Tuesday, June 11, 2013

How Publicly Funded Insurance Doesn't Help Jane Doe

This post was written over a year ago and deliberately left in a file to "ripen," so that people wouldn't be able to guess the real identity of the Jane Doe I'd visited before writing it. My mother works with people like this, so do I, and so do several of my relatives. This Jane Doe could be any of a few dozen people who are alive and suffering today...

Once again the Kingsport Times-News has given op-ed space to a wail in which two nurses describe how two composite characters will suffer if they don’t have tax-funded insurance. The obvious fallacy here is that, if none of us had medical insurance, medical care would become much cheaper and the composite characters would be better off. What we really need to do, if we care about these hypothetical people, is to become uninsured and look for doctors who appreciate cash payments.

But meanwhile, consider a character in Kingsport, Tennessee. Lower-income residents of Tennessee have had “Tenn-Care” for several years now; it’s fair to say that “Tenn-Care” is a program Obamacare would have been well advised to choose as a model. In fact, since Tennessee residents who moved out of the lower income bracket weren’t forced to carry medical insurance but continued to pay taxes that support Tenn-Care, it’s fair to say that Tenn-Care is a legitimate, democratic—although very inefficient—way to help poor people who become ill. Young low-wage workers sometimes, not always, seem satisfied with the treatment they get from Tenn-Care. But then there are cases like...let’s get creative and call her Jane Doe.

This widowed grandmother lives, theoretically alone, in the small, cheap house where she’s lived for decades. She has several children and grandchildren who live nearby and drop in to visit her during the day.

Although she uses an oxygen device marked with warnings not to smoke near it, her children do. She shares her home with two long-haired cats. Though beautiful, the cats’ coats look rough because, well into the summer after a mild winter, they’re being eaten alive by fleas. The finished rooms in the house are close enough to ground level that Mrs. Doe keeps the front windows covered all day. In mild weather she opens windows for fresh air. In her neighborhood the fresh air still carries a good whiff of Kingsport factory fumes. (Kingsporters say their air smells like money. Residents of surrounding counties say it brings other things to our minds.)

Most of the house has a type of carpeting that was marketed as “Body Shag” in the late 1970s. What do you think about when you think about the combination of cigarettes, cats, children, dim lights, and carpets that have been in the house for thirty-some years? That is what you see when you walk into the front room in this house. You do not only smell it, although the combination of ashtrays, litter boxes, ants, roaches, mixed colonies of black, blue, and grey mold, and harsh cleaning chemicals wallops your chest when you walk in. It’s reached a level at which you can see it even if you couldn’t smell it.

Jane Doe doesn’t smell much of the world around her. Jane Doe has chronic obstructive pulmonary disease, COPD. She’s only about 55 or 60 years old. She sees as much as most people do, with glasses, and her eyes are what tell her that her house is bowling you over. She sees you wince, turn pale, decide to keep your shoes on even though you normally take them off in the door. She says, “Oh, if only I could breathe better, I’d love to get up and do a real spring cleaning. The curtains! That bathroom!”

It’s not exactly springtime but you know what she means. If you were brought up by my mother, which I realize only one other living person was, you chirp cheerfully, “I’ve got energy to burn off today. Let me vacuum!” Whether you’ve ever read anything on the subject or not, you just know that all the fur, ashes, and fungi in the air have to be aggravating, if not causing, Mrs. Doe’s COPD.

If you not only were brought up by my mother but are travelling with my mother, you go into full spring-cleaning mode. Without really pausing the conversation you start dusting, vacuuming, emptying wastebaskets. In fact you consider interrupting Mrs. Doe’s train of thought with a suggestion like “Let’s take down the curtains and go to the laundromat,” because it seems so obvious that Mrs. Doe’s lungs need that kind of help. You move chairs and sofas around, run the vacuum cleaner tube over the baseboards, take the cushions outside and whack them. Whack! Ack! Aaack! You knew that cushiony furniture and carpets trap a lot of dust and dirt, but the first ten or twenty whacks on these cushions make you feel like a cartoon character sending smoke signals.

