The healthcare aftermath of June 28, 2012: What we protected, what is missing, and what we still need to do

(Originally posted on the OccupyHealthcare blog June 28, 2012)

--------------------

Yesterday, the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). After nearly 2 1/2 years of partisan misinformation, the Court has established the law's legitimacy.

This is an enormous step forward. The PPACA incorporates many patient protections that will reduce the profit-centered influence of for-profit insurance companies on American's healthcare. Once the law is fully implemented in 2014, insurers will no longer be able to deny insurance coverage to any American even if they have pre-exisiting medical illnesses and will no longer be able to place yearly or lifetime limits on members' benefits. Insurance companies will be required to spend 80-85% of the money members pay in premiums on providing benefits to members as opposed to salaries and administrative costs. Young adults will be able to stay on parents' insurance plans until they turn 26--meaning that they can keep necessary insurance coverage as they finish their educations or start their careers. Federal subsidies will make insurance affordable for Americans who are not offered insurance through their jobs and cannot afford to purchase it on their own. Private insurers have called the shots for too long, and restricted access to necessary care for Americans who could not afford it or who were already ill. These days are now coming to an end.

The PPACA also addresses key needs in our healthcare system. It will strengthen our primary care workforce and our community health centers. It will encourage research that is both patient-centered and evidence-based, to help patients and physicians make informed decisions about the best approaches to individuals' care. The PPACA also makes preventive care available for all without co-pays, allowing healthcare providers to detect and treat (or even prevent) chronic disease before they cause permanent harm.  The law will increase Medicaid access and will strengthen Medicare. Finally, the PPACA includes programs to explore new ways of providing (and paying for) healthcare services that are more effective, more coordinated, and less expensive.

All of these are critical patient protections and healthcare system reforms. The protections will allow us to make sure that healthcare is available with less interference on the part of insurance companies and reforms the most egregious insurance company practices. The reforms will allow us to start to move our healthcare system away from one providers are paid more for doing more care and towards a system that provides better care.  These are significant steps, and reforms that the Supreme Court has now endorsed and guaranteed so long as the Affordable Care Act is in effect.

However, the law is an incomplete step forward.  It still leaves a number of Americans lacking health insurance, and explicitly prevents many immigrants from accessing care.  The PPACA supports private, for-profit insurance companies with public money in the form of subsidies to help low-income Americans pay for insurance.  There were still be fragmented care as patients will still move between private and public insurances or between private insurers.  There is little in the law to address the high and increasing costs of pharmaceuticals and medical devices.  By building upon the flawed structure of individual private insurance companies, the PPACA cannot offer the savings inherent in single-payer systems where administrative costs are lowered, coverage and access are assured to all.  The political environment in Washington, DC would not allow for such a significant move as a single-payer system.  In fact, the law barely survived in its current form.  This does not mean that we should rest on our laurels: even with the PPACA's reforms there will be much more work to do.

We must monitor how the PPACA is enacted, and we must avoid its reforms being co-opted or weakened by special interests and the law's stubborn opponents.  Where the law does not meet its intended results, we must revise it to ensure that it will.  We must identify those who do not benefit from the law as written and work to find ways to extend the law's benefits to all.  We must continue to speak about the law's benefits and make sure that our friends, families, and colleagues understand how very important this law is.

We must be vigilant heading forward.  Although the PPACA is constitutional, congressional opponents can continue their attempts to repeal and defund the law.  Rest assured that, if they are able to, they will do just that.  The House is already planning a repeal vote on July 11. Under the PPACA, the economic and human costs of allowing millions of Americans to go without health care are finally being addressed.  We cannot afford to take any steps backwards: there is still a long road ahead.

Global Health and Underserved Communities: Challenges and Rewards

From May 29 to June 9, I traveled on a medical relief trip to the Dominican Republic.  Below is the text of an e-mail I sent the team, which I include here because I believe it states my position on the challenges and rewards that one can attain for working with underserved communities in the US and overseas.


