The first email I saw today was written in an anguished tone by an anguished person. A friend who had been putting off seeing a doctor for what he knew to be a hernia finally became so wracked with pain he made the decision to go to the emergency room. He hoped they'd have a look and tell him they'd have him fixed up in no time. That didn't happen. This did:

The emergency room......put me on the street with a prescription & a referral.

I was afraid of this. He's been in pain for awhile, and we'd been urging him to get to a doctor or even the emergency room. Hernias aren't life-threatening unless they become strangulated. If that happens, immediate surgery is necessary to prevent gangrene from setting in.

I suppose my friend can take some solace in that, but he doesn't because he is still suffering. In a series of follow-up emails, I asked him to tell his story, not only about where he is in this whole stupid process, but how he got to this place. He's not the type to open up, so it took a series of questions and answers. Here are the high points about where he is in the process.

The ER gave me the WRONG number for Community Health Net. I had to call [them] back for the right number.

Community Health Net won't give me a "sliding-fee" appointment until I've applied for Medical Assistance & been denied.

Community Health Net is a community health clinic funded with federal dollars. Those are the clinics Bernie Sanders fought so hard for in the middle of the health care reform battle, and he won. Funding was stepped up considerably for those clinics, though Congress has tried very hard to pull that funding back in the last two years. According to their website, anyone who is uninsured can apply for reduced payment on a "sliding fee" scale according to their income and ability to pay.

But as you see from his response, there appears to be an additional requirement. It seems that he first must apply for insurance and be denied before they will see him on an "ability to pay" basis. Unless, of course, they are homeless and have joined the "health care for the homeless" program. Then they pay nothing.

My friend has a full-time job which requires him to spend long hours on his feet. His payscale is what one might expect for this kind of job, between $9 and $10 per hour. As his condition has gotten worse, he's found himself in a situation where he has to take short breaks and lay down on the floor to, as he says, "let everything slither back in."

Otherwise, he's in pain from the moment he stands up to the moment he sits down. Searing, debilitating gut pain. In his words:

I can't stay on my feet longer than half an hour or so due to the pain. I can't walk properly. I can't work without risking my guts tearing loose. I am disabled.

His job, of course, depends on him being able to stand up for more than 30 minutes at a time, and when he says he's disabled, that doesn't mean he's regarded as disabled for employment purposes.

Caught in the margins

This is the hole in our safety net that Obamacare seeks to close. This is the hole that people living in the margins -- employed but making hardly enough to keep a roof over their head and food on their table -- cannot close on their own.

The right wingers would say "Let the charities help him!"

There are no charities to help this man. There is only a government-funded health clinic which will not see him without immediate payment unless he applies for insurance and is denied. He doesn't know where to go to even apply to be denied. His employer does have health insurance available, but for him it would cost more than 15 hours of work every two weeks, leaving him short of what he needs to pay his rent, utilities, and bills. From the numbers, it sounds like that cost is even after the employer puts something toward the cost.

In red states, it's complicated. Intentionally complicated.

Pennsylvania used to have a plan called adultBasic, where people with very little means could get insurance for about $36/month. It was very popular, so popular people were on waiting lists until their number came up on a state lottery. Until they hit that lottery jackpot, those same people could opt to buy coverage for about $700/month. (Please don't laugh so hard you forget to read the rest.)

Obamacare created federal high risk pools, which the state of Pennsylvania saw as their opportunity not to expand their existing adultBasic plan, but to terminate it instead. They sent a letter out to everyone on the plan which said they could opt into a BlueCross/BlueShield plan that would cost them nearly ten times what they were paying, or they could enroll in a Blue Cross/Blue Shield plan called "SpecialCare", which would cover people (excluding pre-existing conditions) who did not have access to employer-sponsored health insurance.

My friend would probably qualify for SpecialCare. Or he would have qualified, except that he went to the ER today, and so that hernia that he needs to have treated is now a pre-existing condition. That leaves the federal high risk pool as his sole option, which is about $280/month, has a $1000 deductible and a $5,000 maximum co-payment. That's about what he earns in six months!

For a surgery that costs (on average) $7,000, they would like for him to pay as much as $6,280 in order to have "coverage." That's insane. I say "as much as" because when I was looking around for the average cost of hernia surgery, some hospitals charged as much as $112,000. Presumably it was not the laparoscopic surgery, but open abdomen surgery and presumably there were complications that kept the patient in the hospital. However it seems reasonable to me to assume that the longer he lets this go, the higher the odds that it will cost more than it would if they could have done it tomorrow.

This is what it means to be on the margins. A hard-working, full-time employee faced with a choice between keeping the lights on or health insurance doesn't really have difficulty making that choice.

If his hernia could have waited one more year, he would be eligible for fully subsidized insurance and co-payments under the Affordable Care Act. But you know, sometimes things just don't work that way, and in red states, they really don't work that way.

Republican administrations are hazardous to your health

I loved this little mission statement on their Health and Human Services page:

Welcome to the Department of Public Welfare

Our mission is to promote, improve and sustain the quality of family life; break the cycle of dependency; promote respect for employees; protect and serve Pennsylvania's most vulnerable citizens; and manage our resources effectively.

Oh, I see. Break the cycle of dependency. Who does that sound like? Why that's right, Paul Ryan!

Is it a cycle of dependency to need health care and have no access to it?

Is it a cycle of dependency to work full-time and still not make enough to afford health insurance through one's employer?

Is it a cycle of dependency to be human, subject to human frailty, and in need?

Of course it's not.

In the ultimate irony, my friend is now in a bureaucratic Catch-22, because he's employed, can't afford his employer's insurance plan, can't afford the state high risk pool plan, but isn't indigent. That leaves him with the option of applying for the SpecialCare plan and being turned down in order to qualify for treatment at the Community Health Clinic.

Meanwhile, he's got the meds and a brace, and a maybe appointment on November 29th with the clinic of last resort, assuming he's turned down for insurance in the interim.

I fully expect this to happen: He applies and his ER visit isn't yet in the system, so they accept him to an insurance plan (SpecialCare). He will go to the surgeon and it will be covered, he will have the surgery, and then his claim will be denied because they didn't know he had the hernia when he applied for the insurance.

This is how Mitt Romney wants us all to live. This is how all Republicans want us to live. Forcing down wages, making it impossible to access health care, and removing the only safety net we've ever managed to put in place by repealing Obamacare.

I leave you with this quote from an article this morning in the New York Times:

When cancer is diagnosed among the uninsured, “the system simply ignores them,” Dr. Syrigos said. He said, “They can’t access chemotherapy, surgery or even simple drugs.”

In case you thought that quote was about the United States, guess again. That is a Greek doctor talking about the horrible situation in Greece brought on by forced austerity foisted on them by Germany, et al. Greece never had a debt problem. Greece had a revenue problem. But thanks to those who wish to "break the cycle of dependence", Greece now has serious health problems going untreated among nearly 25 percent of its population.

Conservatives built that. They own it. Speaking for me, I'll take the better alternative.