If Ashcroft Were Uninsured...

From the moment Attorney General John Ashcroft was diagnosed with gallstone pancreatitis on March 4, he has without a doubt received the best and most efficient medical care in the world.

While Justice Department officials haven't released many details, the Attorney General, because of his status, was most likely whisked through the emergency room at George Washington University Hospital, into intensive care and then surgery, and has all the while been doted on by a team of concerned and caring medical experts.

Ashcroft has little reason to worry about the charges he's incurring. Like virtually all civilian federal employees, Ashcroft is presumably covered by any one of the impressive health plans offered by the United States Office of Personnel Management. The most popular plan, Blue Cross/ Blue Shield 'Standard,' could conceivably pay for close to 90 percent of Ashcroft's hospital care.

But what if John Ashcroft was never confirmed as Attorney General and didn't have that impressive federal health plan? According to the Chicago-based group, Physicians for a National Health Program (PNHP), 41 million Americans don't have any health insurance and the majority of them, the group says, aren't necessarily unemployed.

So, what would have happened if John Ashcroft was not Attorney General, didn't have health insurance and got sick?

What would happen, hypothetically, is this:

One day, on his way into Washington D.C. to see "The Passion of the Christ," John Ashcroft gets a searing a pain in his stomach.

He calls a doctor friend of his for help but the doc is out to lunch. The doctor's receptionist tells him he should make an appointment and asks what type of health insurance he has.

After an infuriatingly incomprehensible conversation about health coverage, Ashcroft realizes that, because he's no longer a Senator from Missouri, he doesn't have insurance. At 61, he's four years too young to qualify for Medicare. And, because of the steady income he gets from speaking engagements, he's not among the desperately poor that receive Medicaid, despite deciding to donate most of that money to a Christian charity leaving him a much more modest man.

The receptionist tells him that without insurance, a doctor's appointment will now run him about $75, and because he's now not nearly as wealthy as he once was, Ashcroft tells her he'll just take some Tylenol.

A week goes by, and Ashcroft's pain grows steadily worse. He doesn't go to a doctor though, because he knows it will cost him money he doesn't have. So instead, Ashcroft pops more Tylenol.

It's worth nothing that according to PNHP, some 18,000 Americans die every year because they don't have health insurance and wait too long to see a doctor. A few more days go by, and he decides drives into Washington D.C. to see "Passion of the Christ" a second time. But before he can get to the theater, he's hit with an unbelievable pain in his stomach.

Bravely maintaining his composure, Ashcroft manages to find his way to D.C. General Hospital, the mammoth public hospital he remembers passing every day on his way to Congress. As he pulls into the parking lot, however, he notices that D.C. General looks abandoned. Now that he thinks about it, Ashcroft vaguely remembers reading some newspaper articles about how D.C. General -- the only public hospital in the Washington D.C., which mainly served poor and minority residents -- was closed by the city in 2001 because in large part, it was overburdened with uninsured patients who couldn't pay.

And so, Ashcroft sets off in his car around predominantly poor and black southeast D.C., looking for another hospital.

Unfortunately, there couldn't be a worse time for Ashcroft to be sick and uninsured. Not only is there not another hospital in the neighborhood that D.C. General was serving, but also those hospitals picking up General's slack -- Providence, Howard University, Washington Hospital Center and Greater Southeast -- have been overwhelmed with patients.

Much like in other big cities across the country, Washington's emergency rooms have seen a substantial spike in visits, there are virtually no beds available and intensive care units are filled to 95 percent capacity. What's more, says Joan Lewis, Senior Vice President of the District of Columbia Hospital Association, now that General is gone, these other hospitals are treating more of the city's approximately 85,000 uninsured residents and spending more of their already depleted cash supply in the process. Since General closed two years ago, the $131 million Washington hospitals were spending annually to subsidize care for uninsured patients jumped an average of about $24 million per year -- an enormous financial strain on a system already stretched too thin. Greater Southeast filed for bankruptcy in 2003 and four more of the city's other seven hospitals are operating in the red. "Everybody feels like we're on the edge," says Lewis. "If there was a big epidemic, a medical crisis, we'd be in real trouble."

Ashcroft, though, doesn't know any of this. He just knows he needs help and needs it fast. He finally gets to another hospital -- take your pick of the four already mentioned -- and stumbles into the emergency room. Packed with people and patients, Ashcroft is told by this receptionist to fill out a not so small folder of forms which all seem to ask him for the same information. He complies, even revealing he has no insurance.

Meanwhile, he's virtually doubled over in pain. But because Ashcroft appears to only have a bad stomach ache, and he's surrounded by people in serious trauma, he might wait up to eight hours before being seen -- according to the D.C. Health Care Coalition, a group of community leaders, clergy and medical professionals pushing for another public hospital.

Finally, Ashcroft is called into an examination room where a nurse takes a quick look and hands him a packet of Tylenol before sending him on his way. The nurse is too overwhelmed with patients who've been shot, stabbed and the like to call an equally overwhelmed doctor to conduct a full examination on Ashcroft.