You went to call on this lady because you were feeling energetic and humanitarian. After an hour you wonder where that feeling has gone. Your muscles are nowhere near being really tired. Your lungs are, however, exhausted from being in Casa Doe, and your back is tired because you’ve not dared to sit down, and your ankles itch. You realize that if you spent a day or two in this house, you’d have pulmonary obstructions that creaked when you breathed, itch all over, have a deep aching cough, have asthma and headaches and hives, just like poor Mrs. Doe, for whom these things have become a disability. Maybe heredity, diet, even some long-past infection have aggravated Mrs. Doe’s symptoms, but anyone who lived in her house would have to have symptoms similar to hers.

By the time some of the heirs of the house come over to check on Mrs. Doe, you’re glad to get out. In about an hour you’ve filled a large-sized Hefty bag with wastebasket contents, ashtray contents, clumps of hair, stray pieces of kibble and cereal, a full vacuum bag, and three hairballs. You’ve rearranged all the furniture in the front room and sitting room, dusted the wooden furniture, rolled up throw rugs and even had a go at steaming the big dark stains the rugs were arranged to cover, because Mrs. Doe has great faith in steaming carpets, although you suspect you’re actually encouraging black mold. When you picture the room in your mind, what leap forward are the things you didn’t have time to do—sponging down the walls with Tilex, dusting the carpets with Borax, laundering those curtains and cushion covers—all the things that you would want to have done before you'd want to sit down in Mrs. Doe’s front room. You did not do these things. Maybe you never will. The air in the house is still sickening. Mrs. Doe is still ill.

It seems obvious that, just to survive to the normal retirement age, Mrs. Doe needs a full-time housekeeper...the kind who’d shoo the smokers out onto the porch, vacuum every cat-accessible room every day, and shampoo the carpet with Clorox until the mold subsided.

So, what does Mrs. Doe get through Tenn-Care? Because she’s conscious, even ambulatory, a daily visit from a nurse is out of the question. There are nurses who, recognizing the importance of house cleaning in Mrs. Doe’s medical care, would be willing to accept lower hourly wages for staying with Mrs. Doe long enough to get that house clean. (Mother happens to be one.) But that’s not Tenn-Care’s policy. Nurses aren’t charwomen. According to the policy, a disabled patient whose health depends on cleanliness is supposed to be able to hire a Merry Maid. Right.

If Mrs. Doe were to become sicker, and qualify for a low-status nursing assistant, she might get some house-cleaning help. “But only light housekeeping,” explains an agent, who shall be nameless. “Our sitters do things like mopping and vacuuming, but they don’t have to launder curtains or rearrange furniture.”

I’m familiar with this routine. Likely you are, too. It’s the one where the day sitter with the little chart on which to check off the box for “cleaning” runs the vacuum cleaner briskly over the throw rugs, but does not pick up the rugs and look at the carpet underneath, nor at what’s under the chairs. If she has time left over, she sits down and chats, or watches television. Her job is to check off everything on the chart, not to think about the role moldy carpets and hairball-encrusted chairs may be playing in her patient’s illness. This kind of day sitter does not particularly want her patient to get well. If a patient gets well, all it means to her is that she has to wait a week or two with short pay until another patient is found, then learn a different route—so she actually has some motivation to want her patients to remain ill. Since her patients are a “case load,” not friends or relatives, she doesn’t care enough about Mrs. Doe to think about things like laundering curtains.

Few if any employees of the Tenn-Care system consciously think that their regimentation amounts to killing Mrs. Doe while she still has twenty or thirty productive years to live. They think about their jobs, about their positions in the system, about what they’re going to do with their wages. They no more hate Mrs. Doe, or want her to suffer, than they love her or want her to get well. This mind-set would have served them well if they’d been Nazi or Soviet prison guards. How well it fits American health care providers is a different question.