Richmond Times Dispatch Article

If you found this blog, it's possible you got here through a link from the Richmond Times Dispatch article that discussed my work in international medicine and in medical service projets. In case you got to this blog without seeing the newspaper article first, here is the link in case you're interested.

Senate Action On Healthcare Reform

Early on December 24, the Senate voted to approve the healthcare reform package that had been under discussion. The process moves forward to conference committee before returning to each chamber for a final vote on the final bill.

Neither bill is perfect. I like a lot of what is included in the House bill, but the abortion limits bother me. The senate is much more conservative and leaves a lot more people without coverage, but is probably going to contribute much to the final product.

So, neither option is perfect. But both are much, much better than what we have now.

Two thoughts on this passage from the same website: this one is short and to the point, while this one is longer and more direct.

I'm getting ready to travel later this week on another medical service trip. As time allows, though, I'll try to give a little more thought and comment to the Senate bill.

This is further than reform has over gotten before...

Words To Live By

I suppose by now, if you read any other posts on this blog, that you might now where I stand politically. I believe that each of us, and our society as a whole, has a responsibility to care for the most vulnerable and marginalized members of our society. I try to live this ethic as much as possible, and I try to give of my time and skills to those who could benefit from them.

I also believe that we need to look beyond our borders to care for poor and marginalized peoples in other nations. Poverty and need exist in our country and cannot be denied and should not be accepted. At the same time, the poverty and need found in developed nations often exceeds the worst cases found in our nation.

When President Obama spoke at the Nobel Prize acceptance ceremony, his speech expressed many ideas that I feel are key aspects of being human: caring for others, striving to improve the conditions of the neediest in our society and our world, and always keeping those goals in mind as guiding forces in our lives. The speech is well worth reading.

Some of the parts of the speech that resonated most deeply for me:

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"[T]rue peace is not just freedom from fear, but freedom from want.

It is undoubtedly true that development rarely takes root without security; it is also true that security does not exist where human beings do not have access to enough food, or clean water, or the medicine and shelter they need to survive. It does not exist where children can't aspire to a decent education or a job that supports a family. The absence of hope can rot a society from within."

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"[T]he one rule that lies at the heart of every major religion is that we do unto others as we would have them do unto us.

Adhering to this law of love has always been the core struggle of human nature. For we are fallible. We make mistakes, and fall victim to the temptations of pride, and power, and sometimes evil. Even those of us with the best of intentions will at times fail to right the wrongs before us.

But we do not have to think that human nature is perfect for us to still believe that the human condition can be perfected. We do not have to live in an idealized world to still reach for those ideals that will make it a better place. The non-violence practiced by men like Gandhi and King may not have been practical or possible in every circumstance, but the love that they preached -- their fundamental faith in human progress -- that must always be the North Star that guides us on our journey."

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"As Dr. King said at this occasion so many years ago, 'I refuse to accept despair as the final response to the ambiguities of history. I refuse to accept the idea that the 'isness' of man's present condition makes him morally incapable of reaching up for the eternal 'oughtness' that forever confronts him.'

Let us reach for the world that ought to be -- that spark of the divine that still stirs within each of our souls."

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I'm sure that the President's detractors will find many ways to cut down his comments and minimize their importance. I hope that we can look past the naysayers and embrace his word and his vision as key elements of our own.

Witnessing History

By coincidence, the Virginia Academy of Family Physicians (VAFP) Board of Directors' (BOD) meeting on November 7 was the same day that the United States House of Representatives (HOR) was due to debate and vote upon H.R. 3962—Affordable Health Care for America Act. This act has been at the center of much of the political debate all summer, and includes significant overhauls of our health care system as well as providing for the establishment of a public health care insurance plan. As we were waiting to enter the Capitol for a tour, we saw a long line of people waiting to enter the HOR gallery to witness the debate on this important piece of legislation.

Following the tour of the Capitol, my wife Janet and I came back to the hotel to meet up with other members of the BOD. While we were mingling, Jan Ragland (the current VAFP President) mentioned that Sterling Ransome (one of the VAPF’s previous Presidents) had received tickets to visit the HOR gallery and we could check with him if we were interested. We deferred, considering that it was already after 7:30 pm and we didn’t want to head back over and wait in line. However, when Sterling showed up and offered the tickets directly, we figured that we really should go and sit in on some of the debate.

When we walked back to the Capitol, we realized that the lines were gone and we were able to proceed directly to the gallery. There we saw the introduction of the Stupak Amendment (which extended the Hyde Amendment restricting federal funding of abortion to the insurance plans purchased on the health insurance exchanges proposed by H.R. 3962) as well as the introduction of House Minority Leader John Boehner’s substitute amendment that would replace the proposed legislation with new legislation put forward by the GOP. As expected, the debate on this was energetic and long, and after being in the gallery for nearly 2 hours Janet and I decided to look for a cup of coffee.

It took a little while to find an open restaurant where we could get coffee and a snack, and we decided that we would head back to the Capitol. I didn’t expect there to be a vote of any consequences for some time—I expected something to happen in the early hours of the morning, but we felt that this was a historic moment (whichever side won) and we wanted to see how long we could last.

As we approached the HOR visitor’s entrance, it was clear that something was happening. People were streaming across the plaza outside of the Capitol, which was now filled with cars where it had previously been empty. We hurried through the security stations and into the line waiting to reach the gallery. As luck would have it, the Capitol security was in the process of moving current gallery occupants out to make room for new visitors and we were able to move forward right away and were soon seated in the gallery.

The floor of the HOR, which previously had only 30 or 40 people scattered in the seats, was packed and standing-room-only. Janet and I realized that the vote was underway on Boehner’s substitution amendment, which was voted down 258-176. Suddenly we realized that this was THE vote—that H.R. 3962 was going to be voted on directly.
Before the bill itself came to a vote, Minority Whip Eric Cantor (of Virginia’s 7th Congressional district) rose with a motion to recommit the bill to committee with instructions to add language regarding tort reform. This motion was voted down 247-187, and the bill itself came to a vote.

In the gallery, I was sure that the bill would pass without difficulty. After all, the two previous votes showed less than 190 votes that would likely also be votes against the bill. As the clock started counting down the time to vote, however, it became evident that the vote was closely matched. The “nays” reached 187, then 190, then 200 as the “yeas” stayed just 3 or 4 votes ahead. Each side increased little by little until, with approximately 3 or 4 minutes left in the vote, the “yeas” reached 218—the number needed to ensure a majority in the 435-member chamber. A loud cheer went up from the Democratic side of the HOR, and from many in the galleries—even as security sought to enforce the no-clapping rule for visitors. The final minutes of the vote expired, with the final count being 220-215 for passage. Whatever your perspective on the debate, it was dramatic and terribly important moment.

I support the bill, and after the vote Janet and I walked over to our Congressman’s office to see if we could thank him for his vote in favor of the bill. Bobby Scott’s office was open, and his aides mentioned that he was due back in a few minutes and if we would like we could wait and meet him. We waited—after all, what were a few more moments when it was already after midnight—and were able to speak with Rep. Scott for a few moments and thank him for his work in support of this bill.
When I went to college, Government was the other major I was considering other than Biology. It was a great chance to see the process at work—ugly and convoluted as it can be—and an opportunity to walk in and meet our representative. Health care reform has a long road ahead of it and, whatever side of the argument you find yourself on, I urge each of us to become active and engaged in the process. If we choose not to, rest assured that someone else will be speaking their mind to our representatives.

Anthem's Response

So, apparently I annoyed Anthem/WellPoint, Inc with my Op/Ed. My reply might not be posted in the paper, so I'll post it here.

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I am writing to clarify claims I made in my Op/Ed dated October 30, 2009. On November 8, a WellPoint, Inc. spokesman called into question some of the claims I made in my Op/Ed, and alleged that I had been dishonest. I would like to take the opportunity to reply to these comments, and to show why I believe I have accurately represented some of WellPoint, Inc.’s business practices.

I would like to start by acknowledging my misstatement regarding WellPoint’s profit. This error was pointed out to me by one of the Richmond Times-Dispatch readers, and the newspaper printed a correction on October 31. I apologize for this error, and am glad that it was addressed.

