Chapter 51: A Time to Talk and a Time to Act

June 3, 1994, Chicago, Illinois

“Thanks for coming to me,” Jessica said. “And thanks for bringing the Chinese food!”

“You’re welcome, Babe. Our schedules are way more flexible than yours!”

“There’s a consultation room we can use without any trouble. Follow me.”

Jeri and I followed Jessica through the doors from the ER waiting room into the ER proper, then down the hall to a small room with a table and four chairs. We set out the food we’d brought from Sixty-Five Chinese, and sat down to eat.

“Steve said you have a suggestion about the expansion of the UofC ER,” Jeri said.

“You saw the zoo out there when you came in, right? And I know Steve experienced it the night of my accident. Some of those people will wait eight hours or more to be seen. And many of them don’t need an ER. But legally, we can’t send them away. We have to evaluate anyone who presents themselves here.”

“Don’t people sometimes leave?” Jeri asked.

“Yes, but that’s different from us sending them away.”

“Can’t your intake nurse do some triage?”

Jessica smiled, “It’s not that simple. Let’s say someone comes in complaining of a headache. The nurse, finding no other symptoms, offers some Tylenol or Advil and sends them on their way. Two hours later, they have a stroke or aneurysm and die. What do you think happens when their family sues the hospital?”

“I know the answer to THAT one,” I said, sure that I sounded just as annoyed as I was. “The big bad hospital and the rich doctors can afford to pay, so juries award large verdicts.”

“Yes. And our only defense is the chart with a record of exams and tests. And because of THAT, we often run needless tests, which not only costs money, but takes valuable time from specially trained doctors. But it’s not just walk-ins. If you call the paramedics, they basically have to bring you in unless you refuse transport. And if you come in with the paramedics, you’ll get seen first.”

“So the quickest way to an ER bed is to call 9-1-1?” I grinned.

“Or tell the triage nurse you’re having chest pains and shortness of breath and are sweating.”

“Heart attack symptoms,” I replied with a grin. “I’ll remember that the next time I stub my toe!”

“You laugh, but people come in for things for which they should see their family physician for. Going to your family doctor would cost $50 or so, and probably less with insurance. That same visit here costs $1500, minimum. Remember, I had my GP license after a single year of Residency. I’ll be a Trauma Attending after seven more years of expensive training. As you love to say, Tiger, somebody’s got to pay!

“And more often than not, it’s the hospital that pays. If you show up here with flu symptoms and no insurance, the hospital is out the $1500 fee and, potentially worse, the time that the Trauma Attending or Resident could have been treating an actual emergent case. Which means that those costs have to be built into the fee structures...”

“OK,” Jeri said. “Obviously you have an idea. But if sending them away is illegal or creates an insurance problem, what do you do?”

“My idea is we create a free-standing clinic across from the new ER. Now, legally, we can’t TELL people to go there, or even advise them to go there. But if people go there of their own volition, then we’re OK.”

“But how?” I asked. “Put up signs with waiting times like some amusement parks are adopting?”

“Exactly, Tiger. You’re joking, but a sign that says it’s going to take six hours to be seen, with a sign that says non-life-threatening-emergency treatment is available across the street in one hour, will encourage people to think about it. And that clinic is going to be way less expensive in the long run. You don’t need trauma specialists, or trauma rooms, or any of the equipment we have to deal with severe trauma. Maybe one room there has a lightweight setup in case someone crashes while you’re treating them, but overall? They’re going to do exams, sutures, and write prescriptions.

“Think about some of the stories I’ve told you, and you’ve heard from Doctor Barton and Bethany. A perfect example would be those two teenagers who ‘lost’ their condom! They didn’t need a fully staffed, fully equipped ER! A nurse with surgical gloves could have solved the problem in a few minutes without the expense of a trauma room!”

“Lost their condom?” Jeri interrupted.

I grinned, “Think about it for a second. Where did they ‘lose’ it?”

Jeri screwed up her face in thought then started laughing, “Uh, yeah; never mind!”

“And by the time all was said and done,” Jessica continued, “they used up more than an hour of valuable ER time because of all the paperwork, charts, tests, and so on. I’m serious about this. If we don’t do something like this, the entire system is going to collapse under its own weight. It’s close to happening here at Cook County.”

“Have you talked to Al about this?” I asked.

