Setting the Stage for the ACA's Second Anniversary

(First published on the National Physicians Alliance blog March 13, 2012)

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In one week, the Patient Protection and Affordable Care Act (PPACA, or ACA for short) will attain its second anniversary.  In preparation for the media attention this milestone will attract, it is necessary to set the stage regarding the ACA's achievements and popularity.

First, a review of what the reforms already in place as a result of the ACA:  this timeline provides a good summary, as does this timeline.   A review of these timelines shows that the ACA has already led to the following changes:

• Young adults can stay on parents' insurance policies until age 26.
• People with preexisting medical conditions who have been uninsured for at least 6 months can access care via Preexisting Condition Insurance Plans.
• Insurance companies can no longer rescind patients insurance, and have eliminated lifetime caps on insurance benefits.
• Children can no longer be denied medical care due to preexisting medical conditions.
• Seniors have received discounts and rebates on their medication costs via Medicare Part D.
• Patients can receive many preventive care services without paying co-pays.
• Funding has been increased for community health centers and for the National Health Service Corps.
• Increased targeting of healthcare fraud.
• Insurance companies will be held accountable for unreasonable premium rate increases, and are being required to spend at least 80-85% of the premiums they receive on providing necessary medical services to beneficiaries.

These are among the ACA's reforms that are favored by individuals on both sides of the political spectrum (pdf link).  Even before the ACA's major reforms become active in 2014, the law is already improving the status of healthcare in America.

It can be anticipated that there will be a great deal of critical commentary about how the ACA represents a governmental overreach and that Americans resent this supposed power grab.  However, in the most recent Kaiser Family Foundation Health Tracking poll (pdf), 35% of Americans would like to see the law expanded, while 19% would like to see the law kept in its current form.  When 54% of the nation would like to leave the law as is or expand its reforms, it is hard to argue that most Americans oppose the ACA in the way that the law's opponents would have us believe: they might highlight that 72% of Americans oppose keeping the ACA in its current form, but 1/2 of that number want the law expanded.  This underlines the disingenuous nature of the claims made against the ACA: the law's opponents highlight those bits of data that can be presented as supporting their claims, but conveniently omit the details that undercut their claims.

Opponents of the ACA also have chosen not to propose any replacement for the law any time soon, despite the fact that the House of Representatives actually voted to repeal the law in 2011.  While the Republican Party delays action, 1/3 of Americans are struggling to pay their medical bills.  This statistic illustrates the reasons that the ACA's reforms were so badly needed: Americans cannot easily afford necessary medical care.  The law will address this directly as the health benefits exchanges come online in 2014, but the reforms noted above stand to improve this statistic.

We will certainly hear more and more reasons that the ACA was unconstitutional, especially as the Supreme Court will be hearing arguments on the law's constitutionality the week following the law's anniversary.  One of the major arguments against the ACA focuses on the law's mandate that individuals purchase health insurance or face paying a penalty.  This article nicely encapsulates arguments as to how and why the ACA and its individual mandate are both constitutional and necessary.

This is where we stand: the ACA is already benefiting Americans, many of whom are in favor of the law's reforms or who would have preferred more expansive reforms.  The need for reform is clearly evident, and the ACA's opponents have not proposed any meaningful answer to the current crisis in healthcare access and affordability.  Despite the law's opponents' fervent claims and beliefs, the law's constitutionality can be supported in a number of ways.

If you support the ACA's healthcare reforms, get ready, be vocal, and stand tall.  The week of March 19-23, 2012 promises to be quite active.

Poverty in Richmond, Virginia: We Have Our Work Cut Out For Us

Today, I attended the first part of a three part series of presentations focused on the nature of poverty in Richmond, Virginia.  Today's presentation was focused on a review of the data; the next will discuss the history that led to this situation, and the final presentation will discuss suggested interventions that might address this issue.  The nature of poverty in the city is especially notable because concentrated poverty compounds desperation and leads to hopelessness and alienation.  The presentations are based on the work of Dr. John Moeser, of the University of Richmond's Bonner Center for Civic Engagement.

