PERSPECTIVE DEAD MAN WALKING However unconscionable we deliberate over whether to imple- Seventy percent of our clinic may find the story of Mr. Davis, ment health insurance exchanges patients have no health insurance, a U.S. citizen who will die because and expand Medicaid eligibility, and they are all frighteningly vul he was uninsured, the literature how can we as physicians ensure nerable; their care is erratic, they suggests that it's a common tale. that the needs of patients like Mr. are disqualified from receiving a 2009 study revealed a direct Davis are met certain preventive and screening correlation between lack of in First, we can honor our funda- measures, and their lack of re- surance and increased mortality mental professional duty to help. sources prevents them from par and suggested that nearly 45, 000 Some have argued that the onus ticipating in the medical system American adults die each year for providing access to health care And this is not a community-or because they have no medical rests on society at large rather state-specific problem. arecent coverage. 1 And although we cant than on individual physicians, study showed that underinsured confidently argue that Mr. Davis yet the Hippocratic Oath compels patients have higher mortality would have survived had he been us to treat the sick according to rates after myocardial infarction, 4 insured, research suggests that our ability and judgment and to and it is well documented that possibility; formerly uninsured keep them from harm and injus- our country's uninsured present adults given access to Oregon tice. Even as we continue to hope with later-stage cancers and more Medicaid were more likely than for and work toward a future in poorly controlled chronic diseases those who remained uninsured which all Americans have health than do patients with insurance.5 to have a usual place of care and insurance, we believe it's our indi- We find it terribly and tragically outpatient medical visits, and to to treat people in need onsibility inhumane that Mr Davis and tens a personal physician, to attend vidual professional resp of thousands of other citizens of receive recommended preventive Second, we can familiarize our- this wealthy country will die this care.2 Had Mr. Davis been in- selves with legislative details and year for lack of insurance. sured, he might well have been educate our patients ab e forms provided by the authors offered timely and appropriate posed health care reforms. with the full text of this article screening for colorectal cancer, our appointment with Mr. and his abdominal pain and ob- he worried aloud that under the stipation would surely have been AcA, "the government would tax sity of Louis ville school of Medicine, Louis. him for not having insurance. Elected officials bear a great He was unaware(as many of our deal of blame for the appalling vul- poor and uninsured patients may This article was published on October 23 nerability of the 22% of American be) that under that law's final rule 2013, at NEJM.org adults who currently lack insur- he and his family would meet the 1. wilper AP, Woolhandler S, Lasser KE, Mc (ACA)-the only legitimate legis- and hence have access to compre- Am]Public Health 2009 99:2289.95 lative attempt to provide near-uni- hensive and affordable care 2. Finkelstein A, Taubman S, Wright B, et al versal health coverage remains Finally, we can pressure our The Or health insurance experiment under attack from some members professional organizations to de- evidence from the first year.QJEcon 2012: of Congress, and our own two sen- mand health care for all. The 3. Huddle ts. Centor RM. retainer ators argue that enhancing mar- American College of Physicians, cine: an ethically legitimate form of ketplace competition and enacting the American Medical Association, that can improve primary care. Ann tort reform will provide security and the Society of General Internal ed2011:155:633- In discussing (and grieving ciple of universal health care cov- mortality after an D), Lau B Young JH enough for our nation,'s poo Medicine have endorsed the prin-In over)what has happened to Mr. erage yet have generally remained in Maryland. J Gen Intern Med 2012:27 1368 Davis and our many clinic patients silent during years of political 5. Institute of Medicine. America's unin- whose health suffers for lack of debate. Lack of insurance can be sur insurance, we have considered our lethal, and we believe our profes- National Academies Press, February 23 gations.Assomeconsionalcommunityshouldtreat2009(http://www.iom.edu/reports/2009/ gresspeople attempt to defund inaccessible coverage as a public Americas Uninsured Crisis.Consequences bamacare, and as some states' health catastrophe and stand be- for-Health-and-Health-Care. aspx) Do:10.1056/NEMp1312793 governors and attorneys general hind people who are at risk. Copyright @2013 Massachusetts Medical Society. N ENGL J MED 369: 20 NEJMO VEMBER 14, 2013 1881n engl j med 369;20 nejm.org november 14, 2013 PERSPECTIVE 1881 However unconscionable we may find the story of Mr. Davis, a U.S. citizen who will die because he was uninsured, the literature suggests