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ear Secretary Price,

In the wake of the recent failure to pass the American Health Care Act, I would like to share with you some reflections on the state of American health care from my perspective as a resident physician at Grady Memorial Hospital, Atlanta’s public hospital, where you trained in orthopedic surgery more than thirty years ago.

I first heard about Grady when I was applying to medical school. I read about a 53-year-old woman who arrived at the hospital with a plastic bag containing her cancerous breast, which had fallen off at home. She couldn’t afford health insurance when she needed it most, delaying care until her body literally started to rot.

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That is what we call a Grady story. As Grady physicians, the biggest barrier we face is not diagnosing disease but the lack of resources — our patients’ and our own — to deliver first-line health care. Just last week, my elderly patient Audrey experienced her first seizure, possibly resulting from critical blockages in the carotid arteries supplying blood to her brain. Just one day after coming off the ventilator that had been breathing for her, she checked herself out of the hospital against my medical advice before we could further investigate her arteries. She did this because she was so terrified of the medical bill she was accruing in the intensive care unit.

As a medical student, I worked at Bellevue Hospital in New York, the country’s oldest public hospital. I collected many Bellevue stories. One was about Hector, a man in his 50s who came to Bellevue blue and gasping for air. He had end-stage lung disease, and just weeks to live. Hector had waited until the last minute to seek care, not just because he was uninsured but because he feared losing his apartment and his new dining set. Both could be taken away if he didn’t pay his rent during hospitalization. Hector had waited seven years for subsidized public housing, and this was the first apartment he had lived in that was not filthy or infested with insects. The instability of his life and his health insurance accelerated his death.

When a doctor trains at Grady or Bellevue, his or her first lesson may not be the differential diagnosis of chest pain, or how to treat pneumonia. It is more likely to be that a patient cannot afford a $10 life-saving medication — not $10 a pill, but $10 for a 90-day supply. The irony is bleak: in the world’s richest nation, where we spend 42 percent more on health care per person than Norway, the next-highest spending country, we let preventable maladies turn into costly end-stage illnesses.

We who staff America’s safety-net hospitals see this happen all the time. These hospitals care for some of the 28 million Americans who remain uninsured; the 29 percent who have trouble paying medical bills; and the 27 percent who have postponed getting needed care or report not filling a prescription because of cost. Their stories represent an American moral crisis that leads to the preventable suffering of millions who go undertreated or untreated. America’s public hospitals know this tragedy intimately, as they fight to provide care to any American in need, regardless of insurance status or ability to pay.

When you were a Grady resident, where did you go to unwind after a long day? My co-residents and I meet at a bar and restaurant called Ladybird to decompress, trade war stories, and gear up for our tomorrows. We take pride in being the last and sometimes only line of defense for many sick, vulnerable, low- and middle-income Americans. We strive to live up to the motto “Atlanta can’t live without Grady.”

As only the third physician to lead HHS, you will have the power to shape health care that few of us will ever achieve. The first two, Otis Bowen and Louis Sullivan, expanded Medicare, battled HIV/AIDS, and campaigned against tobacco use. They advocated for expanding access to care for the most vulnerable amongst us. How fitting that a Grady-made doctor now has the opportunity to make policy that can equip every American with a healthier future.

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But, Secretary Price, you seem to have forgotten some of the basic training we get at Grady. Your proposal to replace the Affordable Care Act with the Empowering Patients First Act would have increased premiums almost three-fold for a large majority of Americans, many living below the federal poverty level. Your support of block grants essentially means that states could either cut benefits or cover fewer people as the cost of health care continues to outpace inflation. The now-defunct American Health Care Act was a tax break for the rich and a grim sentence for the poor, who would have paid more for care or, more likely, have gone without it. Millions who gained coverage under the ACA would have lost the dignity of health insurance and affordable access to health care such insurance provides.

Audrey and Hector would have benefitted not from repeal and replace but from expanding and improving the ACA — or from true universal coverage. Here in the South, many states, including Georgia, did not expand Medicaid under the ACA. As a result, many Southerners earn too much for Medicaid but not enough to receive ACA subsidies. Indeed, a staggering 91 percent of adults in this coverage gap reside in the South, the majority of them in working families. Expanding the coverage gap rather than reducing it is immoral and, as a former Grady physician, it should be unacceptable to you.

Tanya arrived at Grady one evening unconscious. Her heart was having trouble pumping blood to her brain. When she was stabilized, she told me that she had delayed getting a pacemaker to help her heart beat properly because she had lost her job and her insurance and had been too ashamed to ask for help. Insurance was essential not only to her health but also to her dignity as a human being. How can I restore not just Tanya’s health but also her dignity? What can I say to my patients who recently got health insurance under the ACA and are finally getting the medical treatment they need if that coverage is lost?

Secretary Price, as a surgeon, you know what it’s like to hold a life in your hands. What will you do with these lives?

I don’t have all the answers but I know that voting, as you have, against the Violence Against Women Act, against tobacco regulation, against funding for malaria and AIDS and tuberculosis, against the Children’s Health Insurance Program, against better mental health coverage, against stem-cell research, against expanding the National Institutes of Health budget, and against coverage for Americans with preexisting conditions will not improve America’s health.