Ashcroft makes it into his car and out of the parking lot before the unimaginable pain finally causes him to go into shock and collapse.

Alerted to a man passed out in his car in the middle of the street, an ambulance rushes Ashcroft back into the emergency room. This time, because his condition is more urgent, he's seen immediately by doctors who diagnose him with gallstone pancreatitis -- a serious illness that occurs when gallstones block the duct of the pancreas -- and advise that he be placed immediately in intensive care. Unfortunately, for Ashcroft, ever since D.C. General and its 22-bed Intensive Care Unit (ICU) shut its doors, there's been little room anywhere for patients requiring intensive care. As a result, says Joan Lewis, doctors sometimes have to keep critically ill patients in the emergency room and check on them when they can. And so, Ashcroft, barely conscious, is kept in the emergency room until, a few hours later, he's brought up to the ICU.

There, for four days, Ashcroft, is put on an intravenous, given aggressive pain relief and treated with antibiotics by doctors and nurses who visit him around the clock.

On the fifth day in the ICU, doctors decide that Ashcroft should have his gall bladder removed to prevent any reoccurrence. The surgery goes well, and Ashcroft is taken back to the ICU. The next day, he's removed to a room for less critical patients so that he can fully recover.

Sometime during the next five days, as he's recovering, financial staff contracted by the hospital politely question a woozy Ashcroft about how he plans on paying for his time there.

Joan Lewis says such staff would try to convert Ashcroft to the D.C. Health Alliance insurance plan instituted in 2001 to combat the growing rate of uninsured. But the plan only works for people who are at 200 percent of the federal poverty level, leaving the majority of the city's uninsured still without coverage, including Ashcroft.

"Well," the money guys tell Ashcroft. "Here's how much you owe us."

While it's almost impossible to figure out the exact figure on Ashcroft's bill, one can estimate. Five days in an ICU unit alone at Providence Hospital in Washington, for example, would run up to $30,000. And then there's the laparoscopic gall bladder surgery and the five days in recovery -- which could cost an additional $28,000 (according to Fairview University Medical Center in Minneapolis). But there are still all the expert doctors who've visited him daily and have their own separate charges. That price tag might run Ashcroft as much as $5000 for the ten days he's in the hospital, says Dr. Quentin Young, PNHP's National Coordinator and former Director of Medicine at Cook County Hospital. Using such rough estimates, Ashcroft is told he'll have to fork over at least $63,000.

Shocked at such an outrageous figure, Ashcroft insists there's no way in hell he can pay that amount of money and begins to explain his situation.

A financial counselor enters the room and tells Ashcroft that the hospital has done a little research on his "situation," and because he does have assets and a steady source of income, however small, he's not eligible for the hospital's charity fund, reserved for those who truly have no resources. The counselor says the hospital can put Ashcroft on an assistance program, where he'd be charged an incremental fee depending on his financial status. Or, if he's lucky, the hospital might eat a percentage of the bill -- again, based on his status.

The counselor doesn't mention it, but he knows that if Ashcroft doesn't make his payments he can send collection agents after him, and eventually take him to court if need be. After all, the hospital is already strapped for cash and has spent a lot of money treating Ashcroft. Besides, just letting uninsured patients walk out the door could force the hospital to close. Everyone knows what happened to D.C. General.

The D.C. Hospital Association doesn't keep track of how often its hospitals go after patients who cannot pay, but as David Sparks, Chief Financial Officer of Providence Hospital, puts it, "Collections happen every day and every week. It's part of the standard process."

In the end, says Dr. Quentin Young, there's a good chance Ashcroft will have to pay much of the money he owes in some capacity, or face a lien on everything he owns. The fact is, according to Roger Whelan, a resident scholar at the American Bankruptcy Institute and a former bankruptcy judge, medical bills attributed to a lack of insurance or insufficient coverage are a leading reason why a record 1.7 million bankruptcies occurred in this country last year.

As for the real Ashcroft, he'll never know the terrifying dilemma of his alter ego -- a dilemma experienced by millions of Americans throughout the country every day -- because he's a high ranking official in the Bush Administration and probably has that impressive federal health plan, or one similar to it. (A Justice Dept. spokesman said that Ashcroft is insured but did not know whether he was on the federal plan.) Of course, it's the same administration, of which Ashcroft is such an integral part, that has been so opposed to expanding health insurance to all people, regardless of age, employment status or economic well being.

Ironically it's Ashcroft's own health insurance that is saving him -- not only now, while he's in the hospital, but once he gets the bill.

Dan Frosch is a freelance journalist based in New York City. He's been on staff at the San Gabriel Valley Weekly section of the Los Angeles Times, The Source magazine, the Pacific Palisadian Post and most recently the Santa Fe Reporter. Dan also contributes to VIBE and POZ magazines.

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