“Briefly. He’s not opposed; he’s just not sure he can convince the hospital board.”

“What if it’s not part of the UofC hospital directly? Maybe an expansion of ‘Project Lydia’?”

“Now I know why I’m here!” Jeri laughed. “Money! But I can see a problem with this idea right off the bat. The clinic will be used, mostly, by people with no insurance and no family physician, and as such, would have to be fully charity-based. In effect, you’re transferring costs from the hospital to the clinic. Granted, it’s less expensive, but in the end, you’ll need ongoing funding.

“‘Project Lydia’ works because we provide limited services to a limited segment of the population in very controlled situations. And our donors support the specific cause. This would be more like a free-for-all. If the hospital were willing to fund it, at least partially, it might make sense. If you base it purely on charity, you’ll quickly outrun your resources and turn into something like Cook County. Or worse.

“It’s strange, I know, but I can raise $100 million to build and outfit your new ER, but I can’t raise $2 million a year to fund a clinic. I hate to say this, but the people with serious money want their names on something tangible and want to be able to point to something like a hospital building. It’s sexy, it’s cool, and it will be around as a legacy. Not to mention the real source of the problem is lack of basic healthcare for the poor.”

“So isn’t the solution more community-based clinics where these people can go to seek help rather than clogging the ER?” I asked.

“Sure. Who’s going to build them?”

“When did YOU become a socialist?” I asked.

“Come on, Steve. Put on your pragmatic hat and think it through. I know your ideology. It matches mine, and to a point, Samantha’s. But what’s your solution? Where is the money going to come from to do this? With you and your wife, I can lay out the logic to build the clinic and you’ll contribute. Most people won’t. Where does the money come from?”

“With the caveat that all taxation is theft, I doubt there is any reasonable solution besides taxes.”

Jeri laughed, “I knew you’d sneak in Rant #6 somehow as soon as I asked the question. All we’d be doing with this idea is putting our thumb in the dike, and the dike would crumble around us. Our resources are better used for ‘Project Lydia’ or the ER project at UofC. Or a few of our targeted community clinics where we join other groups in funding a small subset of services. Tilting at windmills isn’t a wise choice.”

“Tilting at windmills?” Jessica groused. “Seriously?”

“Doctor Jessica, your idea is wonderful. And it’s probably the right solution. But there is simply no chance of raising funds to operate the clinic. Build it? Probably. Operate it? No. If it could fund half its own operation, it might be a viable idea. Might. I’m sorry, but you’ll have to sell this to your board of directors.”

“Are you predicting some kind of socialized healthcare system down the road?” I asked.

Jeri nodded, “I don’t see any other solution. All the other major Western countries have gone that route to one extent or another. Don’t you think it’s socialized already? Just inefficiently?”

I nodded, “I see your point in that we use insurance to spread risk and share costs, and that the ‘losses’ encountered from treating individuals who can’t pay are ‘socialized’ to everyone else via increased premiums and costs, but I hardly think taxation will solve the inefficiencies!”

“Not all of them, no,” Jeri said, “and it’ll introduce other problems. There are some interesting middle-ground ideas. Singapore or Switzerland are two examples. As for fully socialized medicine in the US, you see what’s happening with the whole ‘Hillarycare’ proposal. It’s a debacle!”

“True,” I nodded. “But a debacle of their own making. Mrs. Clinton’s secret meetings really hurt the plan, despite the court ultimately ruling she didn’t break the law. I think they’ve horribly miscalculated. My take is that the American public is going to reject a top-down, bureaucratic approach to healthcare. And intransigence on both sides means we’ll get nowhere. The Clintons have handed the Republicans the issue they need to make huge gains in the elections this fall.”

“That plan has SO much red tape that it will tie my hands as a doctor,” Jessica said. “It’s bad enough we have to fight insurance companies, but we can usually win on medical judgment. Fighting the government? Forget it. I guess that means I need to talk to Doctor Barton again.”

“For now, I think that’s all that can be done,” Jeri said. “I’m sorry.”

“It’s OK,” Jessica said. “Even you don’t have unlimited money!”

“No, that’s Samantha!” Jeri laughed. “But even with Samantha, her net worth is far higher than the actual cash she could lay her hands on. So much is tied up in Spurgeon Capital. She’d have to sell, which she’ll never do.”

