http://well.blogs.nytimes.com/2009/11/18/p...

November 18, 2009, 10:40 AM
Playing the Health Care Lottery

By THERESA BROWN, R.N.

In the short story “The Lottery,” the author Shirley Jackson describes a small farming community in 1940s America, as picturesque a scene as anything you’d find in Norman Rockwell. It’s “Lottery Day,” and families gather in the June sun, the adults chatting while their children play, gathering up small piles of stones.

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The townspeople laugh, but the merriment is soon replaced by an anxious waiting as one by one the townspeople draw a folded slip of paper from the wooden box. Mrs. Hutchinson ends up with the single chit marked with a large black dot.

It turns out this lottery is a long-standing tradition, an annual ritual whereby the town selects a sacrifice to ensure a good harvest. As Old Man Warner, who has survived 77 lotteries, explains, “Lottery in June, corn be heavy soon.” The reason for the piles of stones the children have been gathering soon becomes shockingly clear as the rest of the townspeople, grabbing rocks of their own, circle around Tessie and begin to stone her to death.

Anyone reading the story recognizes right away that the town’s “lottery” is barbaric, the rationale justifying it ridiculous.

But as a nurse, I see the American health care system as a similar lottery, a market-based system that is sustained only by the sacrifice of certain patients. Many of us who benefit from the current system accept these casualties as legitimate and sadly unavoidable.

One of those lottery players was a man who had endured chemotherapy and a stem cell transplant, but his cancer had now returned and nothing more could be done. He was walking and talking and didn’t feel too bad a lot of the time, but along with the cancer he had a bacterial infection in his lungs. We planned to send him home on intravenous antibiotics to keep the infection at bay so he could feel well for as long as possible.

Every time I went into his room, his wife questioned the need for the drugs...

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Many people, including many nurses, see situations like my patient’s and feel outraged, but in the end we shrug our shoulders, thinking, “Well, that’s the way it is with insurance companies.”

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That’s the problem with playing the health care lottery. You’re a winner and the system keeps you safe and whole — until it doesn’t. And when that moment comes, when you draw the chit that says “claim denied” or “medication not on the approved list” or “treatment no longer covered,” well, as the story tells us, “‘It isn’t fair, it isn’t right,’ Mrs. Hutchinson screamed, and then they were upon her.”

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