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September 13, 2007

Waiting For The System To Catch Up

The Wall Street Journal has a searing report on a particularly bizarre loophole in Medicaid law: States can, if they so choose, cover only conditions diagnosed at federal cancer-detection centers. That means if the cancer is diagnosed elsewhere, it's not eligible for treatment under Medicaid, even if the individual is. Shirley Loewe, for instance, we diagnosed with a large, deadly tumor in her breast, but diagnosed at the wrong facility. So the coverage she would have qualified for was denied. Instead, she had to fight for charity coverage, which means cutting back her working hours till her income fell below $8,000 -- which meant, in turn, moving from her apartment to a small trailer. The cancer eventually metastasized to her brain, and Loewe moved back in with her daughter who, while trying to seek care from her mother, was told by a social worker, "People die every day waiting for the system to catch up. Why is your mother any different?"

She wasn't, as it turned out. Loewe died earlier this year. She was just another person without insurance, waiting for the system to catch up.

September 13, 2007 in Health Care | Permalink


If that social worker had said that to me at a time like that, they would be one dead social worker. Even the most stable people can fly off the handle and become violent if you say truly foolish things to them and they're under a lot of stress. Some people would do well to check what they say in situations like that.

Posted by: soullite | Sep 13, 2007 5:16:13 PM

You wrote that coverage was denied, was care denied?

You wrote: "which means cutting back her working hours till her income fell below $8,000"

Sad and unproductive but many people live in worse places than small trailers. Did her lack of coverage contribute to the cancer eventually metastasizing to her brain?

You wrote: "Loewe moved back in with her daughter who" this is sad but happens to people all the time for many reasons.

"Loewe died earlier this year"

If she had been well covered in the USA what are the odds that she would have lived? If she was living in England, France or Italy what are the odds that she would have lived?

If she had made it through it would have been a happy ending even if she had to live with her daughter in a small trailer, right?

It is a sad story but what useful information can be gained from this story. Back when my family of 4 had far less money than we have now, we where living on about 20K/year, my wife had breast cancer and we had a very cheap healthcare policy with a $5,000 deductible and 25% co pay up to $5,000. We paid $10,000 out of pocket for her care that year but she lived so it was a great deal for us. If it was $200,000 the hospital would have given us terms. Was Loewe offered terms?

BTW that social worker should be fired, I am sure that she could have done more.

Posted by: VeryAnon | Sep 13, 2007 5:49:06 PM

So bottomline Medicaid basically killed her because of a stupid rule and to save polician's budgets. I thought government run healthcare was without fail and only the private sector was in charge of denial of care.

Posted by: Dingo | Sep 13, 2007 6:27:51 PM

I thought government run healthcare was without fail and only the private sector was in charge of denial of care

Well, in the case of single payer, it wouldn't have been an issue at all, because the hospital would have simply billed the single-payer for the care.

When you're and older doctor, embittered at having to run what amounts to an accounts-receiveable business for 20 years instead of actually treating patients like you wanted to, you'll understand.

Posted by: Tyro | Sep 13, 2007 11:20:24 PM

This part bugged me:

"Mrs. Ferguson, who is personally opposed to universal health care because she thinks it would lower the quality of care, was discouraged. "I remember thinking: 'How can they let her die just because she doesn't have health insurance in this state?' " she says."

And she thinks the quality of care is good now..how?

Posted by: WisDem | Sep 13, 2007 11:48:06 PM


There has long been a solution to a lot of these problems with financing, but physicians have been fighting forever against it: abandon fee for service medicine in favor of capitation, or even better, salary.

Of course, getting a salary means working for a larger organization, and this is exactly what physicians have been fighting. It hasn't helped the quality of care at all, nor has it helped the people who have to pay for it. But it sure has helped the physicians and other players who get to keep charging rates twice as high the average in the developed world.

Posted by: jd | Sep 14, 2007 12:14:52 AM


I think Dingo's point is that even a single-payer can make a stupid rule that could kill someone. For instance, Medicare (Medicare for All, is a favorite single payer model) would not pay for an autologous stem cell transplant for my dad's multiple myeloma, because at the time he was considered too old, they wouldn't pay for them for people over 65. Unfortunately, when Medicare changed their rule a couple of years later, he was too sick to benefit from it.

