A Vision to End the Tragedy of Misspent Millions

By Nancy Lewis
RN FNP, CNA/NNOC Public Health Commissioner
May 15, 2008

(Editor’s Note: Family nurse practitioner Nancy Lewis gave an inspiring keynote speech at WEAP’s May 15, 2008 Truth Commission on the Health Care Crisis.  Here are excerpts:)

 THE “CASH NOW, CARE LATER” SYSTEM

 
 Good Morning, I want to thank the Women’s Economic Agenda Project (WEAP) for inviting me to this Truth Commission today to talk about the state of health care.  I also want to thank WEAP for their leadership in educating, agitating, and organizing the movement to ensure every person gets decent health care in this nation.

My name is Nancy Lewis.  I have been a registered nurse and a nurse practitioner (NP) in California for more than 15 years. I am a Joint Nursing Practice Commissioner with the California Nurses Association (CNA) and the National Nurses Organizing Committee (NNOC) and I’m also a member of SEIU, local 790, now 1021, since 1997. It is perhaps fitting that a nurse talk with you today, because this week is National Nurses Week which celebrates the birthday, life, and work of Florence Nightingale, the founder of modern nursing.

Born into the privileged class of British aristocracy in 1820, Florence would shock and shake-up the system that believed that the lot of the poor was God’s plan and that women needed to have a subordinate status within society.  She introduced a revolutionary concept of health that viewed the patient’s environment as central to their healing.  So keep her in mind today as we discuss the present problems in US Health Care and the solutions to help heal it.

The purpose of my keynote is to open a dialogue with you about our so-called US Health Care System, which isn’t really a system.  A system is defined as “a group of elements that interact and function together as a whole.”   One of the most important elements of a health care system is delivering good patient care.  What we have instead is a health care industry, designed to make money off of us, the patients, without delivering adequate care.  

In my opinion, it should really be called “The CASH NOW, CARE LATER SYSTEM” because it asks for your insurance card or your credit card before it asks you “How can we help make you better?”  For those of us who are lucky enough to have insurance, we are being co-paid, deductible’d and fee’d to death, and many are finding they can no longer afford their care.  The situation is even worse for young workers or workers in small businesses, which do not even provide health insurance.

The money spent on health care and health insurance is going less and less into actual care.   At the last count only 30 cents of every health care dollar was spent taking care of patients.  Instead, it is going into the hands of either Corporate Health Care CEO’s, who are making record profits, or to drug companies.

Let me give you some quick statistics before we start: The US Health care system, according to the World Health Organization, has consistently been number one in its expense and 37th in its quality. Our life expectancies have dropped, and for the first time, women’s life expectancies have dropped by 5 years when compared to equivalent industrialized nations like Canada, Britain, France and Scandinavia.  Infant mortality is up, especially among minorities and the poor.


Nancy Lewis testifying at the 2008 Oakland Truth Commission.
Credit: Austin Long-Scott


THE CLINIC HORROR STORIES

Let me tell you what I am seeing on a day-to-day basis in my daily practice as an NP in Public Health, San Francisco.

. . . I came to public health because I wanted to take care of at-risk kids, kids our society all too often stereotypes and deems disposable -- not worthy of education and health care resources. The Public Health System that my clinic is a part of is the safety net for thousands of patients in the city who lack health insurance and yet budget cuts continue to take place at an alarming rate.  It is also there to prevent and treat communicable diseases and provide emergency care, even for people who do have health insurance.  It would be the backbones of care in a disaster situation, like an earthquake or a pandemic flu out-break.

I see patients 5 days a week and most of them apologize about not having health insurance, for being sick and not seeing a doctor for a long time, or how badly they smell, in the case of our homeless youth or the marginally homeless. My reply is always pretty much the same: It isn’t your fault.  Access to care is getting harder and crazier, so you are not responsible. Let’s work on getting you better.

I’m seeing more homeless youth than ever before. One of my colleagues made an important observation about 6 months ago: homeless patients are more mentally ill and suffer more hygiene problems than a year ago. This is probably due to more youth and homeless adults living in our parks or in abandoned buildings in San Francisco. There has been a growing trend in treating the homeless under criminal nuisance laws -- criminalizing the poor and the down and out. The steady decrease in the numbers of public health nurses in the field makes it even more difficult to find patients who need follow-up.  

Gary and Rick are typical of the growing problem of community acquired staph infections that are creating a nightmare locally and nationally about MSRA (multi-resistant staph aureus).  The bacteria is now immune to drugs like penicillin, so the patient can die if not treated with the proper anti-biotic.  In addition to living in Golden Gate Park, Gary and Rick have repeatedly been treated for lice and scabies (a mite that burrows under the skin), both of which exacerbate staph colonization and are highly infectious.  Because they were treated in our clinic, they are both free of boils for the moment, and are bringing in other youth in the hood who also have staph.  