that it’s a common tale. A 2009 study revealed a direct correlation between lack of in￾surance and increased mortality and suggested that nearly 45,000 American adults die each year because they have no medical coverage.1 And although we can’t confidently argue that Mr. Davis would have survived had he been insured, research suggests that possibility; formerly uninsured adults given access to Oregon Medicaid were more likely than those who remained uninsured to have a usual place of care and a personal physician, to attend outpatient medical visits, and to receive recommended preventive care.2 Had Mr. Davis been in￾sured, he might well have been offered timely and appropriate screening for colorectal cancer, and his abdominal pain and ob￾stipation would surely have been urgently evaluated. Elected officials bear a great deal of blame for the appalling vul￾nerability of the 22% of American adults who currently lack insur￾ance. The Affordable Care Act (ACA) — the only legitimate legis￾lative attempt to provide near-uni￾versal health coverage — remains under attack from some members of Congress, and our own two sen￾ators argue that enhancing mar￾ketplace competition and enacting tort reform will provide security enough for our nation’s poor. In discussing (and grieving over) what has happened to Mr. Davis and our many clinic patients whose health suffers for lack of insurance, we have considered our own obligations. As some con￾gresspeople attempt to defund Obamacare, and as some states’ governors and attorneys general deliberate over whether to imple￾ment health insurance exchanges and expand Medicaid eligibility, how can we as physicians ensure that the needs of patients like Mr. Davis are met? First, we can honor our funda￾mental professional duty to help. Some have argued that the onus for providing access to health care rests on society at large rather than on individual physicians,3 yet the Hippocratic Oath compels us to treat the sick according to our ability and judgment and to keep them from harm and injus￾tice. Even as we continue to hope for and work toward a future in which all Americans have health insurance, we believe it’s our indi￾vidual professional responsibility to treat people in need. Second, we can familiarize our￾selves with legislative details and educate our patients about pro￾posed health care reforms. During our appointment with Mr. Davis, he worried aloud that under the ACA, “the government would tax him for not having insurance.” He was unaware (as many of our poor and uninsured patients may be) that under that law’s final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to compre￾hensive and affordable care. Finally, we can pressure our professional organizations to de￾mand health care for all. The American College of Physicians, the American Medical Association, and the Society of General Internal Medicine have endorsed the prin￾ciple of universal health care cov￾erage yet have generally remained silent during years of political debate. Lack of insurance can be lethal, and we believe our profes￾sional community should treat inaccessible coverage as a public health catastrophe and stand be￾hind people who are at risk. Seventy percent of our clinic patients have no health insurance, and they are all frighteningly vul￾nerable; their care is erratic, they are disqualified from receiving certain preventive and screening measures, and their lack of re￾sources prevents them from par￾ticipating in the medical system. And this is not a community- or state-specific problem. A recent study showed that underinsured patients have higher mortality rates after myocardial infarction,4 and it is well documented that our country’s uninsured present with later-stage cancers and more poorly controlled chronic diseases than do patients with insurance.5 We find it terribly and tragically inhumane that Mr. Davis and tens of thousands of other citizens of this wealthy country will die this year for lack of insurance. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the Department of Medicine, Univer￾sity of Louisville School of Medicine, Louis￾ville, KY. This article was published on October 23, 2013, at NEJM.org. 1. Wilper AP, Woolhandler S, Lasser KE, Mc￾Cormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. Am J Public Health 2009;99:2289-95. 2. Finkelstein A, Taubman S, Wright B, et al. The Oregon health insurance experiment: evidence from the first year. Q J Econ 2012; 127:1057-106. 3. Huddle TS, Centor RM. Retainer medi￾cine: an ethically legitimate form of practice that can improve primary care. Ann Intern Med 2011;155:633-5. 4. Ng DK, Brotman DJ, Lau B, Young JH. Insurance status, not race, is associated with mortality after an acute cardiovascular event in Maryland. J Gen Intern Med 2012;27:1368- 76. 5. Institute of Medicine. America’s unin￾sured crisis: consequences for health and health care. Consensus report. Washington, DC: National Academies Press, February 23, 2009 (http://www.iom.edu/Reports/2009/ Americas-Uninsured-Crisis-Consequences -for-Health-and-Health-Care.aspx). DOI: 10.1056/NEJMp1312793 Copyright © 2013 Massachusetts Medical Society. Dead Man Walking