I would also like to note that my Op/Ed represents my personal opinion. I do not speak for VCU Health Systems, and VCU Health Systems has not requested, endorsed or approved of my comments. My employment there was mentioned only because I understood the Richmond Times-Dispatch required it to be noted.

Moving forward, I would like to demonstrate some examples of why I believe that WellPoint’s business model actively seeks to deny care to patients. Mind you, in my Op/Ed I never accused individual employees of improper conduct or of refusing care for patients. Rather, I draw attention to corporate policies that I believe harm patients. Some examples of these policies are:

• During a June 16, 2006 hearing of the Oversight and Investigations Committee of the House Energy and Commerce Committee, subcommittee Chairman Rep. Stupak noted that the committee's investigation has "found that at least one insurance company, WellPoint, evaluated employee performance based in part on the amount of money its employees saved the company through retroactive rescissions of health insurance policies. According to documents obtained by the committee, one WellPoint official was awarded a perfect score of five for exceptional performance based on having saved the company nearly $10 million through rescissions." Therefore, it is not only me but also a subcommittee of the U.S. House of Representatives that asserts that Anthem rates employees based on their ability to retroactively deny care to policyholders. It is also striking that Anthem’s representative at this hearing would not commit to ending rescissions and stop retroactively canceling patients' insurance--even if the reasons for revoking the policy had nothing to do with any intentional fraud on patients' parts or any connection with the patients' insurance claims. I could provide numerous examples included in this subcommittee's report, but do not have the space to do so. The transcript of the hearing and its supporting documents can be viewed at http://tinyurl.com/m4w24a.

• An article in the Los Angeles Times (February 13, 2008) reports on Blue Cross of California’s decision to stop asking physicians to search through patients’ medical records to seek information that might be used to cancel patients’ insurance coverage. To quote from the article:
Blue Cross sent physicians copies of insurance applications filled out by new patients, along with the letter advising them the company had a right to drop members who failed to disclose “material medical history.” That could include “preexisting pregnancies.”

The letter asked physicians to “immediately” report any discrepancies between their patients' medical condition and the information in the applications.
Again, this sounds like a practice designed to find patients whose health insurance can be terminated—after they have applied for the policy and paid premiums. At least some of those interviewed in this article raise concerns whether these letters violated privacy laws.

In closing, allow me to make it clear that I did not accuse Anthem’s associates of any wrongdoing. Instead, I believe that a great deal of what is wrong with our current health insurance system is related to the activities of for-profit companies and the steps they take to ensure that profits are made. It is WellPoint’s and Anthem’s corporate policies that I am critical of. Considering the information I have provided above, I believe that I have good reason to be critical.

A public option would provide a counterbalance to policies such as these described—although it would still face fraud and abuse, it would at least be answerable to the people and not to stockholders seeking profit. Once WellPoint and other for-profit insurance companies choose to engage in an honest public discussion, we should welcome it. We should also ask them to explain the harmful policies I have outlined above.

Sincerely,

Mark H. Ryan, M.D., F.A.A.F.P.

The American Medical Association's Position on Healthcare Reform

I was at meeting recently where a representative of the American Medical Association (AMA) spoke about the organization's perspective on the current healthcare reform proposals under debate in the congress.

The AMA's template for reform includes:

1. Provide coverage for all

2. Insurance market reforms to expand affordable coverage, address pre-existing conditions, etc.

3. Assure health care decisions will be made by physicians (not insurers or government agencies)

4. Invest in prevention, wellness, and quality improvement.

5. Repeal Medicare's Sustainable Growth Rate.

6. Medical liability reform.

7. Reduce administrative burdens.

The AMA's perspective is that physicians generally agree on these ideas, but differ on the proportions that each of these ideas should contribute toward reform.

My main disappointment is that during the conversation, the issue of universal coverage was discussed very little in proportion to issues of physician payment and such. I guess that shouldn't be a surprise considering that this was a physician's meeting, but I guess I expected more.

There was a representative on the panel discussing these issues who is a member of the "Coalition to Protect Patients' Rights." This person seemed pretty set that the only right reform was to give tax breaks to individuals and allow them to negotiate with their providers regarding the costs of care. I'm going to try and review this group a little more--I don't think this proposal has any validity, but I want to check into it before I criticize it.

Initial Reaction to the Op/Ed

As I noted a couple of days ago, the Richmond Times-Dispatch posted my Op/Ed. The discussion has been interesting, to say the least. A few personal attacks, some half-formed arguments, but a lot of honest and concerned people sharing their opinions on this incredibly complicated issue.

My point of view is that, without a national public alternative to the for-profit plans, reform will not amount to much. It will be interesting to see how the debate continues over the next few days.

Op/Ed

I intend to post more later on, but I thought I'd note that the Richmond Times Dispatch finally posted my Op/Ed.

If You Don't Believe Me, Believe Them

The Institute of Medicine is an independent, non-profit organization whose goal is to improve decision making on issues of healthcare. The Institute of Medicine's Committee on the Consequences of Uninsurance has proposed 5 key features that would be required of plans to extend health insurance. This list is from the Institute of Medicine's Uninsurance Checklist.

1. Health care coverage should be universal.

2. Health care coverage should be continuous.

3. Health care coverage should be affordable to individuals and families.

4. The health insurance strategy should be affordable and sustainable for society.

5. Health care coverage should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient centered and equitable.

A single payer plan--such as Medicare for all--is probably the best way to achieve this, but seeing the heartburn caused by the proposal of a public insurance option I doubt that single payer is in the cards right now. However, when you consider these key points, HR 3200 and the Senate HELP show the most promise. Both include the public option, which would stand to keep the costs of the private plans under control. The Senate Finance bill is probably not sufficient--state-based co-ops are not likely large enough to incorporate a pool of covered lives to adequately share the risk and keep costs low enough to be viable (especially if Republicans refuse any federal backing to ensure financial stability in the early stages).

So far, I have not seen conservative plans to reform healthcare in a way that would meet the criteria noted above. Plans like this from Gov. Bobby Jindal don't really seem to answer the call. I don't really see how they will address the cost issues. Even if HSAs and government tax credits make some form of coverage available to all in theory, how will the costs of insurance be kept in check? There is nothing in this proposal that would keep costs of plans contained. In fact, costs could rise quickly if patient costs are being subsidized in some way and the insurers can get away with raising costs some--overall patients might pay less, but the subsidy would need to cover more.

I'm sure Republicans would like to claim that the magic of the free market would work all this out--that competition between insurers would keep everyone in line. The fact is that, right now, insurers do not really compete among each other. Communities and states will have one or two insurers that dominate the market, to the exclusion of other companies. The free market is not working.

Free markets only work when consumers--patients, in this case--can reasonably refuse to purchase a product if the cost is not reasonable. I can choose not to buy a new car, a new TV, a new house, or a certain brand of mustard of the cost is more than I choose to pay. However, every single one of us will need healthcare. Maybe not much, and maybe not right now, but everyone will have to make use of this resource. With that being the case, consumers cannot really decline to pay for this product and therefore insurers have no real cost pressures to reduce the amount they charge.

So: real, honest healthcare reform that will meet the obligations listed above must include a public option to keep costs affordable. It also needs to have a mandated set of benefits in order to make sure that the affordable plans are actually worth something. Coverage must be available regardless of pre-existing conditions and regardless of your current employer.

Do Physicians Support a Public Option?

Recently, an acquaintance brought this poll to my attention on Facebook, and claimed it shows that physicians don't trust a public option.

Interesting to note that this poll is from Sermo, a group whose founder posted this letter to discredit current healthcare reform efforts.

Remember: be careful how much weight you put on polls that are not randomized and that are not objective. Sermo is a self-selected group of physicians that does not favor the current proposals. If you ask this group if they like the current plan, the answer will be "No!". If you find this surprising, then you know nothing about research or polling.

As a counter-point, I'd like to re-post this link--from a top medical journal--showing the overwhelming support physicians have towards a public option (70%).

Remember: just because your favorite pundit says something is so doesn't make it so.

Healthcare Co-ops

At this point, I am sure that everyone is aware that the Senate Finance Committee voted down 2 amendments to introduce a public healthcare option into their proposed bill. Opponents of healthcare reform have trumpeted this as a major victory, without realizing that this has not killed the proposal. The Senate is a much more conservative body than the House of Representatives and the public option was going to be a tougher sell in that group. What healthcare reform opponents don't seen to realize is that the key action of the senate is to pass SOMETHING out of the chamber. If they Senate passes a bill and the House passes out HR 3200, then they go into the reconciliation process where the public option can become the primary method of making healthcare accessible to all.