Secretary Price, you lived the same kinds of Grady stories as my colleagues and I do. Remember the Grady patients who have everything to lose and no one else to turn to. Remember the sleepless nights you endured in pursuit of those moments of exhilaration when you cared for fellow human beings in their most vulnerable moments. Please, Dr. Price, take the lessons you learned at Grady and use them to improve the health of all Americans.

Allyson Herbst, MD, is an internal medicine resident at Grady Memorial Hospital and Emory University in Atlanta.

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  • Dr. Herbst: I too trained at The Grady’s and Emory / 1955-1966Thanks for your wise
    Comments… Check Amazon for my Grady book “Promises Kept.” I should be pleased to send you a copy…

  • Possibly the most significant letter Dr. Price will receive as the new Secretary of HHS. Pundits have criticized him for looking out for physicians’ financial welfare over the patients’ needs. So, a letter like this to him may be the trigger to get him to take the oath he took when he became a physician more seriously. Thanks for sharing!

  • Excellent letter. It is long past time when we join the rest of the civilized world and have national, universal health care.

  • +

    My son is Georgia born, American residing in Canada.He is a American tax payer but yet to vote in American election due to involvement of President Carter And Hillary Clinton.

  • I worked at mostly public hospitals my entire nursing career. The people were grateful for the small things we did for them. Today, I look back on those memories, the patients and families I met and the professionals I worked with. They were great times and I would not give them up for a minute. We have to be fair to all….always

  • Cooper, please share with us some examples of where Secretary Price is acting in a humane and compassionate manner in this or another health related issue.

    • I’m not interested in nitpicking decisions and proposals on either side of the aisle. I’m simply disdgusted at the country’s inability to understand the reality that republicans and democrats are both going to have to compromise if there is any hope of breaking this broken system. Name calling and grandstanding (which is all this article represents) are counter productive and turn a blind eye from the true issues.

    • Cooper can’t cite even one instance of humane and compassionate behavior on Price’s part. Besides, coming up with actual examples would be “nitpicking.”

      The Republicans are the ones refusing to compromise, Cooper. That’s why they can’t even agree with each other enough to pass a healthcare bill now that they have their chance to “repeal and replace.”

      The Democrats are willing to work with the Republicans to improve the ACA. Throwing it out entirely just because the Republicans hate Obama and don’t want him to get credit for any major accomplishment is a non-starter.

  • Well, wait a minute. Orthopedic surgery is an honorable profession that brings comfort and hope to many people. They work long hours. They are compensated well (see below).

    But most of their procedures do not involve life and death issues (see top 25 procedures below). Nor are they concerned primarily with individual life long or population health outcomes. Except for critical spinal or oncology issues, most orthopedic surgeries involve “patch them up and send them back home or to work”. Their professional perspective provides little special insight into how to lower costs and raise outcomes in the American health care system.

    Secretary Price, in particular, has shown little interest in a better functioning American health care system. He has long advocated a pre-Medicare, pre-Medicaid, pre-Children’s Health Insurance Program (CHIP) world where the upper middle class and the wealthy get world-class care and everyone else gets charity. He is not the right person to be leading this effort.

    Tweak the ACA to make it work. Most of the solutions are already in the law.
    ———————
    Info available from many sources, including Wikipedia:
    According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are as follows:

    Knee arthroscopy and meniscectomy
    Shoulder arthroscopy and decompression
    Carpal tunnel release
    Knee arthroscopy and chondroplasty
    Removal of support implant
    Knee arthroscopy and anterior cruciate ligament reconstruction
    Knee replacement
    Repair of femoral neck fracture
    Repair of trochanteric fracture
    Debridement of skin/muscle/bone/fracture
    Knee arthroscopy repair of both menisci
    Hip replacement
    Shoulder arthroscopy/distal clavicle excision
    Repair of rotator cuff tendon
    Repair fracture of radius (bone)/ulna
    Laminectomy
    Repair of ankle fracture (bimalleolar type)
    Shoulder arthroscopy and debridement
    Lumbar spinal fusion
    Repair fracture of the distal part of radius
    Low back intervertebral disc surgery
    Incise finger tendon sheath
    Repair of ankle fracture (fibula)
    Repair of femoral shaft fracture
    Repair of trochanteric fracture

    A typical schedule for a practicing orthopedic surgeon involves 50–55 hours of work per week divided among clinic, surgery, various administrative duties and possibly teaching and/or research if in an academic setting.”
    https://www.forbes.com/sites/jacquelynsmith/2012/07/20/the-best-and-worst-paying-jobs-for-doctors-2/#5dfe8a4a2a3a

  • The judgements set forth in this article that paint Dr. Price and anyone who agrees with him – and particularly tying those judgments to some unilateral personification of Grady Memorial – falls very short of grace. What is the purpose here in describing a physician as “immoral” and utilizing the stories of unfortunate patients to sway opinion without presenting any semblance of an alternative? I work at Grady as well and I can assure all readers that this article does not represent the entire story.

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