Posted by: umbrelladoc | Sep 14, 2007 2:21:15 AM

VeryAnon wrote: If she was living in England, France or Italy what are the odds that she would have lived?

Actually, this is a really simple question to answer. If she was living in England, she would have received treatment for her cancer, regardless of her ability to pay or where her cancer was originally diagnosed. (Even if it was diagnosed in a clinic outside the country.) The five-year survival rate (the normal cancer survival metric) for women with breast cancer in England is over 80%. I would assume that the situation is similar in France and Italy.
Loewe would not, of course, have been forced to drive herself into poverty and homelessness, nor to beg for charity coverage. In Britain we do not leave our fellow citizens behind to die.

Posted by: ajay | Sep 14, 2007 5:44:05 AM

Let this be a cautionary tale

Everyone should shout it from the housetops tell your friends and enemies alike:

Young people should get an individual health insurance policy NOW! Even if you are poor there are high deductible policies that are relatively cheap.

Women get regular mammograms even if you have to pay for them yourself! Your life could depend on it. Better to live on $200 and spend $100 a week on health care than to die.

Some people make it sound like healthcare is unaffordable but what is really unaffordable is not having healthcare.

Posted by: VoxCaution | Sep 14, 2007 9:14:02 AM

Of course, getting a salary means working for a larger organization, and this is exactly what physicians have been fighting.


At a conference I attended earlier this week, healthcare expert, David Brailer, was the luncheon keynoter on the first day. During the Q&A, in response to a question, he commented that most new doctors graduating from medical school today want three things – (1) a decent income, (2) reasonable hours, and (3) health IT. In other words, he said, they want to work for a large healthcare corporation rather than be an entrepreneur in a solo or a small group practice. I was surprised by his comments. Perhaps this part of the healthcare world is starting to change for the better.

Posted by: BC | Sep 14, 2007 9:19:03 AM

This is a good example as well why leaving it to the states might be a very bad idea. The unfortunate reality is is when you have any sort of division of services and responsibility, it's going to happen..consider it a form of moral hazard if you will...that you will have each side saying that it's the others side's responsibility.

Posted by: Karmakin | Sep 14, 2007 9:19:44 AM

One point, if you read the story, the Doctors and the Hospitals say that they did not and do not deny care as described. So it is a case of she said he said only the social work organization admitted anything.

It seems to have been a case of mistake after mistake. Mistakes will always happen and will sometimes cost lives.

If some paperwork had gotten lost in England and delayed a woman’s breast cancer treatment the privatize people would be quoting the story.

Antidotal it adds little to understanding.

Are a random sample of American women more likely to die from breast cancer than a random sample of British women. Even if the American woman are less likely to die what cost per year of life added.

Posted by: Floccina | Sep 14, 2007 10:35:19 AM

ajay has it just right. This is not about whether government health coverage or private health coverage is better, cheaper, or make you live longer. It's about making, as one of our nation's values, treating fellow human beings with dignity. For this woman, that surely would not have happened. In any other modern country, it would have, even if it was her lot to die anyway.

The golden rule applies here: treat others the way you would want to be treated. Would VeryAnon or Dingo like to "take one for the herd," so to speak, and die in this undignified manner so that we could have their ideal (such as it might be) of a healthcare system?

Posted by: Rick | Sep 14, 2007 10:38:29 AM

What is fascinating here is that the cost of treating the patient probably didn't change significantly. But the cost to the US economy of having a productive worker stop working to retain access to care was significant.

