A sick woman's odyssey without health insurance

"At the end of the day," said welfare spokeswoman Stacy Witalec, "the response that she got, that's unacceptable. We didn't provide the help to this woman that she may have needed."

Leonardo Cuello, acting director of the health-law project, explained that there was not one program for medical assistance in Pennsylvania, but actually a family of programs - for pregnant women, for children, for the disabled, for the elderly, for women with breast cancer, and more - all with different income limits.

In a technical sense, Cuello explained, Ruby's income of $23,664 a year exceeded the limits for all programs she was eligible for at that moment. But there is one program, Medical Assistance for Workers with Disabilities, MAWD, that she could qualify for if she were working. And work, for this program, has been defined by welfare as something as simple as folding laundry for a few hours a month.

Ruby, had she been advised, could have qualified for MAWD, he said. And Witalec, the welfare spokesman, agreed. But there are 1.9 million Pennsylvanians on Medical Assistance, only 12,220 of them through MAWD. The caseworker at the Germantown office likely never heard of it, Cuello said.

"This case is obviously a fantastic illustration of just how little help people get in navigating the system, and just how much it is needed," Cuello said.

"When she finally does get treatment," he added, "she will be in a much more advanced state of disease, meaning there will be more invasive and expensive interventions needed, and of course her health results will be worse."

Temple University Hospital defended its treatment of Ruby Spencer.

"We didn't fail at all, in no way whatsoever," said John Cacciamani, chief of clinical operations for Temple University Health System. "We did the right thing."

Cacciamani also said her lack of insurance made no difference. "If this was my mother," he said, "I wouldn't admit her."

"When a person shows up in an ER," he said, "they have to be sick enough to have something that makes them unstable and requires them to need immediate attention."

In Ruby's case, he said, "she had a mass. Her labs [blood work] were OK. She's not obstructed. Her blood pressure was good. No fever. There was nothing that made us at all think that she was going to acutely decompensate."

A city clinic should schedule the appropriate tests and surgery, he said.

"If she'd come back to the ER two or three times, saying to us I'm just not getting anywhere, then I'd say we had a higher obligation, ethically, to try and get something done."

He agrees the system is broken and that the outcome - Ruby got no help anywhere - was unacceptable.

"This issue is really about us as a country," he added. "What do we do for people who have the most need? We did the right thing for her in our emergency department. But in our society she should have primary care."

Donald Schwarz, a physician and deputy mayor who oversees the health department and its free clinics, said this when told Ruby's story:

"Oh, my God, if she's not cared for, and she doesn't have care tomorrow, let me know. I will get her care."