Because I didn’t hear about it, not once. My overwhelmingly religious, hysterical, republican coworkers were respectful of the sanctity of our shared workplace and the feelings of the haggard liberals in their midst, and refrained from mentioning it.
No, you’re right. They went batshit crazy.
I tried to head off my inclusion in any conversations that mentioned “obamacare” by stating that I am a communist and that I want to take everybody’s shit and redistribute it. I want a single-payer healthcare system. I considered draping myself in flashing christmas lights and running around with no pants, to emphasize the I AM CRAZY I AM NOT ONE OF YOU message, but in the end, every the insane are not spared. I got to listen to the “he’s going to kill us all and let black people on medicaid move into our houses” spiel for months on end.
It all came to a head on election day. I was working, and trying to avoid thinking about the zombie apocalypse. Because, you know, we were this close. We’re still pretty close. But I digress.
My righteously angry white colleagues were certain of victory. They had the election playing on every available screen. My black colleagues had voted at the earliest possible moment, and were very, very quiet about it. Initially, it looked good for Mittens. There were cheers. Then the tide turned.
Those of us who voted against the zombies started smiling.
My facebook (now full of work people and nursing school people) exploded with racist, hysterical, “our children will be paying for this for ever” nonsense. This included all my relatives on my father’s side of the family. I got into a heated argument with a couple of people over a comment that included the phrase “muslim kenyan.” Then everyone settled down a bit, and started harping on all the ways in which working in the ED makes you an embittered libertarian bootstraps-pusher. And you know, I can kind of feel them on that one.
They’re still wrong, but the anecdotal evidence is overwhelming. Every single person could trot out 115 stories about medicaid patients who were demonstrably trashy, wearing a new manicure and talking on an expensive phone but refusing to pay the $3 copay, entitled, and obnoxious. People who won’t take their kids to the pediatrician but will bring them to the ED in the middle of the night because, eh, it’s free. And you’d better not make them wait in the lobby for their sniffles while you take care of sick people, either.
Daily, we see a parade of these types:
1. Chicks wanting pregnancy tests. That you can buy for $1 at the dollar store. But if you have medicaid, they’re free.
2. People who misunderstand the meaning of the word “free,” and apply it to all things for which they do not have to personally pay.
3. Fat, diabetic smokers who are noncompliant with their medications.
4. People with asthmatic children who smoke IN THE HOUSE.
5. Drug addicts with bullshit pain complaints, who wind up getting dozens of CT scans a year in addition to their ED narcotics fix.
6. Etc. Etc.
Essentially, the ED is overrun with idiots making stupid decision with their lives. And because Valdosta is largely poor, a huge percentage of those served by my hospital are on medicaid or medicare. Certainly, people with private insurance also make stupid decisions. But here, anecdotally, they’re int the minority. I was before I started this job, and I remain, vehemently against all the “lazy stupid medicaid patients” talk in medicine. But now that I’ve worked in the environment and had the “why didn’t you go to your primary doctor for this stupid complaint, oh, okay, yeah I guess making an appointment is an inconvenience” conversation a few thousand times, I’m a little more sympathetic. It’s hard to think about tax dollars being spent on this shit. It’s hard to scrape together the money for my own ED bill ($400 after my crappy insurance pays out, for 5 stitches), and watch others come and go without paying a dime. I wish I’d manned up and taped my cut finger back together, gotten by dad to prescribe me some antibiotics, and saved my $400. That was an $1100 bill before insurance, btw. FFSAKES.
I still want a single-payer healthcare system. But we can’t do it with this model. A lot of things have to change. First and most importantly, expectations have to change in a big way. If your medications are provided to you by the state, and you won’t take them, there should be a 5 strikes policy. 1st strike, we treat you, we restock your medicines, we educate you, we warn you. 2nd-4th strike, same deal. 5th strike, you get moved into a “low interventions, DNR” category. Basic stabilization measures only, comfort care. We will not code you, you are not eligible for an ICU bed. If we can stabilize you and get you compliant with your treatment for 6 months, you can move back into the “full code” category.
If you have certain kinds of terminal illness (not cancer, as that technology is rapidly improving, but multi-systems organ failure, end-stage Alzheimers, etc.) you are automatically a DNR. This is not only to conserve resources, but because coding you is medically futile.
ICU patients should all have their cases reviewed by a team of case managers, intensivists, and social workers. Family member should participate in these meetings, but they should not have the final say. So much of ICU care is about holding onto a dying person because the family “wants everything done.” Billions of dollars are spent every year on such pointless treatments. Palliative care should be considered a regular part of medicine.
Going to primary care for yearly bloodwork and checkup should not be optional. For anybody
Medical malpractice awards should be capped at 100,000. All care for the injured person, including physical therapy and disability support for the family, should be %100 covered by the state, regardless of the family’s “resources.” (The parents of my baby on the vent are currently fighting to keep her medicaid because they have been told by the government that they have too many “resources” in order to qualify for assistance. By which they mean, the family has a second car and a middle-class income. Neither of which enable them to pay the millions of dollars in hospital bills and extended care that their daughter will need throughout her lifetime.)
The problem with medical malpractice as it stands now is that it warps medical care with the premise that there is no acceptable level of risk. Some people are going to have bad outcomes, some clinicians are going to make mistakes. What is needed in these cases is structural review, loss of license for egregious offenders, and payment to the individual/family of pain and suffering compensation, not more than 100K. If doctors are worried about protecting themselves from liability, they will order stupid amounts of testing on everybody.
NO you cannot come to the ED for a pregnancy test, are you fucking kidding?
But! What if the ED was just one part of a large medical complex, centrally located? You walk into a giant building, register, and sit down to be triaged. If you don’t want to wait and you know you want primary care, or to see a specialist, call ahead and make an appointment, then go straight through. Everybody else gets seen by a triage nurse and re-directed to the appropriate place. The ED is reserved for very, very sick people. The mid-acuity people go somewhere else. The people who should have made an appointment for primary care go there instead. All medical records are accessible online, nationally. Every piece of medical information about you exists forever, and can be pulled up at a moment’s notice by any medical professional.
I might like some fingerprint identification, too, for the drug-seekers who like to sign in with fake names.
The whole building is full of doctors and other medical professionals, and it runs 24-7-365. Medical school is paid for by the state, and care areas are incentivized based on community need. If enough people don’t go into primary care one year, the next year people who commit to working in primary care are given a tax break. If the next year the community is short on cardiologists and OBGyns, those specialties get the incentive. Really difficult specialties are better paid in general.
I’m going to keep working on this. What do ya’ll think?