Family Medicine in the era of health reform - 2

This is the second of three parts presenting the content of the 21^st G. Gayle Stephens lecture that I gave at the Primary Care Access Conference. It more specifically addresses the current status of family medicine, and in particular, family medicine training.

What about Family Medicine? There has been something of an uptick of interest in FM among medical students in recent years, which has been reflected in “better” matches: a larger number of US medical graduates (USMGs) entering family medicine residency training and fewer residency slots filled by IMGs; but these are small changes, nowhere near sufficient to meet the nation’s needs for primary care doctors.  In addition, we are not sure of the reason for this yet. We hope that it is a real increase in interest, but it may also be (and continue to be) a result of increases in medical class size and number of medical schools without a concomitant increase in residency positions, leaving more students who cannot match in their more desired specialties and thus “settle” for family medicine.

Common sense, and some recent data (especially regarding loan burdens), suggests that reimbursement is an major issue, and this is something I have addressed on several previous occasions (recently The challenge of expanded Medicaid and the dearth of primary care physicians, Feb 19, 2011). Although money (income and debt) was not found to be a major determinant of specialty choice in the “Arizona studies” several years ago;[1];, debt loads have increased since then, frequently exceeding $250,000 by the time of medical school graduation. More concerning, we are increasingly hearing reports of negative attitudes among medical students toward the real or perceived lifestyle of primary care, as well as persistence of the idea that primary care -- family medicine – is not as interesting or as challenging as practice in other specialties.

A recent article that appeared in the New York Times on Saturday, April 2, More Physicians Say No to Endless Workdays, illustrates many of these issues as it describes the decision of a young female student, Kate Dewar, to enter Emergency Medicine rather than the primary care practice of her father and grandfather. She is the mother of twins and although she says

“Look, I’m as committed to being a doctor as anyone. I went back to work six weeks after my boys were born. I love my job,” she adds “But I was in tears walking out of the house that first day. I’m the mother of twins, and I want to be there to feed them, play games with them or open presents with them on Christmas morning. Or at least I want the option to do those things without fearing I’ll be called back to the hospital.”

Yes, it is possible that her commitment is simply professed, not real; maybe in an objective sense she is not as committed to medicine as her father and grandfather. And if not, if she is more committed to her family, is that a bad thing? Her grandfather, Dr. William Dewar II, is quoted as saying “My son and I had deeper feelings for our patients than I think Kate will ever have… “ and her father, Dr. William Dewar III, adds “I’ve had three generations of [the owner of the café in which they are being interviewed]’s family under my care. Kate will never have that.”

Yes, but she will fewer work hours. The article notes that “…emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services.” And she will not get paid less for working those fewer hours; actually she will be paid quite a bit more. Personally, I have seen little indicating that, overall, students are willing to get paid less in exchange for having more time with their families.

What about the other part? The ostensible lack of intellectual, or at least, adrenaline-infused, challenge? The “Marcus Welby” vs “ER” dynamic? Kate Dewar told the Times “…that treating chronic conditions like diabetes and high cholesterol — a huge part of her father’s daily life — was not that interesting. She likened primary care to the movie ‘Groundhog Day,’ in which the same boring problems recur endlessly. Needing constant stimulus — she e-mails while watching TV — she realized she could not practice the medicine of her forebears.”

Constant stimulus aside – everyone emails while watching TV (is there any other way?) --  is she correct in that primary care does not have enough intellectual stimulation? If we look at medical and surgical subspecialties, it is hard to make that argument. They all see a much narrower range of diagnoses than primary care physicians do. For most of them, their top 5 diagnoses account for 80% or more of their visits; for family medicine our top 20 diagnoses account for perhaps 30%. Indeed, this is in part why we enter FM. 