I wanted to say a few words about the Senate's proposed alternative: health care co-ops. The intent is for these member-owned organizations to be able to bundle people together and allow them to self-insure.

This sounds like a nice idea: let the members decide what benefits will be offered and decide the premiums, costs, etc. There are major problems, though, that have to be addressed:

--Insurance companies are only financially viable if they have a large enough risk pool that the money being paid in in premiums can cover the necessary costs and benefits being paid out. This means that you need a sizable member pool to get a large enough risk pool with enough relatively healthy people that you can achieve the needed net positive cash flow. I don't know the numbers offhand but it is a very large number of people that need to be in the pool for the co-op to work. If we are going to have the 50+ co-ops proposed in the Senate (at least one per state), how can that critical mass of members be reached? Around World War II, healthcare co-ops developed as a way to handle healthcare. Of these, only 2 remain. How will the Senate's plan provide for the longevity and survivability of their proposed co-ops?

--On a more political level, how will the start-up co-ops be funded? I, for one, would be reluctant to sign up to a co-op and start paying premiums into it unless I felt that the co-op was financially secure enough to be around for a while. I suspect many people would be worried about sending money on health insurance coverage that might not be around very long. So: co-ops would have an easier time signing up members if there was some form of assurance that the institution was fiscally sound. For example, government back-up (in the same way that the FDIC protects our bank deposits) would provide the earliest members of healthcare co-ops assurance that their money would not be lost if the co-op is unable to sign up enough members. The political problem: Republicans will not support this sort of start-up assistance or other forms of federal money to ensure solvency.

--Finally, in order for alternative health insurance structures to be successful, they need to be able to compete with the large private insurance companies that are flush with money. How exactly is a Virginia Health Co-Op supposed to compete with Wellpoint (Athem) or Aetna or the like? If you had a nationwide health co-op then this might work. Funny...that sounds familiar...sounds a lot like a national public option...

So, the co-ops are unlikely to make a dent in the costs of healthcare, will have a terrible time enrolling enough members within an individual state in order to have the covered lives to be fiscally sound, and will have an even more difficult time starting up if there is no federal back-up to provide financial security for the early co-op members.

The Finance Committee's proposal for co-ops is probably planned to be a soft alternative that will not scare away conservatives and on the surface might appeal to liberals. However, at the heart of the matter, co-ops that are not structured at the national level and that do not have federal backing at the beginning will probably not make any difference.

Doctors Support Healthcare Reform

Real Support

Just a brief note this time. Previously, I mentioned that I thought the National Physicians Alliance (NPA) represented my views better than the American Medical Association (AMA). Each day that goes by, I feel more and more strongly about this.

As you probably guessed, I believe that real, hones, meaningful healthcare reform is important and that we are in a critical time for reform. Whatever happens, good or bad, the decisions made now will determine the nature of healthcare for the next 15 years or so.

The AMA has signed on to the reform effort, and currently support HR 3200--which includes a public health insurance option. However, my perception is that their support is lukewarm at best and that the public insurance option makes them very nervous.

On the other hand, the NPA has stood up firmly in support of reform including a public option. They have videos like these two describing the situation (one here, the other here), informative links like this one discussing a poll in which health care leaders show a 70% support for reform including a public option and this one which compares the 3 current bills side-by-side. Useful stuff, no?

So: the NPA is again the stronger patient advocate and the better advocate for reform than the AMA. I'm glad the AMA is supporting HR 3200 because it allows the process to move forward. I just wish their support was deeper and more outspoken.

Physicians Support Health Reform With A Public Option

We've already seen that multiple physician groups support healthcare reform, including HR 3200, that includes a public option. We've also seen many, many loud/frantic opponents who would like to stop the process and eliminate any discussion of a public option.

Now, the New England Journal of Medicine publishes the result of a new survey in which most physicians (approximately 3/4) support health reform that includes a public option. This includes physicians of all specialties, though those that have less patient contact supported public options a little less than other clinicians.

In a related note, approximately 3/4 of physicians believe that physicians believe that addressing societal health policy issues is within the scope of their profession and that physicians are obligated to care for the uninsured and under-insured.

So: physicians, those with the most direct and meaningful interactions between patients and healthcare systems, believe that a public option is a valuable part of healthcare reform, and that advocating for this is within our vocation's calling.

So we need to speak up for our patients and we need to support reform that includes a public option. We cannot be silent about this.

Solidarity

I saw pictures from the "conservatives" march on DC today. Some were carrying versions of the old colonial "Join or Die" flag.

I personally find this ironic. This implies solidarity between people and efforts to improve the common good. The irony is that these are the same people opposing efforts to expand healthcare to the marginalized and underprivileged citizens in our nation.

Do they really not see the disconnect? Their flag should read "leave me alone and stay out of my business".

The GOP Reform Plan

So, I'm reading over the GOP health reform plan from June 2009. Some thoughts:

--Tax savings for those who provide their own health insurance will not help if you cannot pay for your own health insurance.

--Will providing tax credits really be enough to account for the full cost of health insurance? If not, then the tax credits may have no impact on the availability of coverage.

--If insurance companies are allowed to pool their insured customers across state lines, which state's rules apply? Each state has an Insurance Commissioner who decides what coverage and obligations are required. If an insurer has a product that is sold in multiple states, will they be able to use the least restrictive rules? In that case, will there be a race to the bottom in which the only affordable insurance plans available are those that offer the fewest benefits and the least coverage?

--I agree that medical liability and tort reform would be nice. As a physician, I would be very happy not to be burdened by ever-increasing malpractice costs. Medical malpractice caps do limit the malpractice costs for physicians, but there is little/no evidence that it stops physicians from over-ordering tests or that the cost savings are passed along to patients or to the system as a whole. So--malpractice and tort reform would be great, but will not really fix the system. Including this reform might be best used to help get physicians on board, but not to remedy any real problems. [The way to stop over-ordering might be to allow physicians to see fewer patients and spend more time with each patient--a good history and physical exam could save a lot of tests--without going broke or out of business.]

--I do not see how health savings accounts (HSA) will help people who are too poor to save money. No-one has yet explained to me how patients whose incomes are used up by their bills and other obligations are supposed to benefit from access to an HSA unless someone is putting the money in on their behalf.

--Making health insurance portable and guaranteeing health insurance to all regardless of preexisting conditions: both already in the proposed legislation.

--Has the GOP paid any attention to the fact that health insurance costs are severely limiting business's ability to compete in the global marketplace? Are the proposed tax credits going to be enough to balance this out?

--Expanding SCHIP programs and allowing minors to stay on their parents insurance plans for a longer time: already in the proposed legislation.

--Enhancing incentives to enter primary care and promoting community health centers as an accessible model of care: already in proposed legislation.

So, one big missing piece: nowhere do I see any mechanism for controlling insurance costs. In the the current proposals, the public option would provide a means for controlling insurance costs. Under the GOP plan, is this supposed to magically appear as a gesture of goodwill on the part of the insurers? Or is a health insurance exchange going to help moderate costs (you know--like the exchange in the currently proposed legislation)?

I don't see how the GOP plan actually expands care to those who lack access now and I don't see how it makes health insurance more affordable.

It's a little like Medicare Part D (the drug coverage plan passed in the Bush years). This plan specifically restricted the government Medicare program from negotiating prices with drug companies. So, as a result, the program has been tremendously expensive for Medicare and a windfall for big pharmaceutical manufacturers while not providing maximal benefits to patients. The GOP healthcare refomr proposal would give patients and businesses tax credits to buy private insurance, in effect rewarding the very same companies that have failed us thus far.

Passing along public money to improve private companies' bottom lines. We've seen this show before, and it never ends well for us.

The Real Reasons We Need Health Reform

Over the last few months, many people (including me) have been making the point that health care reform / health insurance reform is necessary and urgent. I've tried to make the point by giving examples of patients who have suffered under the system, the additional fees and costs incurred by uninsured patients, the challenge to finding useful and affordable health insurance, etc. These are all valid reasons, but I don't know if they are the REAL reasons why we need healthcare reform.