The data is focused on the Richmond Planning District.  In 2010, the poverty level for a family of 4 was a yearly income under $22,314.  In Richmond City, the rate of those living in poverty increased from 22.1% to 25.8% 2009-2010.  Poverty rates rose 18.2%-25.8% 2000-2010.  Poverty in the city is at an historical high since 1970.  Just as important is the fact that the proportion of those living in poverty in surrounding counties increased from 2000 to 2010 by 94% in Henrico and 71% in Chesterfield.  46% of those in poverty in the Richmond area live in the city; 54% of the region's poor now live in the suburbs.  This shift in poverty in the Richmond area reflects a national trend of increasing poverty in suburbs.

There is also a significant level of wealth inequity in the region.  In Richmond City, the wealthiest census tract has an average income 17x greater than the poorest. Wealthiest census tract in central VA has an average income 21x the poorest.  Despite this great difference between the riches and poorest residents in the city, there is very little physical distance: there are only 3 1/2 miles separating the wealthiest census tract in the city (Windsor Farms) and the poorest (Gilpin Court).

Further details regarding who is poor in Richmond is also striking.  Currently, 38% of children in Richmond City live in poverty; this is double the rate from 1990.  If one looks at poverty by race, it is notable that 48% of the poor are black.  However, the % of all whites and Hispanic community living in poverty have increased.  In particular, the % Hispanic community living in poverty increased from 8%-23.5% from 1990-2009. [Editorial note: I think this might represent the fact that the Hispanic community has nearly doubled throughout the Richmond metro area in the last 10 years; many of these newly-arrived individuals and families earn annual incomes below the poverty level.]

Most poor whites live in the suburbs (69%) in suburbs; 61% of all black poor live in the city. Asian and Latino poverty is largely suburban.  Overall, Hispanic and black poverty are typically higher density, whether in city or in suburbs; while white poverty less concentrated.  More than 20% of the population living in poverty in Richmond City is concentrated in south and east Richmond.  5 census tracts in the city have more than 50% of their residents living in poverty; Gilpin Court has 69% of its residents living in below the poverty line.  Concentrated poverty in the City of Richmond is largely found east of Chamberlayne Ave, and on both sides Jefferson Davis Highway south of the river.  These areas of concentrated poverty align with the locations of public housing developments.  There is no concentrated public housing in counties, but concentrated poverty in the city spills over from the city to the older inner ring of suburbs.  There are some census tracts in the city where poverty rates declined, and older housing stock is renovated via gentrification.  At the same time, there are some census tracts that have increased in the % of their residents living under the poverty line.  Overall, "South Richmond is the city's new East End" with increasingly concentrated poverty.  This shift appears to be largely related to increased Hispanic poverty.

For anyone who believes (as I do) that the social determinants of health matter, then this information is striking and relevant.  Improving communities' and individuals' health will require more than disease-focused outreach and prevention programs.  We will need to refocus on affecting and influencing public policy in such a way as to take health, education, income, etc. into account whenever policy decisions are made.  This is less immediate, and perhaps less gratifying, then working one-on-one with patients...but it is equally (or, perhaps, even more) important work.  Physicians need to involve ourselves in discussions about policy changes and we need to hold our elected leaders accountable for making decisions that will improve the health status of all people--both by improving healthcare, and by including healthcare considerations when discussion all policy issues.

#MedRead (part 2) Non-fiction books: Patient narratives, culture, society, and science

This is the second in a series of blog posts that will list books recommended for medical students as a result my asking for suggestions on Facebook and Twitter.  This second installment (the first installment can be read here) focuses on society, patient narratives, science, and culture.

In each case, I've linked the book title to its Powells.com listing...mainly because I didn't want to link to larger sites such as Amazon.  In practice, I would strongly advise looking for these books at the library (to test them out--use this site to find the books at a library near you) or at your local independent bookstore (such as Chop Suey Books, in Richmond).  Remember that if you're local bookseller doesn't carry these titles, they can probably order them for you--and they'll keep your money local.

Alternately, if you wish to support the authors directly, feel free to see if you can purchase the book you are interested in from the author's own website.

