11am, and the hot November sun beats down on the waiting line. E-day minus 2, and the atmosphere is pregnant with hope and expectation. We are two days away from the making of history, the first female President of the USA, the shattering of the glass ceiling. We are hours away from seeing President Obama, introduced by Stevie Wonder, jetting in for a final rallying cry in decisive divisive Florida. We have flown across the world to help get out the Clinton vote, and now we are in line to see the President.
This line is going nowhere slowly, but the atmosphere is almost festive. There are horses doing what looks to me to be dressage steps, a flotilla of bikers remembering the victims of the Pride Orlando shooting, and a golf buggy of elderly ladies driving round adorned with American flags, in what I can only assume is a rallying spirit.
It is against the backdrop of the gunning motorbike engines that I start chatting to Rhiannon. She’s standing behind me, in line with her cousins, her children and her elderly Mum. A day out for all the family. Rhiannon, it transpires, works as a pharmacist. Before long we have established that I am a doctor, and conversation turns rapidly to healthcare.
Rhiannon is a pharmacist unlike any I have encountered in the UK. She does dispense medications, and she can help people with weight management, self-limiting illness and their flu shot, but that’s not what she spends most of her time doing. In a low-income part of this sprawling Floridian city, most customers at her pharmacy can’t afford the medications they’ve been prescribed. Omeprazole for a stomach ulcer might be a hundred dollars a month, a long acting insulin several hundred a week. In economically deprived populations co-morbidity is common and polypharmacy too. And in what Rhiannon refers to as the ‘donut hole’ (more formally known as the ‘Medicare coverage gap’) many people she sees don’t have insurance to cover their drug bills, or the money to pay them. For her patients, a prescription isn’t the drugs you will take, it is a wish list of those you might take if you have means to do so. Rhiannon will help you choose which ones to leave off that month to fit within your budget. Insulin is always a tricky one she tells me; ‘it’s so important, but it’s so expensive too’.
The arrival of snipers on the roof suggests that Obama is close, but the conversation continues. Rhiannon’s sister tells me about a friend who had a cancer scare last year. The mole turned out to be benign, but now she can’t get insurance. Would the sister think twice before getting a mole check? ‘Of course. I don’t much like my job, but it comes with insurance. If I got a scare I’d never be able to get new insurance. I’d be chained to this job forever’.
When the conversation turns to the NHS I feel suddenly uncomfortable. Universal healthcare, a flat prescription fee with exemptions for many long-term conditions and the over 60s…the comparison is stark. I fear ill health for many reasons, but financial ruin for myself and my family is not one of them. That for Rhiannon and her family it is feels palpable. She is amazed when I tell her that we have problems with compliance here. I think it seems like an insult; her patients want drugs but can’t afford them, mine seem (to her at least) to choose not to take them. I cannot bring myself to discuss the complexities of patient choice, communication and shared decision making that her compliance question raises. In a way she is just right.
10 days later and I have not forgotten Rhiannon. I will not. The ease with which we point to facts and stats about healthcare in the US to make intellectual arguments for universal healthcare belies the realities of living within that system for the millions without adequate insurance. In the United Divided States, the result on November 8th put the dream of universal healthcare even further from the reach of Rhiannon and the patients she cares for. That it is in our grasp but slipping away feels more real than ever, and more important too.
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