• Dr. D

Before the Affordable Care Act

Before the Affordable Care Act (ACA) was enacted, I wrote a number of vignettes based on real patients' lives. Once the ACA went into effect, many of the issues that caused so much trouble disappeared. Given that the future of the ACA is now in doubt, I thought I would resurrect those vignettes so that those who miss the pre-ACA days can better remember how things really were. I don't offer an opinion as to what should or should not happen in each case. I merely present the facts.


At 48, Mr. Smith has a wife, three kids, a house and a mortgage. He also has hypertension, diabetes, and tops the scales at 310 pounds. He works for a small company and buys his insurance through his office. The insurance has a deductible of $10,000, a copay for medical visits of $25, and requires prior authorization for nearly all procedures, both in-patient and out.


A night out with the guys


While watching football at a local bar, Mr. Smith has a few beers with friends. However, he begins to feel odd. Minutes before, he’d been screaming at the referee, cheering for his team and generally having a great time. Now, suddenly he is sweating profusely. His head is throbbing. It feels like it will explode. He excuses himself to go to the restroom, thinking he’ll put some cold water on his face and feel better.


No one is sure how long it was before his friends realized he’d been gone for a very long while. He is found on the floor of the men’s room, lodged between the toilet and the


wall, unable to get to his feet. He is conscious, but his speech is incomprehensible and he seems unable to move his arm.


The trip to the hospital is delayed as the EMTs require extra assistance to get him from the narrow restroom where he lies to the gurney, then down the several steps from the bar to the sidewalk. Traffic is heavy, and despite the red light and siren, they are slowed almost to a stop several times.


He is taken to the emergency room where it is decided that an infusion should begin immediately to try to limit the spread of a likely stroke if possible. However, due to his size, they have a great deal of difficulty finding a vein. Finally an anesthesiologist is called to find or make an access point.


They think he suffered a stroke

Much time has elapsed. The treatment team desperately wants to get a CT of his head to confirm the presence and location of a brain hemorrhage. The IV is begun but a CT must wait. He is too large for the usual machine and the open CT machine is currently in use by an accident victim. After nearly three hours, a view of his head confirms the presence of an acute cerebrovascular accident (CVA), a stroke.


As he is transferred to Neurological intensive care (NICU) he has a seizure. At one point he appears to stop breathing but due to his size no one can perform adequate chest compressions and mechanical CPR is required.

Intubating him is made more difficult by his large neck and repeated efforts are necessary before the staff are successful. By then his oxygen has dropped to below 60. The doctors fear further neurological damage from anoxia.


Days of intensive care follow. He develops pneumonia at one point and requires massive amounts of expensive IV antibiotics. The bill for his care passed $100,000 weeks ago.


Eventually he is able to begin physical therapy, though he appears already to have developed significant contractures from the weeks of inactivity. It is doubtful that he will ever be fully ambulatory.


The red letter day comes when it is decided that he should be transferred to a long term rehabilitation facility where work will continue to help him relearn to feed himself, transfer from wheelchair to bed and toilet himself with assistance. While he is there the family receives the first of a number of letters informing them that because of his pre-existing conditions, high blood pressure and diabetes, both of which were excluded on his policy, none of the bills will be covered.


Image of men with drinks by: Nejron

Image of bathroom by: Baloncici

Image of head CT by: stockdevil