--------------------

I wanted to send this note to thank everyone for their hard work and for making the trip successful.  For those new to global health projects such as this, I realize it is a difficult adjustment to make: the long hours, the constant work, the uncertainty around schedules and plans, and the constant feel that we should, somehow, be doing more than we are.  The recognition that the need is greater than our ability to respond to it, and how we can come to terms with that without necessarily accepting it, and how we can use our resources and skills to do our part in helping the patients we work with. 

This is a heavy task: in healthcare, we all would like to think that we can make big differences through our profession, when the humbling truth is that often the best we can do is to be a small part of a larger process.  I believe we are obligated to help our patients to the extend of their needs and to the best of our abilities, but this means that there will always be someone who we could not reach, or for whom our skills were not sufficient. 

This is not a comfortable place to be, whether in the US or overseas.  I think working in developing nations makes this gap between resources and needs more evident, but as you continue your training in Richmond you will start to notice more and more examples of the mismatch between what people need and what we can offer. 

The best approach to help as many people as possible is to determine where you can have an impact, and to work as a team to get the most out of what we have.  We chose to put a lot of focus on diabetes and high blood pressure because, as medical and pharmacy professionals, this is where our greatest skill set lies.  However, our summer clinical work fits into the larger picture of our ongoing community development work in the Dominican Republic: work that aims to address sanitation, flooding, and other broad social determinants of health.  The fact that our ongoing commitment to the community leverages our skills and matches them to with community development project allows us to address health on many more levels than if these two initiatives were separate.  We may have only done a small part, but it is a small part of a greater whole.

At the same time, our part was not especially small.  In the community, we provided healthcare to nearly 500 people: people who would have lacked care if we were not present.  For some, this involved treating blood pressure and other chronic illness.  For some, this involved parasite medications and vitamins to enhance nutrition.  For some this involved coming to get medications to use if problems such as back pain or stomach pain developed in the future.  However, I was taught that the role of a healer is to "cure sometimes, relieve often, comfort always" and, as with that as a guiding principle, I believe that there is value in doing our best to care for everyone regardless of the objective severity of their illness.

It would have been impossible to have seen the over 600 patients (when both clinical sites are added up) without teamwork, collaboration, and a unified sense of mission.  Despite the challenges noted above, you responded brilliantly.  Whether working registration, vitals, pharmacy or seeing patient, everyone willingly stepped forward to do what needed to be done to make sure that we met our commitments to our patients and to each other.

For all of this, I thank each and every one of you for being part of this exceptional team.  I look forward to working with some (many? all?) of you again in the future.

#MedRead (part 3): Non-fiction books: Health policy, healthcare reform, and healthcare redesign

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.

This is the third installment, focused on health policy, healthcare reform, and healthcare redesign.  The first installment is here, and the second is here.

Pathologies of Power – Paul Farmer

Landmark: The Inside Story of America's New Health Care Law, and What It Means For Us All – Washington Post Staff

Understanding Health Policy -- Bodenheimer and Grumbach

The Social Transformation of American Medicine – Paul Starr

The Last Well Person: How To Stay Well Despite The Health-Care System – Nortin Hadler

The Truth About the Drug Companies: How They Deceive Us and What to Do about It – Marcia Angell

Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients – Ray Moynihan

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer – Shannon Brownlee

Overdosed America: The Broken Promise of American Medicine – John Abramson

Creative Destruction of Medicine: How the Digital Revolution will Create Better Healthcare – Eric Topol

Time To Die : How American Hospitals Shape the End of Life – Sharon Kaufman

Let the Record Show: Medical Malpractice, the Lawsuit Nobody Wins – J. Kelley Avery

AMA Code of Medical Ethics

Money Driven Medicine: The Real Reason Healthcare Costs so Much – Maggie Mahar

Health Care Will Not Reform Itself: A User's Guide to Refocusing and Reforming American Health Care – George C. Halvorson

Through the Patients’ Eyes: Understanding and Promoting Patient-Centered Care – Margaret Gerteis

Caring for the Country: Family Doctors in Small Rural Towns – Howard Rabinowitz

Beliefs and Families: A Model for Healing Illness – Lorraine M. Wright, Wendy Watson, and Janice M. Bell

On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health – Jerome P. Kassirer

The Patient Paradox: Why Sexed Up Medicine Is Bad for Your Health – Margaret Mccartney (A more-detailed description can be found here.)