“It’s like us,” I said. “But on a different scale. Most of our net worth is in the house, our investments, and NIKA. But to get access to that cash, we’d have to sell everything.”

“You know the Foundation’s finances, Steve. It’s the same. We generate significant income from bonds, Treasuries, and REITs and we use that income to fund our projects. If we used the capital, there would be no Foundation.”

“Well, at least I got a nice Chinese lunch out of this,” Jessica sighed. “Sorry to have wasted your time.”

“It wasn’t a waste,” Jeri said. “Talking about solutions is the way to find them. Our ‘leaders’, and I use that term loosely, yell at each other. Keep talking. We’ll find a way.”

We finished our lunch and I kissed Jessica goodbye. Jeri headed back to her office, and I headed back to NIKA, where we had a brief afternoon celebration of our ninth anniversary with cake and ice cream in the ‘Lemieux’ conference room. The tenth anniversary was going to be a blowout, and Elyse and Kimmy were already planning it.

June 4, 1994, Chicago, Illinois

The talk with Jeri and Jessica on Friday had caused me to spend a couple of hours in my study very early on Saturday morning before Guys’ breakfast. Birgit was sitting in my lap and I was typing away in my journal, debating with myself whether there was any solution other than some kind of tax-funded system, and if there wasn’t, was there any way to retain control of my health care choices.

I thought back to Stephie and the choices she’d made, and wondered if the solution, or at least part of it, lay in education, rather than compulsion. Jessica had shared studies with me that showed some insane percentage of medical costs occurred in the last five years of life, and much of that was families refusing to allow a loved-one to die in peace and dignity as Stephie had chosen to do.

That refusal wasn’t going to happen in our family, as we’d all had Gwen draw up living wills with clear instructions that precluded long-term life support when there was little or no hope of recovery, and power-of-attorney documents which clearly and specifically authorized ‘plug pulling’ in such cases. I knew if the time came, I’d have a very difficult time with the decision, but Stephie had shown me the way, and to reject what she had herself done would, in my mind, dishonor her memory.

I’d seen that behavior early in the school year when one of the kids who had come to the Rap Session had made the comment about his grandmother dying of cancer, and his admonition to his parents to not let Grandma die, no matter what. As I’d tried to explain, she was going to die. It was only a matter of when, and in what condition. That attempt to explain ‘the fate of all men’ as Don Joseph had called it, had led that student to depart in anger and never return.

I hadn’t written that in my journal at the time as it had occurred just before Jorge’s death, and I had stopped writing for several weeks. I wondered if there were other things I should have written that fell by the wayside, but I wanted to focus on getting my head wrapped around the current debate. That wasn’t to be, as thinking about Jorge took me down a very different path. I stopped typing, leaned back, and reminisced about him, and others.

“What’s wrong, Daddy?” Birgit asked a moment later.

“Daddy was just thinking about some things that he’s trying to figure out.”

“What?”

“About dying.”

“Like Jorge?” she asked.

“Yes. And my friend Stephie. The one in the picture in the ‘Indian’ room who used to be married to Jason. And my friend Joseph, who died before you were born. And my girlfriend who died who had the same name as you.”

“You miss them?”

“Yes, I do. You know how you miss Katy? So you send her cards and she sends you cards and you call her on the phone?”

“Yes!”

“Well, it’s like missing Katy and not being able to write to her or call her or hear from her.”

“I would be very sad,” Birgit said.

“That’s kind of how it feels when someone dies. You miss them and you can’t do anything about it.”

“Are you sad, Daddy?”

“No, Pumpkin. I was sad when each of them died, but now I just miss them.”

“You missed Mommy when she was gone.”

“Yes, I did. And so did you.”

“I’m glad she’s here.”

“Me too, Pumpkin,” I said, kissing her head. “Do you want some breakfast? Daddy will need to go have breakfast with his friends.”

“Waffles! And bacon!”

I saved my work, shut down the computer, then carried my daughter to the kitchen to make breakfast.

June 5, 1994, Chicago, Illinois

“You still seem uneasy, Tiger,” Jessica said on Sunday morning.

Jessica, Kara, and I were in the ‘Indian’ room drinking tea before I was supposed to leave to meet Mitsuko at the dojo, and take her to the NIKA apartment. The two-week delay had brought back the concerns I’d had before about how she’d feel. But, as I’d thought about it, that wasn’t the real problem. The real problem was how I would feel.