In medical school, we took a class in medical ethics. As part of the class, we were taught the 4 key principles of medical ethics:

Beneficence
Non-maleficence
Autonomy
Justice

In more detail:

Beneficence: the requirement to do good for your patients; the obligation to provide benefits to those in need.

Non-maleficence: the obligation not to cause harm (primum non nocere); the obligation to prevent injury to our patients.

Autonomy: patients must have the personal rule of the self while remaining free of controlling interests by others and by personal limitations. This is patient autonomy, not autonomy in the restricted "conservative" sense of "hands off my property." I am referring to autonomy in the sense that without good health we cannot be in control of our lives and that harmful actions by any outside influences (including multinational corporations and the insurance companies) need to be avoided.

Justice: giving to each his due; equals must be treated equally, but unequals need to be treated unequally--if you have greater needs, you might require more resources.

If we value all human life (and "conservatives" claim to value human life more than anyone else), then we should hope that all people have the chance to flourish and to maximize their capabilities. In our economy and government, we do not guarantee equality of results. We do, however, claim equality of OPPORTUNITY. The classic American story is the individual who comes from poor beginnings and reaches great heights. This potential, this opportunity, is greatly restricted or lost altogether if one is in poor health.

Our current health care system violates all 4 principles of medical ethics. It does not allow for beneficence--insurance companies restrict access to care and the costs keep millions from accessing the system at all. It does not allow physicians to prevent harm: patients may not get follow-up tests or visits because of cost or access issues. It does not allow for patient autonomy in any meaningful form--the final decision is oftentimes not really the patients' decision. Finally, the system is evidently and fundamentally unjust. This system also negates any premise or claim we might make of truly valuing other people.

To me, these are the real reasons we need healthcare reform. Physicians and other healthcare professionals must stand behind reform that will make our system effective and ethical.

Uninsured Patients Pay More For The Same Care

So: when last in the Dominican Republic, I was hit in the head with a pistol when 3 men tried to rob our group. 2 months I was still having a little dizziness, so I had an MRI of my brain with intravenous contrast to check things out. Last week I received my bill for the MRI. It cost $3,922.00.

Now, here is where things get a little odd and where uninsured patients get an even worse deal than you would expect. The hospital where I had my MRI participates with Anthem, who provides our health insurance coverage. In order to sign on to participate with Anthem (something that you pretty much have to do in Richmond, as the company is a huge player in the area) health care providers have to agree to accept Anthem's "discount". In this case, Anthem writes off $1,500.55 of the bill and determines that only $2,421.45 are actually allowed. So: Anthem determines automatically that 38% of the charges are not permissible.

Now, I pay my co-pay on the lower cost ($2,421.45). However, if you have no insurance, you do not qualify for Anthem's discount, and you are going to be charged the whole $3,922.00. This means that, if you are not able to afford coverage (or are one of the relatively few who chooses not to buy coverage) you pay a lot more. When you consider that most of the uninsured are also the working poor, you can see how quickly costs add up and threaten to crush families' chances of improving their lives.

To summarize: if you cannot afford health insurance, you will pay more for any health care services than you would if you had health insurance. And not just because you're paying for the charge instead of paying a copay--the actual charge is significantly higher.

[As an aside: for all those critics of health insurance reform who feel that young, healthy people may decide that they do not need insurance, this sort of incident shows why everyone should have some level of coverage. Remember that the hospital fees are increased in order to make up for the money lost on those who cannot pay for the care. I certainly didn't ask to be pistol whipped, in the same way that a 20 year old does not ask to be in an automobile accident or a 40 year old farmer does not ask to be mauled by her hogs. If we all contribute to the common good, then all can be protected and helped. At some point we will all need health care, and I think we should all be contributing to provide that care.]

Op/Ed

I drafted an Op/Ed a couple of weeks ago, in hopes that our local paper might pick it up. No word thus far, so I'm posting it here.

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For some weeks now we have been subjected to the sound and the fury thrown forward by the opponents of the White House and Congress’ efforts to enact health insurance reform. Misrepresentations and outright untruths have been trumpeted by those who would block health insurance reform. This is a shame, as our current health insurance system is terribly broken and this is our best chance to fix it. In a system where 1/6 of the nation lacks health insurance coverage and health care costs are expected to rise from 16% of our GDP to 25% in 2025, the system is in terrible shape.

To date, I have practiced only in communities where access to health insurance was difficult and insurance issues were common. I have had to work with patients to determine which of their $4 prescriptions were most important, as they could only afford to fill one of them. I have had patients ask me to do only the barest of essential tests and procedures and to wait (if possible) until Medicare kicked in before doing preventive and health maintenance care. Patients delay valuable and necessary care because of cost and lack of insurance coverage. Meanwhile, for-profit insurance companies make enormous profits while working to deny care to patients who have paid for their insurance as well as rationing health care services. Small businesses (and large corporations) are unable to invest in growth because they are hamstrung by the ever-increasing costs of health care insurance for their employees. Even those households with insurance face a choice to pay higher premiums or switch to cheaper plans with less coverage. On the world stage, our health care system ranks first in terms of how much money we spend, but only 37th in overall performance (World Health Organization rankings).

The current health insurance system has not answered these challenges. Studies have shown that patients who actively look to purchase health insurance are unable to do so 75% of the time due to cost or pre-existing conditions. Public health insurance plans—such as Medicare and Medicaid—are burdened with covering those patients with the greatest needs (elderly, disabled, children) as private insurance plans cover a disproportionately large proportion of young, healthy patients who need less health care per person. 50% of personal bankruptcies in the United States are the result of health care costs, and most of these patients had insurance when they first got sick. This is no way to care for our nation’s citizens.

For the first time, business, government and health care organizations have joined to support health insurance reform. This reform must accomplish key goals: it must be universal, affordable (for patients and for the country) and accessible to all. For-profit health insurance plans have not been the answer, and coupling a high-deductible insurance plan to a health savings account would leave too many people uncovered. The only true path to reform is to develop a public health insurance plan option. This public health insurance plan would set a standard for costs, coverage and access that for-profit plans would have to answer. This would work to make coverage more available for all. Current legislation—thus far endorsed by such groups as the American Academy of Family Physicians, the American Medical Association, the American Academy of Pediatrics, the American College of Physicians, the American College of Surgeons, and many others—proposes such a plan while preserving patient choice of health care plans and physicians. This legislation also would enact deeper reforms that would promote preventive care and health maintenance services, enhance primary care training (as you cannot have an efficient health care system that is not founded on the bases of solid primary care), make for-profit health insurance plans more accountable to their patients, and ease the costs burdens on small businesses.

As a country, this is our chance and our opportunity to change a system that is flawed and failing. Enough shouting and enough lying. The current legislation is supported by a breadth of health care professional organizations and numerous other stakeholders. This is the time to act decisively. The next few months will dictate healthcare in this country for the next 15 or 20 years. If we fix it, then the nation will benefit. If we don’t, more and more people will be lost to the system. Congress needs to pass comprehensive, meaningful health insurance reform now.

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Public Support For Health Isurance Reform

If you watch the news much, you probably think that the public is opposed tooth and nail to any efforts and health insurance reform. After all, all we see on the national news are people screaming their opposition to any of the current reform plans.

It's good to read, then, that the public supports reform. Strongly. Especially when the plan is described honestly.

Another analysis of public sentiment can be read here.

So, why isn't the media paying more attention to these significant levels of support?

Facebook Debate

Funny how a brief Facebook status update can spark a debate. It's on a friend's page, so I don't want to publicize his name. But I think the discussion is interesting. It's crazy long--and I actually edited out some of it when I wasn't directly involved--but I still think it's interesting.

My friend: FRIEND

Me: ME

Person 1: not fond of current proposed insurance reform

Person 2: not fond, either.

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Friend:

wants Medicare for all

Person 1: The government can't run cash for clunkers (or social security, or medicare, or medicaid), why would you want them to mess up the health care system?

Friend: It's not working now so why not try something different? Medicare does work and less expensive to run with more choices.

Person 1: Seems to work fine to me. There isn't anyone in this country (including illegals) who can't get medical attention when required. Medicare is going broke, it doesn't work, AARP wants improvements to it. What is needed is a stop to all the lawsuits against doctors and hospitals...that is what is driving up the cost of healthcare in america. Cap the lawyers.