Is the Emergency Department really that different? There are certainly the big, exciting cases, but also a lot of routine. ED docs often complain that they have to do so much primary care – and they do it without gaining the satisfaction that doctors like the older Dewars get from seeing people get better over time. In addition to the primary care, there are the overdoses, and accidents, and the “frequent flyers” that characterize much of ED work. Yes, ED physicians can resuscitate people from the overdose – but they don’t treat the depression or the domestic violence that frequently was the cause. Yes, they stabilize fractures and abdominal trauma so that patients can be admitted to the surgeons (unlike on television’s “ER” where they seem to do major surgery in the ED, not to mention pushing babies back into the uterus of eclamptic women for whom there is “no room” on the labor floor – this would never happen!) – but they can do nothing to prevent the next one walking in. Yes, they admit the person from the nursing home with decompensated congestive heart failure and get them into the ICU – but if the patient lives until they can be discharged, they will be back again soon. Yes, they complain about the lack of primary care services available that make people come in with relatively minor illnesses, or even worse, with advanced stage illnesses that could  have been ameliorated by primary care – but they don’t want to be the ones to do it.

Kate Dewar says “I like it when people get better, but I’d rather it happen right in front of my eyes and not years later… [I] like to fix stuff and then move on.” At its face value this can be seen as an immature statement; while such attitudes can and do persist for an entire career for some people, they become less pervasive as doctors learn both the satisfaction that her father and grandfather demonstrate that comes from following patients over years, as well as the frustration that comes from “fixing” the same stuff over and over again. Of course, if she is an adrenalin junkie, maybe the ED will be a good place for her.

But the adrenalin rush can wear off, or be eroded. I worked for many years at Cook County Hospital, where there is a Department of Trauma. It recruits many skilled young adrenalin-junkies who want to be like Hawkeye Pierce on “M*A*S*H”, seeing people get better right in front of their eyes. Except not always. Often they don’t get better, they die. And then you have to tell their family. Another auto accident, another gang shooting, another alcohol-enhanced beating.  And then you have to tell their family. And then again, and again. And then, after a while, you get tired of it, which is why so many trauma surgeons spend so much of their time out in the community, talking to people, trying to prevent themselves from having more business. They want to decrease, not increase, their business. 

Or maybe Kate Dewar just doesn’t have the interest in working with people over time and developing the relationships with patients that her father and grandfather did, and that all the stories they tell about their great longitudinal relationships with patients are, for her, dissolved in a memory of beepers going off as her dad sat down to dinner, or on Saturday and Sunday morning. Or maybe she is just selfish. I don’t know about her, but I think that all of these possibilities can apply to many different students.

What remains true, however, is that we  -- this nation – needs to change our health care business model, to keep people from getting so sick that they need emergency rooms and high-tech procedures. In Denmark, for example, the number of hospitals dropped from 190 in 1980 to 52 in 2004[2];, not because some have driven their competitors out of business but because they are no longer needed.

Wouldn’t that be a victory?

                                                                                      

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[1] Senf J, Campos-Outcalt D, Kutob R, “Factors Related to the Choice of Family Medicine: A Reassessment and Literature Review”, J American Bd of Family Practice, 2003, 16:502-12.

[2]Kristensen T, et al., “Economies of scale and optimal size of hospitals: Empirical results for Danish public hospitals”, Health Economics papers 2008:11, University of Southern Denmark

Reinventing Primary Care: Themes and Challenges

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My May 27 entry, Universal Coverage and Primary Care: The US needs both, focused on one article from the May 2010 issue of the journal Health Affairs. That article, by Barbara Starfield, (“Reinventing Primary Care: Lessons from Canada for the United States”) was just one of 65 articles in this issue that addressed the topic of “reinventing primary care”. The articles cover the gamut of the history of primary care, the problem of undersupply of primary care providers, proposals for increasing the number of primary care providers, analyses (such as Dr. Starfield’s) of the health systems of other nations’ that are based on primary care, proposals for how the organization and structure of primary care practices need to be changed, and case studies of models of practices and demonstration projects that have implicated innovative approaches to primary care delivery. Many of these practice changes are contained under the rubric of the Primary Care Medical Home (PCMH), which is also the abbreviation for the related Patient Centered Medical Home. Indeed, the Patient Centered Primary Care Collaborative (PCPCC), a coalition of major employers, insurers, providers, pharmaceutical and device makers, and consumers, uses both “PC”s in its name (one hesitates to say that it is thus very PC!)

