Evan Ashkin is a doctor of family medicine at the UNC Medical School. He serves patients at the Prospect Hill Community Health Center in Caswell County. A majority are Spanish speaking and poor. Almost half are farmers (black, white and Latino). A quarter are on Medicaid, 30 percent receive Medicare, 40 percent are uninsured.
Dr. Ashkin notes his patients don’t fit the proffered stereotype – lazy freeloaders looking for a handout.
“That viewpoint is possible only if you’ve never worked with anyone in this patient population,” he says. They are farm hands, waitresses, gardeners, motel workers, dishwashers, day laborers, retail employees, housekeepers, and, ironically, home health care workers. They perform tough jobs, for long hours.
“Poor folks pay a terrible cost for not having health care coverage,” Ashkin explains. When you can’t get care, your health suffers, you frequently become poorer, you’re more likely to become unemployed, your family and kids are more apt to suffer. And, of course, there’s more harm to North Carolina. “Right now, we pay a huge toll for not expanding Medicaid,” he says.
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Ashkin oversees a special clinical track for young doctors who choose UNC explicitly to learn to work in distressed communities.
“The students come here wanting to serve, we take them to clinics to learn this kind of work, to make the excruciating decisions (poverty) doctors have to make.” They know what they’re getting into, he says. They’re brave souls.
Ashkin describes the choices restricting Medicaid triggers. A man comes in with chest pains, but he’s uninsured. “Do we give him the stress test we would order if he could pay?” The clinic often can’t afford to subsidize costly procedures. So maybe the patient gets the test, maybe not. What if the doctor guesses wrong, and he has a heart attack?
“We say we couldn’t stand to have a two-tier health system or to have rationing,” Ashkin notes. “But this is rationing by ‘wallet biopsy’ – the worst basis to allocate care.”
Ashkin speaks of one of patients who is undocumented, having lived here seven years after fleeing violent abuse in Mexico. She was in significant distress early in a pregnancy – bleeding, needing an ultrasound, presenting the serious possibility of ectopic pregnancy. Because of constraints on public funding for her care, even if Medicaid is expanded, the clinic was hard pressed to provide the needed ultrasound. And, if it did, the decision might work, under existing regulations, to economically foreclose scans late in the pregnancy essential to protect both mom and baby. The child, of course, will be a citizen, as is his sibling – suggesting how artificial noncitizen funding restrictions can be.
“So I have to help her through this wrenching choice no mother should ever face,” Ashkin says. “We need to avoid an early sonogram, but if we guess wrong, it might prove disastrous,” he notes. “I can’t imagine my own sister having to make such a call.” But we force these dilemmas on impoverished patients every day.
And because of arbitrary restrictions, Ashkin reports, lots of his patients roll in and out of Medicaid. They get re-hired, get a little money, so they lose coverage. Or they’re laid off, so their status changes. But a patient who has asthma needs an inhaler, insurance or not. When he goes off Medicaid, he can no longer afford it. Or the same might be true of blood tests, or insulin treatments, or heart pills, or blood pressure medicines. Then, as he gets sicker, Ashkin notes, he loses his job and goes back on Medicaid. As a result, he again gets the inhaler or the insulin or the hypertension medicine, but permanent damage has been done in the meantime.
“I see these cases every week,” Ashkin says. They represent an immensely destructive way to practice medicine. Patients receive worse outcomes and later trigger much higher emergency room costs because they move on and off of Medicaid coverage. With expansion that wouldn’t happen.
Another of Ashkin’s uninsured patients, in his late 40s, has multiple sclerosis. He can’t qualify for Medicaid because he makes a little too much money. But he doesn’t earn nearly enough to afford his MS medications – which combat the disease effectively, but are pricey. So he’s been forced to go off his meds for over a year, while trying to get accepted by a charitable care program. If he gets accepted, he’ll have suffered “real and irreversible injury in the interim.”
“I believe health care is a human right,” Ashkin concludes. “I also believe, on a purely economic basis, the argument to extend Medicaid is unassailable. Locally, regionally, statewide. We’re doing ourselves a terrible disservice. Ideology is overcoming rational decision-making. And we’re inflicting hideous costs on the most vulnerable North Carolinians in the process. It is, literally, morally indefensible.”
Gene Nichol is Boyd Tinsley distinguished professor of law at the University of North Carolina.