Me: 1/6 of Americans lack health insurance, and many with insurance still face hardships. As a family doc in an underserved community, I can assure you that there are many, many people who lack access to health care. Just because the ER can't turn you away doesn't mean that people can actually get needed health care there. ERs can't handle care for chronic illnesses.

Medicare is going broke b/c it disproportionately insures older patients and many disabled patients--2 groups that are higher users of healthcare services. Medicare is actually 3 or 4 times more efficient than private insurers but is handicapped by its patient profile. Voters who are on Medicare LOVE Medicare.

As a physician, I'd be happy to cap the lawyers. But it won't expand health care to those who don't have it and it won't fix the issues of costs. Medicare for all, or a strong public health insurance plan option, will keep for-profit plans honest, keep prices down, and ensure that anyone can afford care.

Person 1: I don't agree with your 1/6 number...can you back that up with a reference? Many of the people who do not have healthcare choose to not have it because they would rather spend the money on other things. '1/6' people in america are looking for a free handout as long as they don't have to pay for it, lets get the people who work for a living to pay for it for us.
If the public option cost users $300 a month do you honestly think the '1/6' of people who don't have healthcare would pay? My wife paid for her own plan from Blue Cross for around $300 a month and she had a previous condition, now take your typical 20-year-old and consider what they spend a month on going to the bar and drinking. Lets all sacrifice.
Public healthcare is crap healthcare...I lived in Canada for 30 years so I know. Look at how well the government manages our money. Regardless of which party is in power, they spend our tax money recklessly. Adding 50 million new users with no new docs,nurses,etc does not expand healthcare. It dilutes it. As for the gov't plan, it will destroy the free market insurance companies, it will not keep prices down (see Canada), and yes 100% of people will have 50% the healthcare that used to exist. Great if you have 0%, but '5/6' who have healthcare get screwed.

Me: I found 2 estimates of uninsured Americans: either 46 million or 54 million. If the US population is 307 million and we average the uninsured # at 50 million: 16% = slightly less than 1/6 of the nation.

# of uninsured references:

1. DeNavas-Walt, C.B. Proctor, and J. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau., August 2008

2. Chu, M. C. and J. Rhoades, The Uninsured in America, 1996-2007: Estimates for the the U.S. Civilian Noninstitutionalized Population Under Age 65, Medical Expenditure Panel Survey, AHRQ, Statistical Brief #214, July 2008.

Now, if you take out the population over 65 (almost universally covered by Medicaid) then 18% of the country is uninsured.

Me: "Over 8 in 10 uninsured people come from working families"

The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008. http://www.kff.org/insurance/7672/index.cfm

Me: "Studies estimate that the number of excess deaths among uninsured adults age 25-64 is in the range of 22,000 a year. This mortality figure is more than the number of deaths from diabetes (17,500) within the same age group."

Dorn, S, “Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality,” Urban Institute, 2008.

Me: (In my comment above re: # uninsured--I meant to say if you're over 65 you're almost universally covered by Medicare, not Medicaid).

Me: Finally, re: your disparaging comment that people who don't have insurance are simply spending their $ frivolously: The Commonwealth Fund published a study showing that when patients sought to purchase health insurance in the private market, 75% of those families studied ended up not buying a policy either because of cost or because they were denied due to pre-existing conditions.

M. M. Doty, S. R. Collins, J. L. Nicholson, and S. D. Rustgi, Failure to Protect: Why the Individual Insurance Market Is Not a Viable Option for Most U.S. Families, The Commonwealth Fund, July 2009.

Me: "Of the 37.8 million people of working age who lacked insurance in 2005, 27.3 million worked at some point that year, according to the Census Bureau figures, which approximate the number of people uninsured at some point in the year. The number of uninsured full-time workers grew from 20.5 million in 2004 to 21.5 million in 2005."

Geri Aston, AMNews Staff. Sept. 18, 2006

Stupid, lazy, good-for-nothing full-time workers!

Mind you, this was 4 years ago. Not getting any better.

Me: Maybe you're worried that a public health plan will put undue burden on small business? A valid concern. However:

"Without health care reform, small businesses will pay nearly $2.4 trillion dollars over the next ten years in health care costs for their workers, 178,000 small business jobs will be lost by 2018 as a result of health care costs, $834 billion in small business wages will be lost due to high health care costs over the next ten years, small businesses will lose $52.1 billion in profits to high health care costs and 1.6 million small business workers will suffer “job lock“— roughly one in 16 people currently insured by their employers."

The Economic Impact of Healthcare Reform on Small Business, Small Business Majority, June 2009

So, comprehensive health insurance reform actually is pro-business.

Person 1: I will agree with you on one of your points, one area of reform that should occur is in the area of pre-existing conditions.
Your 75% statistic does not differentiate between cost vs. pre-existing conditions. I don't buy the cost arguement, you look at people below the poverty level and the majority of them have cable tv, big screen tvs, cell phones, etc. Sacrifice of the "toys" can easily free up money for buying insurance.
As for small business, cut the lawyers out of healthcare and costs will stay well under control. The government cannot guarantee it will keep costs down any more than private industry, historically it is never successful, and Canada is a perfect example at how costs are not controlled in a way that benefits the people. Also "Small Business Majority" is an Obama supporter, if they were truly representing small business, they wouldn't be donating money to support political parties. I think Arensmeyer would back up any recommendations the dems want.


Person 2: The plan the Gov. is voting on "healthcare reform" is more about taking rights and controlling money. Most politicians voting have not read it! Our system may not be great as is, but adjusting it is FAR better than the "reform". Can you imagine being Punished by the government for paying cash for needed health care that they won't cover because bureaucrats (not doctors) decided that it was too expensive?

The other part is the many costs (taxes) levied on insurance companies along with hoops to jump through will get them out of the health insurance business quickly, leaving Only the Public Option. There is even a provision that won't let you go back to your "old" insurance company if you cancel - you must go with the public option - despite Obama's speeches (carefully worded).

It is all leading to eventual single-payer gov. run healthcare, just like Canada and Britian have - with waiting periods of up to years, just to get a gen. practitioner, among many other problems!

Person 2: Healthcare coverage for everyone is a nice idea, but just look at the school systems (public vs. private). More and more money but less and less efficient. The "war on poverty" has not eliminated poverty, or even significantly reduced it. "war on drugs", etc etc.. Government involvement does NOT make anything more efficient. Obama (and congress) claims he can bring down costs. He is not in the business of insurance or health care finances, but he knows how to cut costs where all others in the business have failed?
Just think about it.

Person 2: The proposed bill (if voted in) will open your medical records and financial records - and Require you to give credit info and bank access to the gov so they can extract payments for medical services.
Think of the eventual controls that a single payer (socialized) system will have. They will control your day to day habits, such as what you eat, smoking, drinking, driving, grilling, sleep? you name it - all under the idea that it Costs money for you to be unhealthy or risky!

This CNN/Fortune magazine article is pretty good on the basics:

http://finance.yahoo.com/insurance/article/107408/5-freedoms-you-would-lose-in-health-care-reform.html?mod=insurance-health.

Person 1: An idea I read online this morning is a system that provides low interest loans...like they have for college students.

Person 2: If I had to pay for a medical procedure for someone in my family, even now, that was not covered I would not hesitate to borrow or mortgage or sell whatever I had to... Interesting idea.

Person 1: There was a lady complaining about how private healthcare was rationing a cancer treatment that her husband was trying to get. She felt that he may have lived had they not spent so much time fighting to get treatment approved by their healthcare company. My thinking is if you are going to die, you get the treatment and worry about how it will be paid for afterwards.
Another gov't comparison, the IRS. Press 1 because you owe them money...no wait. Press 2 because they owe you money...I hope you like Muzak.

Me: Person 2: the current legislation does not block you from returning to your previous insurance if you so choose and will not give the gov't access to your financial accounts. If it's in the bill, I'd ask you to point out where.

Re: mortgaging the house to cover medical bills--probably won't work.

"According to another published article, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs."

Robertson, C.T., et al. “Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures,” Health Matrix, 2008.

