Wednesday, August 26, 2009


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.


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.


Sunday, August 23, 2009

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?

Wednesday, August 19, 2009

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.



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.

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

The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008.

"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 t
he Individual Insurance Market Is Not a Viable Option for Most U.S. Families, The Commonwealth Fund, July 2009.

"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.

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:

Person 1:
An idea I read online this morning is a system that provides low interest 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 wait. Press 2 because they owe you money...I hope you like Muzak.

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.

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?

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.

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.

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

"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...

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.

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

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

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.

(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...

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:
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?

Sunday, August 16, 2009

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:


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.


Mark Ryan, MD, FAAFP


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.

Saturday, August 15, 2009

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.

Tuesday, August 11, 2009


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.

Monday, August 10, 2009

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.

Sunday, August 9, 2009

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.


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.


Why We Need Effective, Meaningful Healthcare Reform

For all those opponents to healthcare reform, how would you answer this? As a country, we aren't we universally appalled by the fact that patients need to go to these lengths to receive even minimal healthcare. What the story doesn't state is that the doctors were working in cleaned animal stalls and the other providers were similarly working in barns and other county fair buildings.

Without affordable and effective healthcare, I suspect that RAM 2010 will be just as busy.

So: if you oppose healthcare reform, how would you fix this?

Friday, August 7, 2009

Sarah Palin = Not Truthful

A quote that would be funny if only people didn't take her seriously:

"Former Alaska Gov. Sarah Palin called President Barack Obama's health plan 'downright evil' Friday in her first online comments since leaving office, saying in a Facebook posting that he would create a 'death panel' that would deny care to the neediest Americans. 'Who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course,' the former vice Republican presidential candidate wrote on her Facebook page"

Where to start, where to start...

First: I clearly missed the Death Panel Clause in the current legislation. Didn't see it at all. I challenge her, or anyone else, to show me where this is written. Not some worried projection, not some doomsday scenario, not some outside-the-mainstream opinion. Show me where it is written. I'd wager anything on the fact that it is not there.

Second: Although her concern for the elderly, sick and disabled is laudable, would it be rude of me to point out that many of these very same patients are already covered under public health plans (Medicare and Medicaid)? You remember them--some of the most efficient health plans in the US? Medicare, as you might know, is the health plan that politicians are scared to mess with because it's so popular with older patients. If Sarah is right, we should be kept awake by the howls of injustice from those who Medicare and Medicaid have failed. Instead, I care for them daily in my practice as they take advantage of their available health care options. In some cases, I see patients who have delayed or deferred needed medical care until they could qualify for Medicare or Medicaid because no private options were available for them. Not that the plans are perfect, mind you, but I haven't had to send anyone to a Death Panel.

Third: Is Sarah aware of the fact that health care is rationed every day? Granted, not by the nefarious "government bureaucrats" that the right wing likes to demonize. Instead, it is for-profit middle managers and executives who make these decisions. Is that really any better than the right's nightmare scenario? As of now, healthcare legislation that has been proposed does not include any layer of bereaucrats who would dictate coverage. So why are we so terrified of something that isn't even on the table yet?

Finally: private-only insurance markets have failed and show no signs of righting themselves. A robust public plan might put some private plans out of business, but these would presumably be the less efficient and less responsive plans. Isn't that the point of competition?

Sarah Palin: at least she keeps things interesting. Maybe she's an expert because she's been to a doctor's office before? At least her healthcare experience trumps her foreign policy experience.

Thursday, August 6, 2009

Why The NPA Is Better Than The AMA


early this year I learned about the National Physicians Alliance. Sort of like the AMA if the AMA was progressive. They have a strong mission, and represent my beliefs much better than the AMA.

The NPA's guiding principles are:


We place the best interests of our patients above all others and avoid conflicts of interest and financial entanglements. The health of our patients is our first concern. (Oath of Geneva)

We affirm the World Health Organization's definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

We believe health is determined by a wide variety of influences beyond biology, including familial, social, psychological, environmental, economic, political, legal, cultural and spiritual factors. Understanding and addressing these complex connections is a duty of our profession.

We recognize that health and disease are not limited by national borders. We must advocate for national and international policies that support health promotion and disease prevention.

We advocate for a clean environment, a fundamental requirement for a healthy society.

We believe that the health care workforce must reflect the diversity of the population.

We believe every health professional must value and respect cultural diversity in order to provide sensitive and effective care to all patients.

We seek collaborative and creative solutions with other health professionals and our local communities to protect and improve public health.

We believe that individual health is tied to the health of communities. Physicians have an important role in ensuring a strong and viable public health system.

We support an approach to knowledge acquisition grounded in empirical research, evidence-based conclusions, professional peer review, and transparency of process.

We acknowledge and respect the long history of medical practice and tradition in all cultures and encourage research into these practices.

