A few years ago, I had dinner with an old friend, who brought his sister, an ED nurse.  In the conversation, she complained bitterly about people who didn’t have money who sought care in the ED.  They were dirty, smelly, unkempt, “frequent fliers” who misused the system.

My wife asked, “Should they just leave and die?”

The nurse replied, “Yes.”

I am not making this up.

I have been quiet regarding the future of the country.  In large part, I was worn out mentally from the sense I had had for months that the outcome would not be good.  I have long learned when people tell me everything is going to be OK, without solid facts to back up their assertions, it may not be.  I had said for a long time that the Democrats had a good chance of losing the election.  I was right.

We are now entering a time of darkness in America. I have been quiet, because I first had to process how this could have happened, then deal with conflicting emotions about what I was going to do or not do as a result.

I will start with the Affordable Care Act.  That is its name. Use it.  Words matter.  It will be repealed, should the Republicans have their way, and in the foreseeable future they will—8 years minimum in the Executive Branch (you don’t think the Democrats can win again in 4 years, do you?), a generation (20 years) or two in the Judicial, and judging by all the Democratic senators up for re-election in 2018, at least 8 years in the Senate, if not permanently—the ACA and other safety nets are on the chopping block.  I’m hoping the American public will eventually see through this unraveling, but I have little confidence in the American public, who could care less about ideas and competence and more about “scandals to go,” and fail to call bullies out on their lies.

The Republicans have had an irrational hatred of the ACA from its inception and now can kill it. If they had a solid plan to replace it (besides prayer, medical savings accounts, GoFundMe and staying healthy), that they were ready to roll out this spring, had the Democrats only been less intransigent, that would be another matter.  But no, the ACA is being repealed without a replacement.  The CBO (Congressional Budget Office) says this would increase deficits $137 billion by 2025 (about $350 billion total in the interval, from looking at their graph) and increase the uninsured 32 million , many of whom being poor rural whites who voted for the president-elect, ironically, because they didn’t seem to understand until now the consequences, because, well, Hillary couldn’t be trusted and what did we have to lose?….)

The incoming president says he will cover everybody with insurance, but Congressional Republicans have no knowledge of his plan.  Repealing something that is working, however imperfectly, without a plan to replace it is a bad idea.  I am reading letters and posts from people who complain that “the rest of us are subsidizing them.”  One who agrees, a good friend, has a pension and is on Medicare.  Those of us who bought his product and live in America pay for his health care, too.  It’s just not as obvious.  It’s like the Interstate Highway or the National Park System.  They are national, and those in the west for the most part enjoy them on the backs of taxpayers in the east, who are remarkably patient with us.  Of course poor people need subsidies to get medical care.  Did you think they suddenly became rich?  In the past, they were excluded by having pre-existing conditions or skipped care altogether, like columnist Nicholas Christoff’s friend, who one day saw blood in his urine, ignored it because of costs, and discovered months later he had Stage IV prostate cancer.  His friend is dead.  Is that what we want in America?  If I am wrong, please tell me, so I will know I no longer belong in this country, for I say it is NOT wrong to try to cover people who have illnesses that the rest of us should be glad we don’t have. The America I served in uniform overseas is about compassion, not a strict fairness/pull yourself up by your bootstraps/I made it by working and so should you/don’t be so damn lazy/it’s my money not yours. Each of us is a microbe, an aneurysm, a bad driver, a malignant cell, or a blood clot away from incurring a massive multimillion dollar hospital bill.  EACH OF US.  Not providing medical care when we could is immoral.  Yes, immoral.  Of course the ACA costs a lot of money.  Twenty million people are accessing medical care who either didn’t access it earlier or weren’t able to pay for it, and it was subsidized by medical personnel like me or hospitals, who couldn’t buy capital equipment or hire more nurses to improve staffing levels.  Some might say that hospitals should do that anyway and pay administrators less.  I agree, but as one who practiced medicine and became a medical administrator, let me assure you that practicing physicians have neither the knowledge, the discipline, nor the time to run a hospital.  Having a system that isn’t paying executives such outrageous sums would be a good start.  But it won’t insure millions of people.