Me: Re: the article you mentioned:

--the mandated minimum benefits would be present because otherwise it's a race to the bottom. mental health coverage, substance abuse, Pap smears, mammograms, vaccines, etc are all essential services. I do agree, though, that you have to draw the line. These services could be based off the United States Preventive Services Task Force (USPSTF), which recommends evidence-based services.

--the idea of community ratings is based on the concept of cost sharing; I agree that it's a challenging set-up, but cost sharing will be needed. Remember that the healthy 24 y.o. could still end up having an accident or injury or a retinal detachment and require 10,000s of medical care (which currently has to be absorbed by the system)

--I guess it might threaten HSAs and high-deductible plans. However, those plans would not be excluded. Also if a public option has a lower deductible and better coverage (and is competitively priced) this doesn't seem so bad.

--In terms of keeping your plans vs. offering approved plans: is it really so bad to require insurances to cover certain essential/necessary services?

--The medical home is not a gatekeeper/HMO model. A complete misunderstanding of the model. The patient-centered medical home (PCMH) would have a primary care physician acting as your principle physician and coordinating and tracking care you get elsewhere. Rest assured--the physician groups promoting the PCMH do not like gatekeeper models; the idea is to ensure that patients have access to needed care and that physicians would be reimbursed for quality care, not for denying care.

--I'm curious about "the flexible, employer-based plans" that the article mentions: I guess they mean the current system, the one that is failing millions and limits the profits and growth of small business?

What value are these five freedoms to those who have no access to care?

Friend: Okay so I do not have a flat screen TV or cable or a fancy cell phone (mine doesn't take pics and is black and white and was free with my monthly plan) nor do I spend tremendous amounts at the bar or on "toys" or any of that. I live a rather modest life style and still can't afford health insurance. And I have to be honest even if I could afford it I'm not too keen on paying such high monthly premiums only to be dropped at the discretion of or denied care by a giant corporation that is so money hungry that simple compassion is no longer part of the equation. An example of this is SO's plan at work. Her co-pay went from $15 to $20 per visit to the first $3,000 having to be payed by her in turn discouraging her from seeking even basic health care because she simply doesn't have the cash to drop. A change for the worse in my opinion only serving to further discourage the "insured" to not use their benefits while the fat cat keep getting fatter by collecting monthly from her employer.

Friend: I don't think my situation is the exception here. We aren't talking about 20 somethings that could perhaps tighten it up and spend their cash more wisely. We are talking about everyday folks who are just a layoff or major medical situation away from being completely without health care. Situations can change quickly and even if you've got it good right now it can all be gone with one bout with cancer or one major car accident.

As far the low interest loan goes ... really? Let's put folks even further into debt by making them pay interest for being ill. That's if they are even still able work to pay off the loan to begin with. Chances are if they can't afford insurance they can't afford another loan. Also I see that as another way for the already engorged financial institution the get even fatter by preying on the sick.

Me: Hear, hear!

A lot of evidence showing that cost shifting to patients reduces use of medical care. Even though the premiums are still being paid.

Friend: Person 2 I don't think you are alone in the thinking that you would do anything you could for a family member in need. Most people would. Some people don't have a house to mortgage or much to sell to make a huge impact on a looming medical bill. I know too many people who are working hard just to make to the next week hoping nothing serious happens to them. A good portion of the population is just a paycheck away from being homeless much less insured.

"My thinking is if you are going to die, you get the treatment and worry about how it will be paid for afterwards." – Person 1

Correct me if I'm wrong but it isn't up to her to get the treatment or not. I'm sure she would have done just that. Sad thing is doctors seem to be bound by the HMOs and if it not approved it doesn't get done.

I'm just saying is so terrible to have some compassion for your fellow human being and act like other civilized countries and provide at least basic health care your citizens.

Me: "A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance."

Himmelstein, D, E., et al, “Medical Bankruptcy in the United States, 2007: Results of a National Study, American Journal of Medicine, May 2009.

Person 1: Life insurance is much the same way. You pay in, and if you don't die while the policy is in affect, you are out the money. You choose to not pay for insurance because you don't think it is worth it, then it is you who takes the risk. Society isn't responsible for paying just because you don't think it is a good return on your investment. Neither is any other kind of insurance that you buy unless your number comes up.
Making the insurance companies the villains is not realistic either, neither I nor Kristen have ever been denied treatment for anything, she had half her lung removed and the insurance company didn't give her any issues during the whole process. America was built on providing services and making a profit from it. Everyone who has 401k retirement plans has ownership in those insurance companies, that profit is shared by millions of shareholders.
I totally support the charging of co-payments. People abuse the system when there is not consequence, this is one of...

Me: Co-payments are one thing, but a $3000 deductible (or a $10,000 deductible) basically means you will get no health care unless in a crisis. No preventive care, no check-ups, no addressing problems early on before they explode.

Person 1--I agree that society shouldn't pay for people's decision to defer health insurance. Fact is, we all pay every day. Costs are simply shifted to everyone else, with higher physician, hospital and insurance charges to those who are paying into the system.

Person 1: the many failures in the Canadian system. If obamacare makes it through, I would hope someone has the wisdom to incorporate co-pays.
As for everyday folks, 5/6 people (to quote Mark) have insurance, 260 million people. They manage to pay for insurance, or their companies pay for them (can't be any of those big businesses out to make profits only for themselves).
I'm sorry if you choose to not pay for health insurance for yourself because you don't think it to be a good value, but I shouldn't have to pay more taxes for your choice.
I feel sorry for those who have been laid off, if obama spent the stimulus on job creation instead of bailing out everyone who gave him election contributions maybe the unemployment issue would reverse. COBRA is available to them, a perfect example of how crap government options are. A friend of mine who was laid off, her COBRA would have been $850 a month, she called Anthem, $325 a month.
As for the poor, the poor have Medicaid paying for healthcare.

Me: Medicaid: successfully providing preventive care, vaccines, etc for underprivileged children.

Approx 50 million patients uninsured. I couldn't produce a #, but I would wager that most of them would like to have health insurance.

Me: Re: employer-provided health insurance:

Rapidly escalating health insurance premiums are having a profound impact on
business operations:

· The surge in health care spending over the last five years is a drag on
economic growth.
By cutting into operating margins, high health insurance premium costs are
reducing the capacity of businesses to grow by investment in research,
capital spending, product development, and marketing.

· High health insurance costs slow the rate of job growth by making it
more expensive for firms to add new employees or retain existing
employees.

Larger firms during this period of high health insurance inflation have been
reluctant to add new jobs. Smaller firms have been experiencing larger
annual increases in premiums over the last five years (15-20% annual jumps)
compared to large companies, making it more difficult to create new jobs1.
Health insurance costs are the fastest-growing business expense for
companies.

Friend: Just because you haven't been denied yet doesn't mean that it isn't happening to thousands everyday. I also didn't say that I choose not to pay. I said that I am not too keen on the idea that I could be dropped or denied care at the discretion of the insurance company who clearly has profits in mind before patient care. I completely understand that I take a risk everyday by not being insured. There is still a risk even if I were that I would be die at the hands of the insurance companies. Or just because I turn 64 I am dropped because of my age only to then have to pay even more just to maintain coverage all of this at a time when I may need it most. It's just dirty man.

Me: (quick aside re: Canadian or UK health care: for all the issues that patients have w/ those systems--and there are certainly issues--no serious political movement is underway to undo the systems. They have been too successful at providing needed care.

Delays for services and for elective surgeries do happen, and the UK and Canada admit that. But patients can receive needed care.)

Person 1: I don't know about your finances, but I don't doubt the majority of people without healthcare could come up with the money to pay for insurance if they made some sacrifices. Maybe they have to work more hours at their job. Maybe they need to go back to school and get a better education so that they can get a better job that pays benefits. There is a certain level of responsibility people need to take for themselves. The government was not meant to be a babysitter for sheeple.
As to Marks statement about what the current legislation says, it has been written so vaguely at this point so that after it passes, it can be interpreted as the government sees fit. Ultimately the government plan is to expand control over the people of america, which means everyone will be forced into the public option. This has been well documented on the internet by independents.
Health Matrix? are they legit?

Person 1: Hey if the plan was so great it would have been passed already. He has the house, he has the senate...we can all agree that reform of the system is required...but obamacare is not supported by the majority of americans, is not even supported by many of his own party. He needs to back off and work on each piece in a bipartisan way that is very open to the public. This bill is not about helping americans, its about government control and who gets the money.