One of the articles is in fact “The multistakeholder movement for primary care renewal and reform”, by Paul Grundy, et. al., specifically addresses and discusses this collaborative, as well as its proposals for change in the entire structure of the primary care delivery system. Grundy, who is vice-president for global health reform of IBM, is president of the collaborative. It has brought together these various stakeholders in recognition not only of the overwhelming data that shows systems that are built upon primary care are more efficient, more cost-effective, and lead to better health outcomes, but on the actual experience of IBM and other multinational companies. These companies find that their health costs, and the health (and thus lack of time off for illness) of their workers is dramatically lower in countries in which the health system is built upon a primary care base. It is actively involved in educating, advocating, and demonstrating the importance of developing such a base in the US.

Many of the other articles in the journal address changes that need to happen to allow the small (and, as I have pointed out, likely to stay too small even if there is a significant increase in production from our current paltry 16%) number of primary care providers to care for larger panels of patients, while maintaining or increasing quality of care, patient satisfaction, and efficiency. Two of these are co-written by Thomas Bodenheimer, MD, ‘Primary Care: Current Problems And Proposed Solutions”, by Bodenheimer and H.H. Pham, and “Transforming Primary Care: From Past Practice To The Practice Of The Future”, by D. Margolius and Bodenheimer. Another perspective, more from that of the individual physician than the overall health system, is Lawrence P. Casalino’s contribution, “A Martian’s Prescription For Primary Care: Overhaul The Physician’s Workday”

What is striking about these articles in the similarity of their recommendations. The recurrent themes include the need for multi-disciplinary teams of health professionals who all play roles in caring for patients, and panels of patients. This goes beyond the simple “nurses doing callbacks” to patients before, or instead of, the physician. It means that nurses provide the care that they can, that pharmacists and psychologists and social workers all are part of the team, communicating with each other but often operating independently. Group visits are another theme; often people with the same (or, in fact, different) conditions can benefit from being seen in a group. This can be for a more formal didactic session of patient education about their condition by a nurse, or pharmacist, or health educator, or physical therapist, or physician, or medications, or other treatments, often combined with a great deal of person-to-person interaction. There is more to this than efficiency; people actually benefit from the fact of being in a group, of sharing experiences, and ideas, and successes and failures.

Another important and recurrent theme is that of physician-patient interactions that do not involve face-to-face contact, but rather phone calls or emails. Again, this is not just a matter of efficiency for the physician; patients often have concerns that can be successfully addressed by one of these other methods that do not involve them having to take off work, drive a long distance, look for parking, and wait in the waiting room. A physician can be far more effective, and interact with a much larger number of people, if an afternoon consists of seeing a few in person, a much larger number by telephone, and an even larger number by email; a number of products exist that provide not only secure email communication, but provide a structure for the patient to supply information that will help the doctor (or NP, or nurse, or whoever on the team is most appropriate) provide the greatest help.

In his article, Casalino lists five reasons why a physician should see someone in person:
“(1) for a first visit; (2) when it may be necessary to engage in some physical maneuver for diagnostic purposes—such as palpating the abdomen, listening to the heart, or performing a skin biopsy; (3) for specific therapeutic purposes, such as injecting a joint; (4) when the patient has problems for which lengthy discussion would be helpful; (5) when for psychological or emotional reasons it seems better to see the patient face-to-face; and (6) when face-to-face visits are necessary to build trust.”
These are very good, but I would simplify it even more: the physician should see the patient face-to-face when either the patient or the physician think it is important.

The effectiveness and satisfaction from increased phone calls substituting for visits was clear in the late 1990s when capitation, rather than fee-for-service, was a dominant mode of payment (of course, at that time the internet was not yet developed enough for most people to be using email). To reprise, and to improve upon that process will, obviously, require a reimbursement system that does not pay only for face-to-face physician visits. This is another common theme to many of the articles in this issue. It is also not happening in most places. It is, however, a sine qua non for such practice reorganization. And increasing the primary care supply.