Funding homeless visits is easy though.  They qualify for Medi-Cal.  The real nightmare funding problems are the working youth over 18 who have jobs that pay little, and have no benefits or inadequate ones.

The story of Gina is typical.  I received a call from her six months ago in pretty dire straits.  She had developed a rash in class at City College the week before and called her insurance company to find out where she should go.  They told her to call a number and she did.  They diagnosed her over the phone and called in a prescription for a cream.  She used it over the weekend and before long the rash not only got worse, she also got hives and started having an allergic reaction to the treatment.  She called again and this time they gave her another number to a clinic they thought was in her plan.  No luck, they couldn’t see her for at least two weeks.  Getting desperate, she called me and I saw her that day, even though I shouldn’t have, since my clinic is not suppose to see patients who have health insurance. But this was truly an emergency.  It was clear that the treatment had caused an allergic reaction, and I proceeded to treat her immediately.  She came back in two days with remarkable improvement and continues to return to the clinic for primary care.


OUR BROKEN HEALTH SYSTEM SUBSIDIZES THE CORPORATIONS & PUNISHES THE POOR!

These are just a few of the stories.  Many patients rely on our services and in some sense seem puzzled when we now ask if they have health insurance when they call for a visit.  Many long-time patients remember that we never asked that question before. Now, with Governor Schwarzenegger proposing a 10% reduction in public health, there will be more emphasis on billing than ever before.

A few weeks ago, the phone company came into the clinic to install a special line for a credit card and ATM card reader, so we can start collecting payments directly from patients under our new, “universal” health care system, known as “Healthy San Francisco”.  This plan was implemented less than a year ago and was designed to take care of those working adults living in San Francisco whose jobs offered no insurance benefits. Initially, the city would kick in a little over half the cost of the programs with businesses, large and small, signing up to pay for the other half.   It sounded great in the beginning but with the ATM card readers in our clinics now, including our homeless sites, the burden of cost will fall directly on the patients.  Last week, we were told that if a potential patient couldn’t pay the fee at the time of treatment, we were to reschedule the patient for a time in which they could pay. Most of my NP (Nurse Practitioner) colleagues were shocked.  Some doctors using the system won’t fill out a billing form, and see the patients anyway.  I offered to use my own credit card if a patient couldn’t pay, and my medical director offered to chip in, also.  

My diagnosis for our health care delivery system is that it is sick, and without the proper surgery and nursing expertise, soon to get even sicker.  Public health budgets are being slashed, and patients will be shouldering more of the cost of their own care.  With or without insurance, patients and their care providers are being squeezed to do more with less.  We are also being asked to make their medical and nursing decision on the budget bottom line or the corporate insurance bottom line rather than the medical line.
 

THE SOLUTION: MEDICARE FOR ALL, SINGLE PAYER

To me, the answer to the problem of funding and fixing the problem is the proposal for a “Medicare for All, Single-Payer system in which all are in, no one is left out, and with an emphasis on preventative care.  It would allow us to start asking, “How can we help you?”  rather than “What kind of insurance do you have?” or “How will you pay for your visit today?”  We have the blue prints for such a health care system, both in State Senator Sheila Kuehl’s SB 840 for California, and Representative John Conyers, HR 676 for the nation.  More and more Americans, now believe it’s the best answer and a solution to the crisis.

But there are those who believe that the push for single-payer is a dream that sacrifices the more practical, incremental approach of mandated affordable health insurance for all rather than the perfect world of national health care for all.

I would argue, when a nurse is taking care of a patient, that patient expects the best care the nurse can give.  There is no such thing as incremental nursing, nor any concept of accepting less than the best standards of nursing care for every patient we take care of.  When nurses are licensed, part of our Practice Acts is to be advocates for our patients.  I want you to look at this card that I am holding up.  It is not a credit card; it is my nursing license, one received by everyone who has earned the right to be a Registered Nurse.  So, lets get busy, we have a lot of work to do.  And if Florence could change her society, I think we can do it too.

Thank You.
 
Nancy Lewis, RN FNP
CNA/NNOC

“So long as a sick man, woman, or child is considered administratively to be a pauper to be repressed, and not a fellow creature to be nursed into health, so long will these shameful disclosures have to be made. They are not paupers, they are poor in affliction.  Society owes them every care for recovery.  Sickness is general and human, and should be borne by all.”

-Florence Nightingale, 1863