Friend: Yes we can agree that reform is needed.

Me: Part of the reason that reform is being slowed down: untruths told by opponents. Death panels, unplug grandma, etc: all shameless lies. Rather than have an honest debate (like we're having here), the sound and fury has drowned it out.

Politics of division: make sure that enough people get angry over things that aren't true, and you might drown out the potential good to everyone involved.

Me: If opponents to reform have a better option, I'd like to hear it. High-premium catastrophic plans and health savings accounts: not going to cut it.

Medicaid is only available to some poor adults--it depends state to state. Virginia is 47th in the US in providing Medicaid to adults: you could be homeless, on the street, eating out of soup kitchens and penniless: not good enough for Virginia.

Me: Person 1: in terms of "sheeple": how would you address the young adult who has a high school education, no money for college (and no role model to encourage higher ed), works a full time job at minimum wage ($7.25 per hour) and has no choices? Just supposed to work harder, I suppose?

If you make minimum wage, work 8 hrs a day, 7 days a week for 52 weeks: you will make $21,112 before any tax or deductions. Considering that the average employee's contribution to their health care premium is over $3000--how on God's earth can this work?

Person 1: There is truth behind the death panels and unplugging grandma...the people obama have working on his healthcare plan, the czars, all believe in eugenics.
"When implemented, the complete lives system produces a priority curve on which individual aged between roughly 15 and 40 years get the most chance..." E. Emanual
"Saving the life of one teenager is equivalent to saving the lives of fourteen 85-year-olds" P. Singer
obama said to judge him by those he as around him.
This isn't lies, read up on Emanual, john holdren, and the rest of the czars who shouldn't be where they are today...they were not elected by the people.
People aren't angry because they want to cause disruption to town hall meetings. People are angry because the government doesn't listen to the people any more. If you think obama is any more for the people than Bush was, that is a farce. Both parties need to go, and that is where americans are now starting to look.
The republicans do have a plan, the lib media likes to say that the republicans have no answer, that they just say no, no, no...well they do...
http://www.cbsnews.com/htdocs/pdf/GOPHealthPlan_061709.pdf

Person 1: I went to college with no money. Millions of students out there right now go to college and will come out with debt...obviously they don't have money either. Yet they go. The work hard, take on part-time jobs to put themselves through school. There is no excuse, just a lack of ambition. Aww...poor ambition-less people...lets give them free health-care.
The solution to minimum wage jobs is to not work at them. Times are tough, you take a minimum wage job to put food on the table, and you continue to hunt for a better job. Maybe you take one college course a semester. Maybe you live with 3 other people to share costs to afford this. Regardless, you make sacrifice. Society doesn't make the sacrifice and provide you with everything for free, the individual needs to make the sacrifice to better his/her own life.

Person 1: Your example, $3000 is a tax deduction, so really it will only cost about $2000. You share a rented house with three other people so your rent is 1/4 what it was. You take a college class two nights a week, I'm sure at $21k a year you qualify for some assistance, at the very least a student loan which you don't have to pay back until a later date. You don't take classes like art appreciation, or african american history...they don't get you a job. inch by inch you work your way out of the pit you allowed yourself to get into. I didn't say to move out of your parents home when you finish highschool and try to live on your own working at McDs. There are consequences to being a schlump, and it isn't the role of society to reward it with free life enhancement. Responsibility starts with the individual.

Person 2: Mark, The bill uses the IRS to gain info and to enforce penalties and taxes. pages 195-196, SEC. 431 of HR3200 states that the IRS will provide taxpayer info for the purposes of Health Insurance Exchange Subsidies (Higher cost to people with more money): Identity, filing status, family members, adj.Gross Income and anything else the secretary sees fit. The employers are also required to provide info on request.
Here is the link to the Actual Bill: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3200ih.txt.pdf
It is not easy to read, so good luck.

Person 2: EVERYONE: I wish that everyone could get the absolute BEST healthcare. [Mark's wife] was obviously upset with the system, but she needs to look at the doublespeak about the proposal without emotion because this proposed bill is NOT the answer.
This is bad politicians using a vulnerability to TAKE from the people, not to give us anything. Making an ok system into a Terrible one will only cause more hurt and cost - even if the politicians are acting like they care.
And our system is ok. Just ask the droves of foreigners who come here for our cutting edge healthcare.
Gov. sponsored research produces less than 5% of the innovative drugs and procedures, where 'greedy' pharm companies provide all the rest. They are not the bad guys.

Person 2: We are not in a crisis as the media and politicians want us to believe, "Hurry we have to pass this awful healthcare bill before its too late"!
He is following in the Clintons template of 'make a crisis, then propose a big Gov. solution, pass the bill and then it is all better'. Funny how suddenly the media would drop the 'crisis' and onto the next one. This is a slow problem, despite the chicken little media.
When politicians are in a hurry to pass something, THAT is when we need to really examine!
Happy reading!

Person 2: Oh yeah, I almost forgot...We have had a high deduct. insurance with HSA for over 3 years. Yeah it is annoying to try to get through the deductible, but it is great for catastrophic events. AND all maintenance (checkups,basic Gyn etc.)is covered with $0 deductible from day one!
The GOOD part is that it is a little cheaper than HMO or other plans and you put the difference into the Health Savings Account pretax. When you go to the specialist etc. you pay out of that acct.. What you do not use that year, if any, is your money next year etc. If you are healthy, you build up a year or more of deductible and then the yearly is low and you are ready for bad events if they come (Janet). The idea is that YOU pay for care so you are more careful - reducing Unnecessary use of insurance money for small stuff - reducing costs for EVERYONE. I think it could work if given a few more years! NOT as painful as people think!

Me: Person 2:
--The gov't using IRS records they already hold is clearly NOT the same as the gov't having unfettered access to your bank account (as you stated).
--I'm tired of those who claim are system is "ok". It's not. Working in underserved communities w/ patients who struggle for access, I assure you that it is not a functional system.
--PhRMA companies buy up large amounts of gov't funded basic research (NIH, universities) and cherry pick the valuable bits and sell it back to us at great increases. Also, a lot of PhRMA "research" is to produce "me-too" drugs that offer little to no extra value.
--HSAs and high deductible plans can work--if you have enough $ to fund the HSA and cover the deductible. If you don't have either--and may won't--you're just as screwed as before.

Me: Person 1:
--Please, come to South Richmond and let my patients and their families know how easy it all as. Just work harder, go to college, and you will be well off! If only the people I care for could see how simple the process is. I assure you, with every fiber of my being, it is NOT simple. It can happen, but for many families and young adults it is not feasible.
--Good to see your answer to the cost of the premium is to make sure you have roommates to share the rent. Another high-level solution.
--I think we can tell what you think of these patients--my patients--by your language. "sheeple" "schlump" "There is no excuse, just lack of ambition." Do you have any concept of what it is like to be poor in these United States?

Support A Public Health Insurance Plan!

While going through e-mails this morning, I saw this news story. Apparently, the White House is starting to get worn down by the criticism they've been hearing. As soon as I saw the story, I wrote the following letter to the White House:

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Dear President Obama;

I am a family physician in Richmond, Virginia. To date, my career has been in medically underserved communities in Virginia (both rural and urban) where healthcare access is difficult. Every day, I see patients who lack insurance or who have lost insurance when they lost their job or their employer dropped coverage. I have had patients ask me to do only the essential minimum of tests or procedures because they need to wait until Medicare kicks in before they could afford more care. I have had to advise patients which $4 prescription is most important because they cannot afford more than 1.

This system, which ranks 1st in the world in money spent but ranks 37th worldwide in key healthcare indicators, which leaves 1/6 of our nation's citizens uninsured, which values technology and intervention more than primary and preventive care, is crumbling and inadequate. We need to do better.

Private health insurance plans have clearly failed. In one study, 75% of patients who sought to purchase insurance in the private marketplace failed to purchase a plan because of cost and/or pre-existing conditions. Private health insurance premiums are soaring, even though they tend to cover healthier patients than public plans (Medicare and Medicaid cover a greater proportion of elderly, disabled and chronically ill patients) while insurance companies make enormous profits and deny care to millions of Americans.