Which of these themes is the most important: increasing the supply of primary care physicians, reorganizing practices to become true Patient Centered Medical homes, utilizing all of the strategies above and more, or restructuring the way health care is paid for? They are all important, all related, and all dependent upon each other for success. What is not addressed in most of the articles in this issue of Health Affairs, however, is arguably the most important: ensuring health coverage for everyone. The work of the Patient Centered Primary Care Collaborative may go a long way to having a more rational delivery system for those with access, but as long as the same old hands, in particular the insurance companies but also the drug and device makers, are part of the decision-making process, they are unlikely to come up with a plan that truly covers everyone, single-payer, “Medicare for All”, or any other rational system. And without that, all the primary care reform is not going to really work. It is not only a moral issue (although that should be enough!); it is that the cost, in terms of work hours lost, unnecessary suffering, direct dollars spent on diseases that have advanced too far because people have delayed care, and ultimately worse outcomes, is unsupportable and unsustainable.

We’ve passed PPACA. Now it’s time for real health reform.
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Primary Care and Rural Areas

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"The primary care physician and health reform”,[1] by Robert H. Brook and Roy T. Young of the RAND Corporation, appears In the April 21, 2010 issue of JAMA. Rather than review the various components of the new Patient Protection and Affordable Care Act (PPACA), as I have recently on this blog, they focus on the need to increase the number of medical students entering primary care, an issue I have also previously addressed. It is a good piece and worth reading, but contains this interesting paragraph:

“One approach to this situation is to do nothing. As a result, the number of primary care physicians in practice will continue to decline. Patients who want a primary care physician will probably need to pay some kind of retainer and enroll in a concierge-type practice. Those who cannot afford this luxury will have to endure a medical care system that is even more fragmented than it is today.”

Clearly, they do not endorse this as a desirable plan, and go on to suggest that the alternative is to find a way to get 50% of American medical student graduates beginning with those entering June 2010 to enter family medicine, general internal medicine or general pediatrics (which raises the question of: Why not those who are already in medical school?) They emphasize both the importance of closing the salary gap (which we have heard many times) and redefining the role of the primary care physician, something we hear less about. The basis for this is contained in an earlier paragraph:

“The scope of practice for primary care physicians is contracting…the 200 000 physicians who identified themselves as office-based primary care clinicians… manage most of the care for diabetes, hypertension, and obesity; address acute problems such as viral or bacterial infections; and provide general examinations. On the other hand, a large proportion of the visits for conditions that could be managed by primary care physicians such as rheumatoid arthritis, epilepsy, depression, angina pectoris, and other chronic conditions are diagnosed and managed over time by specialists. The role of primary care physicians in the hospital has also narrowed, driven by the emergence of hospitalists and the trend to move a substantial portion of medical care to outpatient facilities.”

Taken together, the two paragraphs that I have quoted contain the implicit assumption that “the patient” we are discussing lives in a major metropolitan area with a large number of physicians, especially subspecialty physicians. However, at least 20% of Americans live in rural areas where this is not true, and many others live in underserved (read: poor) urban and suburban areas. While 23% of family physicians practice in rural areas, they are the only primary care specialty (and we can include here nurse practitioners and physicians assistants) that distribute themselves in this way; NPs and PAs, as well as general pediatricians and what remains of general internists cluster overwhelmingly in urban areas and their suburbs. When the only doctors in town, and for a long way around, are family physicians, they are going to manage the rheumatoid arthritis, epilepsy, depression, angina, etc. And they are most unlikely to charge concierge fees for their patients to be able to access them. However, rural areas remain underserved because 23% of family doctors, while parallel to the percent of rural people, is still too low a percent of all doctors.

I do not mean to be critical of Brook and Young; their commentary is good and makes excellent points, not the least of which is that even people living in urban and suburban areas want to have, and deserve, primary care physicians: “Virtually everyone would like to have a primary care physician—a trusted physician who provides comprehensive, continuous care.” I also commend their clear statement that most of the chronic conditions cared for by specialists – in metropolitan areas, where there are specialists – can be perfectly well taken care of by primary care physicians in either urban or rural settings. I mean only to point out that even the most thoughtful and well-meaning commentators can miss the special and critical needs of rural people, and make assumptions that do not apply to inhabitants of those areas.

