Provision to eliminate lifetime benefit caps in medical insurance allows life-saving heart-lung transplant

Jul 14 2011

You could say health care reform saved Milton Gilmer's life.

“He said, 'I think I'm having a heart attack.' I told him to call 911. And then he said, 'But I'm here.' I said, 'You're here where?' And he said, 'I'm at the front of the hospital in my truck.'”

The Affordable Care Act was signed into law March 23, 2010, with the aim of extending medical coverage to more Americans. The law has been a political football, and arguments continue to rage over whether it's good or bad for the country. This, however, is simply the story of how it affected one person.

Gilmer, who owns a crane and piling service in Boulder, Mont., was diagnosed with pulmonary hypertension in 2006. By the end of 2010, he was dying of the disease, which causes abnormally high blood pressure in the lungs and right side of the heart. "His condition was very, very bad," said David Weill, MD, medical director of Stanford Hospital & Clinics' Lung and Heart-Lung Transplant Program.

On Feb. 8, Gilmer, 61, underwent a successful heart-lung transplant at Stanford Hospital. It alleviated the chest pain and breathing difficulty that had thwarted his ability to work and enjoy life on his beloved 300-acre ranch in Montana's high country. But the operation almost didn't happen.

When Gilmer first turned to Stanford for a heart-lung transplant, his health insurance refused to pay for it; the cost exceeded the medical plan's lifetime dollar limit for this kind of procedure. His predicament was not unique. Many other patients in need of organ transplants have been stymied by insurance limits, which often turn out to be a death sentence. But that changed after health care reform was enacted. A provision of the law requires medical insurance providers to eliminate lifetime benefit caps.

So with the help of a Stanford Hospital social worker, Gilmer rented an apartment in Mountain View in January of 2011 so he could easily shuttle to and from Stanford's medical campus for appointments.

"We were pretty happy," said Gilmer's wife, Donna. "If anything were to have happened to my husband, Stanford has a lot of knowledge about pulmonary hypertension, and transplant is one of their specialties."

By then, however, Gilmer was running out of time. In early February, a few weeks after the move, he suffered a heart attack while standing in front of an ATM in Mountain View. Stanford pre-transplant coordinator Lisa Levin, RN, MS, remembers getting his phone call that day. "He said, 'I think I'm having a heart attack.' I told him to call 911. And then he said, 'But I'm here.' I said, 'You're here where?' And he said, 'I'm at the front of the hospital in my truck.'" Gilmer had driven himself to the hospital. He was rushed to the Emergency Department and stabilized.

Donna Gilmer later recounted a similar incident that occurred in 2004, when her husband suffered his first heart attack and was about to drive himself 36 miles to a hospital in Butte. She intervened and drove him there herself.

But on that day in February, she was back in Montana, helping birth calves on the ranch in temperatures well below 0 degrees Fahrenheit. "I got a call from the hospital telling me he would probably be transplanted in the next couple of weeks," she said. Because of his deteriorating condition, Gilmer was given priority status on the transplant waitlist. She hastened back to California, and a few days later he underwent the operation.

There are between 30 and 40 heart-lung transplants performed every year in the United States. Stanford Hospital, which has long been at the forefront of transplantation medicine, performed the world's first heart-lung transplant in 1981, and its Lung and Heart-Lung Transplant Program is ranked among the top nationally for patient outcomes.

Today, Gilmer said he is happy to be home on his ranch. "In Montana, you're pretty much free to go anywhere and do anything you want," he said. "In California, there were so many people around. I just felt confined."

But those feelings don't extend to his experience at Stanford.

"The doctors, the nurses, the hospital, the parking lot attendants — there wasn't one unprofessional person that we dealt with there," he said. "It's the best place we could ever have hoped to be."

Source Stanford Hospital & Clinics