Since last year's campaign, I have been hopeful that a viable public insurance option would result form healthcare reform. Although a single payer plan is my preference, a strong public health insurance option acting within the insurance marketplace would at least set a standard for coverage and costs that private plans would have to respect. A public health insurance plan is a necessary part of reform.

I heard the news coverage today that your administration might be willing to back away from a public health insurance plan. I wanted to write you in order for you to know that there are millions of us who support your efforts and who support a public option. We don't shout as much as others, and we don't tell outrageous lies, but we're here and we are standing behind you. Please--do not give up on the public health insurance plan. Our healthcare reform efforts will dictate healthcare in the US for the next 20 or 30 years. If done correctly, we can provide care to everyone in the US while increasing quality and reducing costs. If not done well, we will continue to lose people every year. This is too important to fail.

Sincerely,

Mark Ryan, MD, FAAFP

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These are critical days for healthcare reform. If you support a public option as part of meaningful reform, then you must let the White House know. We can no longer be a silent majority--we have to speak up. We don't have to be loud, abrasive, abusive or angry. But we have to be heard.

Patient-Centered Medical Home

In the debate surrounding healthcare reform, there has been some discussion of the patient-centered medical home. This can be a little hard to get your head around, but National Public Radio ran a story that explains it pretty well. This is not the whole story, obviously--there are a lot of details and behind-the-scenes details. But, at least it helps get things started.

Legislators

Today, Janet and I made a round of our Representative and Senators' offices to express our support for healthcare reform. Bobby Scott's office was closed--it appears that they are in the process of relocating--but we spoke to one of his staff members by phone and she said that our comments would be forwarded to to the Washington office. However, we met with staff members at both Jim Webb's office and Mark Warner's office, and were able to express our thoughts and our support for reform.

Note--"we were able to express our thoughts and our support". The way adults do, not like these people or these people.

So--go, speak to your representatives. It was amazingly painless, and well worth it. Be polite and respectful--if your representatives don't agree, then still be calm and thank them for their time. We aren't children, and we should at least be respectful and decent towards each other.

I'm Flattered

Recently, a graduate student at VCU wrote up a profile regarding some of my international medical service trips. I think she did a good job of discussing the background, and I'm posting it here in case you're curious.

Another Hair-Pulling Letter to the Editor

Sometimes, when I see letters to the editor in our local paper, I wish I had more hair because it would make it more dramatic when I pulled it all out. Rest assured, the Richmond Times-Dispatch (RTD) and I would not be friends under most circumstances. We have different points of view on many things, and probably would not make good roommates.

However, now and then, they publish things that seem more egregious than normal. Such is the case today. To my knowledge, the RTD has not published anything like a fair discussion of healthcare reform. They continued that trend today with this post.

So, when I see things like this, I feel like I need to respond. I write letters back. Sometimes I send them, sometimes I don't. But, if I write them, I tend to post them here because it makes me feel better.

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To the Editor;

I am writing in response to Dr. Stephen Long’s opinion piece titled “Mad Rush to Reform Seems Certain to Harm the Patient” that was published in the Commentary section of the August 9 2009 Richmond Times-Dispatch. Although I have not been in practice as long as Dr. Long has, I have chosen to practice in medically underserved communities throughout my medical career: from studying at the Virginia Commonwealth University School of Medicine (formerly MCV) to completing a residency in Blackstone Virginia to 4 years as a Family Physician in Keysville Virginia and now 2 years working on the south side of Richmond at the Hayes E. Willis Health Center. During this time, I have run into healthcare access issues on a nearly continuous basis, and I feel that I have a different perspective on healthcare reform than Dr. Long does.

Dr. Long states that legislators are over-inflating problems with the current healthcare system in order to scare voters and to pass significant healthcare reform. The truth is that (by Dr. Long’s numbers) nearly 17% of the country is either uninsured or underinsured. On a near daily basis I have to guide patients as to which $4 prescriptions are the most important and which can wait, as patients cannot afford all of them at once.

Dr. Long speaks about the concern that a public health insurance plan will “adversely impact the current excellent and immediately accessible care available to all Americans.” I think this statement is incorrect. Uninsured patients (1/6 of the nation) lack excellent and immediate accessible care. In fact, in many cases, they lack care of any kind unless they work with a free clinic or community health center, or end up in the Emergency Department. A number of those who have insurance have high-deductible plans—the only way they could afford to buy the plans—and try to defer care if possible to reduce costs. In my opinion, making the options to access care available to everyone is the better choice, even if the cost might be a delay in accessing elective care. When my patients cannot be seen in a Cardiology clinic for 6 months, then we cannot claim we have “immediately accessible care”.

Dr. Long repeats an oft-told story about how a public health insurance plan would “simply dole out government-controlled health care.” This claim is made over and over and over and over again. I have two issues with it: 1) health care is already doled out—rationed, if you will—by for-profit insurance companies that are trying to make money for their stockholders and 2) there is nothing in the current proposed legislation that would direct such an action. There is a provision for comparative effectiveness research, true, but that would simply provide information for physicians to make better decisions with their patients.

A brief word about the medical research Dr. Long fears might dry up: a great deal of biomedical research takes place with government funding at universities and at the NIH. For-profit pharmaceutical and medical equipment companies tend not to invest at these early stages but rather buy the technology later on and then sell it back to the citizens that played a role in developing it. But that is a whole other argument. Suffice it to say that I do not believe medical research and development would suffer.

Regarding the government’s supposed failure to sustain Medicare: Medicare is failing for any number of reasons, from the fact that it insures an increasingly older and more ill group of patients to the fact that reimbursement for high-cost interventions and specialty care outstrips the reimbursement for solid preventive health care. Medicare is, in fact, much more efficient in its use of funding and resources than private plans are, and patients who participate in Medicare are overall very happy with the program. Medicare’s funding problems are not the result of a failure of the program, but rather to the run-away costs associated with healthcare and the fact that high-cost patients are more likely to be enrolled in Medicare.

I also challenge Dr. Long, and other members of the Coalition to Protect Patients’ Rights, to explain to me how a system based on tax credits, health savings accounts (HSAs), co-ops and vouchers is supposed to work? Tax credits and HSAs stand very little chance of helping my patients who work minimum wage jobs without benefits and who are working paycheck to paycheck to meet other obligations. Vouchers might help with this, but it would depend on how much the vouchers cover and how much the available plans cover. The Commonwealth Fund issued a study showing that, in the private insurance market, 75% of patients who sought to purchase insurance during the study period ended up not buying a plan: they could not find an affordable plan or did not qualify for available plans. So why prop up a system that does not work?

The truth is that America needs meaningful healthcare reform—reform that will provide true access to needed medical care to all Americans. This has not been accomplished through the private market; otherwise we would not be in our current situation. Private, for-profit plans are not the answer. Recently, a former high-ranking executive at Cigna has spoken out about tricks that private health insurance companies use to deny care. A public health insurance plan, such as that being discussed as part of healthcare reform, stands as a strong alternative. This plan would provide a way to control costs in the marketplace while making insurance available to all Americans. The plan could act to keep prices down by negotiating with pharmaceutical and medical technology companies on behalf of the plan members. The plan would also be competing in a public marketplace—if the public plan was not the more efficient, more cost-effective option, than the private plans would outlast it. A public plan would also be answerable to the public—the voters—not to a boardroom and private investors. This plan would stand to reduce costs for all Americans and reduce the costs to businesses, which find themselves ever more burdened by the costs of providing health care insurance.

Health care insurance, as it is, is a terribly flawed system. The New England Journal of Medicine recently published an article showing that if your household income is high, then the status quo is sustainable for a long time. However, if you are low-income, you are already feeling the pressure of these unsustainable costs and will be under greater pressures in the near future. I have chosen to work in communities where low-income households predominate, and I have felt the urgency and pressure they face. I have had patients ask if they could hold off on studies or treatments at least until Medicare kicked in. In a country where over 50% of bankruptcies involve costs of medical care—and most of those families had medical insurance when they first got sick—there is no time to waste. This is an urgent situation. While discussion and debate is important, it must not delay the implementation of real healthcare reform. I also urge concerned citizens to speak to their elective representatives: we need to support the White House’s efforts to enact legislation making access to our healthcare truly free and open to all.

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