The irony is that while insurers, including Medicare, pay higher rates to subspecialists for caring for conditions that generalists could care for, as Brook and Young point out, generalists are reduced to spending more of their time doing procedures, which are more highly reimbursed, in order to make ends meet. This takes away from the time that they can spend with patients being the “trusted physician who provides comprehensive, continuous care”. Producing enough primary care physicians to provide this care to the 80% of people in urban and suburban areas, as well as to usually be the only physicians in rural communities is going to be a big challenge. The only way this is going to happen is to bring the vast difference in income expectations for students dramatically down, and fast.

The fastest way, which should begin immediately, is for Medicare to readjust its fee schedule in such a way that proceduralists can do the procedures, subspecialists can care for the rare and unresponsive or conditions in their narrow area, and generalists can care for the complexity of the whole patient, and for all of them equal amounts of work will bring in much more nearly equal amounts of income. This will mean reducing the income of subspecialists and proceduralists as well as increasing the income of family doctors, but it is a much better solution for the population’s health than turning primary care doctors into rare, concierge-type commodities.

[1] Brook RH, Young RT, “The primary care physician and health care reform”, JAMA Apr21,2010;303(15):1535-6
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Why we need health reform

Health Strong (healthstrong.org) has posted a guest essay by me titled "Why we need health reform" http://healthstrong.org/2010/03/why-we-need-health-reform/#more-508

Democrats have a bad plan; Republicans have no plan

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Sen. Lamar Alexander of Tennessee, chosen to be the Republican “point man” at President Obama’s health care summit presumably because he doesn’t come off like the meanest scold in the school the way Minority Leader Mitch McConnell of Kentucky does, told us afterwards that while his party supported almost nothing in the President’s health care proposal (including those aspects that they formerly championed) they had “better ideas”. This is a good thing, since they have no policy proposal. Those ideas being not on display at the meeting, where they spent their time sniping at the President’s proposal, I went to the Op-Ed in New York Times of February 22, 2010 where 5 prominent Republicans not currently in Congress discussed “How the G.O.P. Can Fix Health Care”.

Some of these are not bad ideas at all. Bill Frist, a heart transplant surgeon and former Senate Majority Leader (when the Republicans controlled both houses of Congress and the Presidency and did not do health care reform), although he cannot resist saying that the power to change is “…just not in the Democratic leaders’ DNA,” because they oppose markets, tells us that “Transforming health care to slow the growth of spending requires a radical restructuring of how health services are paid for. . The most powerful way to reduce costs (and make room to expand coverage) is to shift away from ‘volume-based’ reimbursement (the more you do, the more money you make) to 'value-based' reimbursement.” I agree and think I am on record as advocating that. “Reward value, not volume,” he says, “Medicare and private insurance companies should reimburse providers not for each discrete service they provide but for managing a patient’s condition over an entire episode of care… Health care providers could then compete on the basis of efficiency and success.” He also says, demonstrating more faith than evidence based on past performance, that at the local level waste would “most likely” be eliminated, and that “markets work”. It is a shame that Frist didn’t try to implement any of these changes when he had so much power. He also addresses not at all the other major issue of health reform, which is providing access to care for the poor, uninsured, and underinsured. Maybe not surprising from one who is not only a super-subspecialist doctor but a member of the family that created and owns Hospital Corporation of America (HCA), a huge for-profit chain that has never concerned itself about caring for the underserved.

Mark McClellan, the former head of the Center for Medicare and Medicaid Services (CMS) under President Bush, and now at the Brookings Institution, also has suggestions for saving money, though not as radical as Dr. Frist’s, and also completely avoids the coverage of those who are currently unable to access adequate health care. James Pinkerton, of the New America Foundation and a former advisor to Presidents Reagan and GHW Bush, does begin to address health care, not just money. He says Americans want more medical care but that they should also be able to get better health. I’m all for the better health part, but am not convinced by any evidence that more medical care overall is needed, though certainly some people need more than they are getting. Unfortunately, Pinkerton’s piece is entirely platitudes; while he doesn’t say he thinks we need more medical care, he offers no suggestions that would lead to better health, or (surprise!) even mention the problem of how to cover the uninsured. Another former policy advisor to President GHW Bush and president of the “nonpartisan” Committee for Economic Development, Charles Kolb, begins to get to the issue of coverage, saying both Medicare and the current private insurance market don’t work and we need a plan like the one for federal employees to compete with private insurance companies. He actually mentions the word “uninsured” and tells us that the way to fund coverage for them is to eliminate the tax deduction for employer based health care contributions. This might help but there would require a lot of other money. And this one will increase the costs to those already insured, as businesses will pass them on to their employees.

