, they thought. I'm Sure the Federal Government is paying for his care now, but that is probably what really happened. Is anyone verifying this? I doubt it. Will it get investigated? Will the gross negligence of the hospital be punished? Will the Gross Negligence of Governors like Rick Perry who won't take the Medicaid expansion get punished? I doubt it. They'll prosecute Thomas instead. Ellison notes:

"That’s where factors such as Duncan’s race and level of insurance could have influenced the hospital’s first decision in either subtle or not-so-subtle ways. “There is a lot of research showing that different people get turned away in different places,” argues Walks. “So, if they turned him away at first because he’s an African with no insurance that would not be inconsistent with what we’ve seen over the years.”

Ellison also notes, quoting Walks:

"Walks draws on lessons from a similar event in October 2001 when the D.C. area was struck by multiple anthrax attacks which hit postal facilities particularly hard. When two black Brentwood facility postal workers – Thomas Morris, Jr. and Joseph Curseen - dropped by Maryland hospitals complaining of anthrax-triggered symptoms, the same time news of the attack and Brentwood as a focus of investigation was plastered on every cable channel, they were sent home and died soon after."

Our Hospital system has never been kind to minorities, but it has a duty to treat all people who show at the emergency room and it has an even more important duty to protect public health.

For further reading I suggest you read Ellison's report. He covers it pretty thoroughly in his article in the Root:

http://www.theroot.com/articles/culture/2014/10/where_ebola_meets_concerns_over_race_class_and_the_uninsured.html

References:

NBC Report on Hospital "Texas Hospital Makes Changes After Patient Turned Away":
http://www.nbcnews.com/storyline/ebola-virus-outbreak/texas-hospital-makes-changes-after-ebola-patient-turned-away-n217296
Same Report from Dallas, with more detail: http://www.dallasnews.com/news/metro/20141004-dallas-hospital-under-fire-as-accounts-of-ebola-patients-initial-release-change.ece
Report on his Brother:
http://www.nbcnews.com/storyline/ebola-virus-outbreak/ebola-patient-thomas-eric-duncans-nephew-i-had-call-cdc-n216326
We know he lied on his entry papers. But he didn't lie the first time he showed up at the hospital
http://www.nytimes.com/2014/10/03/world/africa/dallas-ebola-patient-thomas-duncan-airport-screening.html?_r=0
Fact is our hospitals need to employ a virtuous and uniform (just) standard of care, and they don't.

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