The ACA has become like climate change, a hatred of something that goes beyond facts to an ideology that ignores facts. With climate change, there is a small definable chance the extremely high confidence we have that it is manmade is wrong.  To argue it can’t possibly be occurring means an individual knows all the salient parameters of the Earth and its atmosphere, how they interacted in the past and how they will interact in the future. That is simply not possible.  The ACA is working for many millions of Americans.  It is far from perfect, a fact due to the intransigence of Republicans who never planned to vote for it and who didn’t try to make it better, only tried to kill it, like the stimulus.  All sorts of catastrophes predicted did not come true.  The ACA hasn’t ruined America, but enough loud people have said that long enough that the public believes it without realizing the numbers of uninsured are at their lowest levels in since about mid-1960s,  when we had about 100 million fewer people in this country, medical care was far cheaper, back in the days when you called a doctor’s office for an appointment, the first question asked was about your medical problem, not your insurance.  Don’t remember that?  I sure do.

I remember In 1984, my colleagues and I basically bankrolled the Arizona Health Care Cost Containment System, Arizona’s answer to Medicaid, by not being paid for patients we saw (AHCCCS Non-Certified, which we pronounced Access Non-Cert) because the system didn’t find patients with no insurance until after they came to the ED.  We didn’t like it, but you know what?  We made good money anyway in spite of not being paid for these people. Yeah, I hated being called out at 2 am to see some uninsured drunk guy who wrecked his motorcycle and wasn’t wearing a helmet, because Arizona had repealed that law in 1976.  If the patient were lucky, he might have had enough brain function to cuss me out, threaten to sue me, and not end up in a nursing home vegetative.  It wasn’t fair to me, but life isn’t fair.  I got over it. You don’t let these people die at the side of the road, unlike what folk hero Dr. Ron Paul said, to great applause in 2008 and my friend’s sister said that night at dinner.  We don’t behave that way in my America.

Want to get rid of insurance company markups, high salaries and all sorts of exclusions?  Then expand Medicare, which has such a low overhead and high favorably rating by the elderly that some elderly argued against the ACA by saying, “Keep your government hands off my Medicare,” not even aware the Medicare was government subsidized medical care.  Yes, your taxes would go up, and you would lose money if you were not sick enough in a given year.  In exchange would be peace of mind that a major medical bill wouldn’t bankrupt you.  A physician friend’s husband had a $40,000 ED bill  for a kidney stone. Is it not a good thing to pay for insurance you may not use?  I consider it a good year if my veterinary medical bills are more than my personal ones.  If my house burns down, I have fire insurance. I have peace of mind, a concept apparently not appreciated  by many, because it doesn’t have a dollar sign preceding it.  People with peace of mind about their health tend to be happier. We learned that from the Oregon study where those who received insurance in a lottery didn’t spend time worrying about what would become of them if a child got meningitis, a person passed blood in their urine, they had chest pain, leg swelling, or a breast lump.  I don’t begrudge being taxed to pay for basic health insurance for everybody any more than I don’t begrudge repairing I-35 in Minnesota, for it is part of a national road system, or repairing tornado damage in Alabama. With the latter, however, to be honest, if those people are so anti-government, maybe they should try prayer, passing the hat, or just picking themselves up and doing their own repairs.  I protested paying for a war in Iraq that I felt was unnecessary and illegal, and I resent paying for the 75,000 major hospitalizations annually due to gun violence, when a few decide that we won’t even do background checks.  I resented paying for law enforcement to deal with the occupiers in Malheur, when they broke several laws, bullied people, ruined a small town, and tried to take over lands that belong to me, too.  Life isn’t fair.  Act to change things. I write. That’s my voice.

We have yet to deal with the quality of medical care, which the ACA addressed only slightly.  We haven’t adequately addressed end of life and preventive care, plus a host of other issues that would save money, help people and bring peace of mind simultaneously.  To repeal a major first step, because by God, nobody should get something for nothing in this country, is to condemn many people to bankruptcy, misery, and death.  I thought America was better, but I was conned.  Not by the presidential candidate, but by the gullibility and incredible cowardice of the media and the stupidity of the American public.

It’s time to enter the tunnel.  I will keep my light with me.  I also know which way north is.

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