Finally, we have the distinguished Newt Gingrich, the former Speaker of the House whose caucus derailed President Clinton’s efforts at health care reform, as well as every other progressive idea that might help the American people, while posturing as a social conservative family-values guy and leaving his wife – who had cancer – for another woman. Not the first, but certainly not the last of incredible hypocrites wearing the Republican colors. And yes, I know about Eliot Spitzer, but you can’t beat the Republicans for sanctimonious words that are violated by their actions. (Kind of like all the GW Bush “hawks” from Cheney on down who never served in the military but were willing to paint as soft those who had, not only Al Gore but John Kerry and Max Cleland, who lost two legs and an arm in Vietnam, for goodness sakes!) Anyway, Newt is also against wasteful spending, and tells us that we can save $600 billion a year if we eliminate unnecessary care. This is presumably much of the same care that the majority of the people in the study cited by Charles Kolb want more of, but no matter. Gingrich is absolutely right on the need to control unnecessary care, most of it done by sub-sub-specialists (like Frist) and not primary care physicians, but how much is unclear; we do waste money, but most efforts to save Medicare from “fraud” seem to look like across-the-board witch hunts in which a set amount is to be recouped (e.g., we won’t pay for care that is a certain amount, like more than one or two standard deviations above the mean) rather than looking at the need for that care in that patient. And, of course, Gingrich doesn’t advocate using the savings for covering the uninsured, though at least he has “provided” the money. Again, something that he never did when in office, and his successors currently in office are not advocating.

So what do we have? Some reasonable ideas for saving money and controlling costs from Republicans who used to have power in government, but nothing concrete at all being offered up by those who are now in Congress. We have a virtually complete ignoring by these NY Times Op-Ed writers of the fact that there are 45 million uninsured and another 30 million underinsured in this country, a number that is growing , and that increasing large numbers of insured can’t afford it and can’t get the care that they need, while the insurance companies (see “Anthem Blue Cross of California”) are trying their best to seem as voracious and evil as the bankers and financiers who ruined the world’s economy for everyone. (And both, the financiers and the insurance companies, are making out like, well, the bandits that they are!) We have Republicans in Congress who can only oppose and snipe, and fear mainly that the Democrats, who have a large majority in both houses, may actually use it to pass a kind of (weak) health reform by using the budget reconciliation process. That part is ok; it still requires a majority and in contradiction to the conscious outright lying by the Republicans is the way most health legislation has been passed. For example, COBRA, that allows you to buy insurance coverage from your former employer when you lose your job, gets its name from the Consolidated Omnibus Budget and Reconciliation Act of 1986, SOBRA (Sixth OBRA of 1986), the State Children’s Health Insurance Program (S-CHIP) and the creation of Medicare Advantage plans (1991) – see Firedog Lake. Also both Bush tax cuts of 2001 and 2003 were implemented by Republican use of the budget reconciliation process.

And a terrible Democratic plan, that, in an apparent effort to garner either Republican or conservative Democratic support, is a huge giveaway to the insurance industry. See the great comments of Dr. Don McCanne, and the Reuters February 25, 2010 article by Drs. Steffie Woolhandler and David Himmelsten. But at least it will eliminate discrimination for pre-existing conditions and cover more people (maybe 30 million; why is covering only 30 million of the uninsured ok?). But given that the best Republican ideas don’t cover more than 3 million of the current uninsured, the answer to getting a better idea is never going to come from that side of the aisle.