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.

ACA triggers insurer reforms...but the law is still necessary.

(First published on the National Physicians Alliance blog, June 12 2012)
--------------------

Yesterday, three major insurers announced that they would keep in place major insurance reforms introduced in the Patient Protection and Affordable Care Act (ACA), regardless of how the Supreme Court decides regarding the law's constitutionality.

UnitedHealth, Aetna, and Humana all announced that they would continue allowing children under age 26 to remain on parents' health insurance plans, allow independent appeals of insurance decisions, and cover certain preventive services.

Although this move by these for-profit insurers appears to be a good thing, there are two important considerations to remember. The first is that none of these insurers have agreed to issue insurance plans regardless of pre-existing conditions. If an individual with prior medical problems applies for insurance from these organizations, the insurers can still deny coverage. This would no longer be possible once the ACA is fully implemented. Therefore, the law is still critically important to make sure that all Americans will have access to health insurance coverage.

The second consideration is that the ACA was the catalyst for insurers to change their practices. For-profit insurers have been around for a long time, and had plenty of opportunity to implement these reforms on their own. However, none did until the ACA was passed and signed into law. The provisions that the insurers plan to keep in place are the law's most popular provisions, but they were not established by the insurers in a vacuum. The ACA put these reforms in place, the public realized that they were beneficial, and now the insurers have decided to reform their practices accordingly. If not for the ACA, I deeply doubt we would have seen any sort of insurance reforms of this sort. In fact, when the law was being developed, insurers defended their rights to rescind patients' coverage. The ACA deserves full credit for forcing insurers to enact these important patient protection reforms.

Despite the fact that insurers have belatedly agreed to support these patient protections, the law is still critically important:

• Not all insurers have agreed to sustain these important reforms. Blue Cross/Blue Shield, Wellpoint, and Cigna are hedging their bets until the Supreme Court's decision is known and declined to make any commitments in response to yesterday's announcements from UnitedHealth, Aetna and Humana. Considering the size of these insurers, this would place many Americans at risk of losing insurance coverage if the ACA's protections were lost.
• The ACA provides subsidies for Americans who cannot afford to pay for private insurance out-of-pocket. These subsidies make health insurance, which is otherwise prohibitively expensive for many Americans, affordable and available. Without the ACA, the insurers could claim to make their coverage available to many in the sense that it is technically available, but could price it at a level that places it out of reach.
• One of the major ways that the ACA will expand insurance coverage is by expanding Medicaid. This will provide access to health insurance for millions of low-income Americans, something that these actions by the insurance companies will not affect.
• The ACA requires private insurers to spend 80-85% of the money they receive in premium payments on providing health care services (instead of using this money for administrative costs, salaries, etc). This is known as the medical loss ratio (MLR). The ACA's MLR requirements will mean that the money individuals pay to ensure they have insurance coverage will actually be used to provide insurance benefits. None of the insurance companies have pledged to maintain this ratio heading forward should the ACA be overturned.

Although it is good to see insurers pledging to keep important patient-centered reforms in place, it is necessary to put this in context. The insurers are agreeing only to keep in place the ACA's most popular reforms and reform some of their most egregious practices. They are not pledging to make their products less expensive (or more affordable) to the average American, they are not agreeing to offer coverage to all Americans regardless of pre-existing medical conditions, they are not agreeing to follow the ACA's MLR guidelines. Finally, not all insurers have agreed to continue the new practices required by the ACA.

The ACA has forced insurers to make some meaningful changes in how they practice--changes the insurers had given no indication they would enact on their own. This shows the law's power and effectiveness: thanks to the ACA, millions of Americans will have more robust insurance coverage, regardless of the Supreme Court's decision. However, what the private insurers have omitted from their promises to extend the ACA's benefits shows why we still need this important piece of healthcare reform: it is a critical step to ensure affordable and accessible healthcare insurance for all.