I really do like these guys. So I was happy to see the effort they are making to advance health care reform. And to read this letter NPA's president elect sent to Sen. Harry Reid:

And that is why the NPA is better than the AMA.

Tuesday, August 4, 2009

Can't We Be Adults?

I was listening to NPR as I finished up charts today and I heard this story about opponents to health care reform heckling government officials who are attempting to discuss the issues.

Come on--this is too important to be treated like a 3rd grade class or a WWE match. Health care matters to all of us, and will matter for as long as we're around. This needs to be addressed honestly and diligently. Whether for or against the plan, is this really the way to act?

Monday, August 3, 2009

A Moment To Catch Up

So, as we approach the August recess without having a healthcare reform bill to work with, it seems like a good time to catch up with the process. If you are following this process, you know there are dozens of moving pieces to watch. The National Physicians Alliance (NPA) (sort of like the AMA if the AMA were progressive and such) has a site that lays things out pretty well. In a recent e-mail the NPA outlined where the playing field stands. I think that part of that e-mail is worth posting: it outlines where there seems to be bipartisan agreement in the reform movement. Despite the naysayers, these areas of agreement look pretty good:

Areas of agreement (generally bipartisan) include:

-Increased regulation of insurance companies to include: accepting all applicants, regardless of medical history; prohibit charging a higher premium because of medical history or current illness.

-Require nearly all Americans to have health insurance.

-Provide federal subsidies to make insurance affordable.

-Expand Medicaid eligibility to 133% of FPL.

-Require most employers to provide insurance to their employees or contribute to the cost of coverage. There is disagreement on the total payroll threshold at which this requirement would begin ranging from $250,000 to $500,000.

-Creation of health insurance exchanges where people can shop for insurance and compare policies.

-Reduce the rate of growth of payments to hospitals and many other health care providers.

-Eliminates the Sustainable Growth Rate ( formula for determining physician Medicare reimbursement.

-Shift toward paying for value, rather than volume of services.

-Eliminate co-payments for many preventive services.

-Democrats agree that the federal government should create some plan that would compete with private health insurers but there is some disagreement as to the form that plan should take: a public health insurance plan or a nonprofit cooperative.

Obviusly, it is this last point that is causing much of the heartburn out there: "Democrats agree..." implies that "Republicans object..." to the idea of a public health plan. Still, this public plan is part of HR 3200.

This is an important time in the process. As legislators leave DC and go home for the recess, they are going to hear from constituents, lobbyists, etc. It is terribly important that they hear from supporters of healthcare reform and supporters of a public plan. I believe that most Americans see the value of the plan so long as it is not being distorted by opponents. For that reason, we need to make sure that our legislators know that we support the public plan.

Sunday, August 2, 2009

A Moment Away From Health Care Reform

Just to remind everyone: without primary care physicians, any healthcare reform is going to be hard pressed to make a difference. In this greater debate about HR 3200 and other plans, we need to make sure we do not lose track of the importance of primary care: Family Medicine, General Internal Medicine and General Pediatrics. Our system does not reimburse primary care services well enough as things now stand, but efforts are underway as part of the healthcare reform process to address this.

A wise colleague once pointed out that in other countries, primary care is funded as the base of the healthcare pyramid and specialists and hospitals get less money. In comparison, in the US hospitals and specialists are funded and primary care gets what little trickles past.

Unless this changes, we are in for a bad situation regardless of what healthcare reform ends up looking like.

So, About That Private Insurance...

Those of us who practice medicine realize that the system is broken, and badly so. We realize that the current structure of public insurance is in bad shape and is losing money badly (though, as I've posted before, this is at least in part because public insurance insures high-risk, high-use patients that private insurance can avoid).

For these reasons, many conservative and/or free-market supporters are pushing for expansion of the private insurance market. Apparently, that would fix all the current problems we're dealing with.

Or would it lead to more of this?. In this extensive interview, Bill Moyers discusses the failings of the private insurance market with Wendell Potter. Mr. Potter was previously a top executive for CIGNA, and he lays out the tricks and underhanded tactics used by private insurers to make money by denying care to patients who need it. Mr. Potter is also interviewed by Amy Goodman on Democracy Now!

So, this is how private insurers think. Even though the private plans are already dealing with the healthier (read: less expensive) patients, they find ways to deny care or cancel policies in order to make even more money. This underlines a key failing of private insurance: how much will a for-profit company pay for your healthcare when they are trying to make as much money as possible? Corporations always claim that they have responsibilities to their shareholders. If so, how much responsibility will they have for providing healthcare?

How are we supposed to trust private insurers? At least a public insurance plan would be PUBLIC and would have public oversight, with more liklihood of transparency and accountability to those who enroll and for those who pay for the coverage.

To date, I have not heard how private insurance markets are planning to address these issues. Something tells me that we probably won't be hearing much any time soon.

(PS--the Bill Moyers transcript can be read here).