Posted by: paul | Sep 14, 2007 10:51:10 AM

What really sad is Medicaid deserted her basically because the diagnosis wasn't made "in network". There isn't a private insurance company in the country that could get away with that, but Medicaid can.
As far as putting physicians on salary, that won't change things for the better it will make it much worse, but we will spend a hell of a lot less on healthcare. If you increase the number of patients to be seen by a UHC plan and salary Docs, you take away all incentive to work hard and be efficient. You are going to have an access problem of unfathomable proportions with a bunch of clock punchers as doctors that only care about chalking up another day towards their pension and getting done at 5o'clock on the nose.
If I was paid on salary, I'd show up 30 minutes late, see one patient, take a 30 minute coffee break, see one patient, go to the bathroom, see one patient, BS in the hall maybe see one more. I would then take a 2 hour lunch break, see one, BS in the hall some more, see one, coffee break, see one. Now its 5 o'clock I'm going home and guess what if you aren't paying, I'm not taking call either.
I'd go from seeing 60 patients a day to around 7 and we would spend a lot less money, but it would take 2 years to get an appointment with me because it takes 4 months now.

Posted by: Dinog | Sep 14, 2007 6:51:38 PM

I deal with the Texas public sector health care system on a daily basis and have for nearly 30 years.

Medicaid is not a single plan nationwide. It is a group of options from which administering entities, chiefly states, can choose. No two states are alike.

Texas, not surprisingly, picks fewer options than most states. Texas does not provide Medicaid coverage for adults unless they meet federal disability standards (eg. SSI), are pregnant, or are the caretaker of a minor (eg. TANF.) The TANF income limits are extremely low, slightly more than 200 per month for a parent with two children.

In Texas, the indigent health care provider of last resort is the county. There is also the concept of a hospital district, which is a taxing entity established by the Texas Legislature to serve an area's medically indigent population. The larger counties have hospital districts with significant staffing that administer medical coverage as a local entitlement. These plans are similar to Medicaid and often have income limits in excess of Medicaid. Hospital district (typically county) residence is a critical component of eligibility since the local tax base supports the institution.

All Texas counties must provide a financial entitlement for assisting their medically indigent residents. The state provides a base plan with extremely low income limits that something like 200 of the 254 counties in Texas implement. Here is a link to the guidleines for CIHCP:


CIHCP was evidently part of Ms. Loewe's coverage. It should be noted that her county has chosen a significantly higher income threshold than the state has required.

It has been my experience that the administrators of local plans in Texas are competent and professional. But a significant part of their job is to make sure that the rules are followed. The rules are complex and arbitrary because our politicians like them that way. Do not blame the messenger. My vote for the ugliest rule is the two year wait for Medicare after being deemed disabled. That cost a good friend of mine his chemo as he slid off SSI into the two year wait.

And Dingo/Dinog: you are a pitiful loser. Medicaid and the Texas hospital districts will typically cover pre-existing conditions. Name me one private insurer who would have provided coverage for Ms. Loewe's cancer retroactively? Ms. Loewe got caught in a Republican selected loophole to save money at the expense of Texas citizens in need.

And I completely believe your admission that you would rip off your employer.

Posted by: Nat | Sep 14, 2007 9:55:33 PM

Name a single plan that would deny someone coverage because the diagnosis wasn't made at the correct facility first. Denying a pre-existing condition is understandable it was someone else's responsibility prior, but to deny coverage because the diagnosis was made in the wrong place is altogether a different thing.
You are completely out of touch to believe that physicians will work just as hard as they do now if you take away all incentives to do so. What exactly is the "employer" going to do fire me, big deal I'll retire and make the list that much longer for the next guy which only worsens the problem. It is simple human nature people work harder when they have something at stake and something to gain, rather than punching a time clock. As repulsive as it may seem to you, you want me and need me and fellow physicians to be on board with any reform measures. One third of physicians are over 55 and will just retire or cut way back if any new system is not to their liking.

Posted by: Dingo | Sep 14, 2007 11:34:37 PM

"Actually, this is a really simple question to answer. If she was living in England, she would have received treatment for her cancer, regardless of her ability to pay or where her cancer was originally diagnosed."

You sure ajay? I was under the impression that if you stepped out of the NHS (for diagnosis for example) then you had to either contimue down the private road or go back to the beginning and start again in the NHS.

Happy to be corrected, of course.

Posted by: Tim Worstall | Sep 15, 2007 7:21:54 AM

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