A single-payer, Medicare for All, plan, would cover everyone, save a huge amount of money initially and provide the mechanism for future cost savings and controls, and is apparently off both the Democratic and Republican tables. It would “take” the money from the for-profit insurance companies who offer little value and run up our costs and wastes in an effort to make their profits. Call the President and your Senators and Congressman and demand single payer. Every day.
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Haiti and Health Reform: We need real leadership

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There is a lot bad in the world, and compared to people in many places, people in the US are doing OK. The most obvious and well-covered venue of desperation is Haiti, where the earthquake smashed a country that had been set up for failure, figuratively raped and pillaged by wealthy nations, including the United State, for two centuries. Less publicized is the horrific situation in the Congo, characterized by literal rape and pillage as painfully described by Nicholas Kristof in his New York Times Op-Ed January 31, 2010, “Orphaned, Raped and Ignored”. I won’t repeat the details – it is a must-read – but he leads with “Sometimes I wish eastern Congo could suffer an earthquake or a tsunami, so that it might finally get the attention it needs. The barbaric civil war being waged here is the most lethal conflict since World War II and has claimed at least 30 times as many lives as the Haiti earthquake.” And, worse, provides details that almost make one hope that with him.

The American people have responded in a truly humanitarian way to the crisis in Haiti, and it gives me new faith in the American people, if not their leaders. Many of us who have money have written checks and made pledges, but so have those without. People on fixed incomes have sent their last $5 or $10. Writing about her volunteer work with Heart to Heart in the Kansas City suburbs a week or so ago, my friend Pat Kelly writes:

“The number and type of people donating goods to the Heart to Heart trailer this afternoon was moving in itself. The live broadcaster from 1540 AM, a local Hispanic radio station wound up hauling boxes with two members of his family who decided to stay and help. Hispanic families, clearly not wealthy, driving very minimal cars, opened their trunks which were full of bottled water, canned goods, toilet paper. Cars with three infant seats in the back seat pulled out bags and bags just purchased from Target and Walmart with soaps, alcohol, hygienic products. Three different guys in lawn service pick-up trucks stopped by with checks or cash. African-American couples, mostly older, had full back seats of donations. There were at least three times as many Blacks and Hispanic donating as Whites--and this was on Shawnee Mission Parkway at Roe, not in the urban core.”

Yes. These people understand what hard times are. Understand how important it is to share and to help and to give. It is a wonderful response, the only comprehensibly human response, people giving all that they have to give. It is also something the bankers, and too many of the privileged in our national leadership either do not understand or reject. In their selfish cruelty they may disparage such giving as weakness, but of course they are wrong; generosity and caring and social consciousness are strength.

And so what will this mean for health care reform bill, I have no idea. Despite being made fun of by everyone from Barack Obama to Jon Stewart, the Republicans are going to continue to revel in being the “party of no”, of sitting on their hands and glowering at the State of the Union, of being completely uncivil when the President walks into their den, and hoping (no, believing) that acting in this way is going to get them “street cred” with the American people. They are, as identified by Frank Rich (“The State of the Union Is Comatose”, NY Times January 31, 2010), the “unpatriotic opposition”.

May it will; maybe the majority of the American people are attracted to mean looking white guys with their arms folded, responding to controversy in a manner that suggests they haven’t had a thought in a long time, but I don’t think so. Because so many of us are, as our response to the crisis in Haiti demonstrates, a caring people. On the other hand, it could be their only available strategy, since every time they trot out “facts” they are completely wrong, and a lot of folks seem to have the bad taste to want to point this out. So, at this point, I will wait and see what happens. There is a better solution – Medicare for all, pass it, let it happen, let the Republicans and insurance companies choke on their bile, and let us move forward. Obama gave a good speech; it is time for him to follow it up.

Health care is only the start. Dealing with the financial industry, in a firm and decisive manner, is also on the agenda. There have been many references to the administration of Franklin Roosevelt, and in particular the aggressive investigations led by Ferdinand Pecora. Citing the actions of a more recent president, Frank Rich’s January 24, 2010 column “After the Massachusetts Massacre”, describes John Kennedy’s dressing down of Richard Reeves, the president of US Steel, in 1962. I look, however, to an even earlier president, Theodore Roosevelt, who broke up the Standard Oil monopoly. If we have banks that are “too big to fail”, the obvious solution is: let’s not have them; break them up. I think that the fact that the one thing that everyone from every sector can agree on is that the banks and financial sector is comprised of heartless, evil people whose greed plunged our nation and world into the worst financial crisis since 1929, it is time to take strong action. Who will oppose it save the Geithners and Summers’? Here is another opportunity for the Republicans, who have been playing populist like they were George W. Bush paintball warriors; they can rush to the defense of Goldman Sachs and Citigroup and see if the American people support them. I don’t think so.