Grand Pursuit: The Story of Economic Genius – Sylvia Nasar

The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures – Anne Fadiman

And the Band Played On: Politics, People, and the AIDS Epidemic – Randy Shilts

A Question of Intent: A Great American Battle with a Deadly Industry – David Kessler

Medicine and Human Welfare – Henry Sigerist

Guerrilla Warfare – Ernesto Guevara

28 Stories of AIDS in Africa – Stephanie Nolen

The Year of Magical Thinking – Joan Didion

Autobiography of a Face – Lucy Grealy

Nickle and Dimed – Barbara Ehrenreich

Wretched of the Earth – Frantz Fanon

Pedagogy of the Oppressed – Paulo Friere

Anything by Emily Martin: A good start might be Bipolar Expeditions: Mania and Depression in American Culture

Immortal Life of Henrietta Lacks – Rebecca Skloot

The Match: "Savior Siblings" and one Family's Battle to Heal Their Daughter – Beth Whitehouse

Medial Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present – Harriet Washington

The Ghost Map: The Story of London’s Most Terrifying Epidemic—and how it Changed Science, Cities, and the Modern World – Steven Johnson

Mountains Beyond Mountains – Tracy Kidder

Treatment Kind and Fair: Letters to a Young Doctor – Perry Klass

As Nature Made Him: The Boy who was Raised as a Girl – John Colapinto

Anything by Richard Feynman: What Do You Care What Other People Think?  Further Adventures of  Curious Character seems a good start.

A Whole New Life: An Illness and a Healing – Reynolds Price

Mama Might Be Better Off Dead: The Failure of Health Care in Urban America – Laurie Kaye Abraham

Let Us Now Praise Famous Men – James Agee and Walker Evans

Broke, USA: From Pawnshops to Poverty, Inc – How the Working Poor Became Big Business – Gary Rivlin

Barefoot Heart: Stories of a Migrant Child – Elva Treviño Hart

Still Alice ­­­­– Lisa Genova

Half the Sky: Turning Oppression into Opportunity for Women Worldwide – Nicholas Kristof and Sheryl WuDunn

If you have read these books (or if you recommended them), please use the comments below to provide us with some thoughts on why the book mattered to you.

#MedRead (part 1) Non-fiction books: Physician Narratives, Medical Practice, and Illnesses

Recently, I made a request on Twitter for suggestions for books that medical students should read.  These suggestions could be books of any sort: fiction, non-fiction, clinically-focused, etc.  I was hoping to get suggestions for books that made a meaningful impact on people.  I'll be posting the lists in a series of blog posts.

In each case, I've linked the book title to its Powells.com listing...mainly because I didn't want to link to larger sites such as Amazon.  In practice, I would strongly advise looking for these books at the library (to test them out--use this site to find the books at a library near you) or at your local independent bookstore (such as Chop Suey Books, in Richmond).  Remember that if you're local bookseller doesn't carry these titles, they can probably order them for you--and they'll keep your money local.

Alternately, if you wish to support the authors directly, feel free to see if you can purchase the book you are interested in from the author's own website.

The first group includes books that focus on medical practice, physicians' narratives, and the medical aspects of disease:



Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis – Lisa Sanders

 How Doctors Think – Jerome Groopman

The Man Who Mistook his Wife for a Hat – Oliver Sacks

How We Die: Reflections on Life's Final Chapter – Sherwin Nuland

The Case of Doctor Sachs – Martin Winckler

House Calls – Thomas Stern, MD

Anything by Atul Gawande: Complications, Better, and The Checklist Manifesto.

White Coat, Clenched Fist – Fitzhugh Mullan

My Own Country – Abraham Verghese

Of Spirits and Madness – Paul Linde

A Fortunate Man – John Berger

The Coming Plague – Laurie Garrett

Betrayal of Trust – Laurie Garrett

Medicine in Translation: Journeys with my Patients – Danielle Ofri

Not All of Us are Saints: A Doctor’s Journey with the Poor – David Hilfiker

Travels – Michael Crichton 

The Motorcycle Diaries – Ernesto Che Guevara

The Great Influenza – John Barry

Final Exam: A Surgeon's Reflection on Mortality – Pauline Chen

The Youngest Science: Notes of a Medicine-Watcher – Lewis Thomas

Aequanimitas – Sir William Osler

White Coat, Black Hat: Adventures on the Dark Side of Medicine – Carl Elliott

The Emperor of All Maladies: A Biography of Cance – Siddhartha Mukherjee

The Demon Under the Microscope: From Battlefield Hospitals to Nazi Labs, One Doctor's Heroic Search for the World's First Miracle Drug – Thomas Hager

Blind Man's Marathon – Steven Hatch

If you have read these books (or if you recommended them), please use the comments below to provide us with some thoughts on why the book mattered to you.