President Obama said many good things in his State of the Union speech (and some not so good ones), but he needs to follow these statements up. Rich (Jan 31) suggests “Obama should turn up the heat on both the G.O.P’s record of fiscal recklessness and its mad-dog obstructionism. He should stop paying lip service to the fantasy that his Congressional opposition has serious ideas to contribute to the cleanup. Better still, he should publicize exactly what those ‘ideas’ are.” His budget proposal is not encouraging, emphasizing increases in defense spending and decreases in domestic services.

There is a lot to do, and there are leaders who get it. As an underlying assumption, I believe that the best statement was: “In these difficult times, the government believes it is important to continue working toward a society in which people feel a sense of togetherness, respect one another and share responsibility.” Absolutely.

Of course, that was not President Obama, but Queen Beatrix of the Netherlands in her Speech from the Throne (NY Times, January 27, 2010). But I keep hoping that the US can also have leaders who can get it, and can act on it. What would be really wonderful is if they could act as nobly as the plain folks in Kansas City.
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Primary Care and Residency Expansion

In discussing some of the things I liked in the bill that passed the Senate (December 23, 2009, Health Reform: The good, the bad, and the bigoted ) one of them was that the proposal to expand by 15,000 the number Medicare-supported residency (or Graduate Medical Education, GME) positions did not get included. The reason was that it did not explicitly require that these positions be used for primary care, which I believe is an essential requirement. I cited the strong arguments made by Shannon Brownlee and David Goodman in their New York Times op-ed of the same date, "Doctors no one needs". Most primary care, and particularly family medicine, groups were also unenthusiastic to opposed.

The Association of American Medical Colleges (AAMC) does not agree, unsurprisingly to those who are familiar with medical education, and was the biggest advocate for that provision. As AAMC President Darrell Kirch wrote in his December 21, 2009 communication “Leader to Leader” (not publicly available on the AAMC website), the news on the Senate bill “…was a great disappointment because we viewed this as a truly historic opportunity to make a positive impact on our future workforce.” In what many in the primary care community saw as a more combative statement, he went on to say “During this process we were deeply concerned that some members of the primary care community spoke out against the amendment, and argued that it would not support the expansion of the primary care workforce. Facing an extremely tight timetable, Senate staff clearly indicated to us that such opposition would discourage the leadership from moving forward on any GME language. The AAMC expressed strong concern that the vocal opposition of the family medicine community threatened to halt progress on GME legislation that did indeed benefit all training programs.”

In a recent letter to Senator Harry Reid, staking out the organization’s positions on what needs to be included (read “benefits academic medicine”) as the Senate and House move to reconcile their health bills in conference, Dr. Kirch writes that the GME expansion is critical, and that the AAMC is “…supporting the inclusion of this workforce expansion as part of provisions to strengthen primary care.” That sounds, good, making nice. However, other parts of the letter indicated that AAMC’s attack on primary care, and particularly family medicine, groups, for not supporting the its agenda of expanding (“benefit[ing] all training programs”) has progressed.

"The AAMC recognizes that primary care is an integral part of health care delivery. Primary care, however, may be provided by many types of physicians and other practitioners. We support defining primary care by the types of services provided and not by a specialty of the physician or other provider.”

What is the problem here? Surely the assertion above is reasonable, that defining primary care by services provided rather than the specialty of the provider makes sense. And the AAMC is saying it is supportive of primary care, and even including goals for more residents in the primary care specialties in the expansion of GME slots. It is a big step for the AAMC to be so supportive, publicly, of primary care, as they have not always been. And, in addition, there are other specialty areas (e.g., general surgery) that are also in great shortage. Indeed, the movement has been to sub-specialization and sub-sub-specialization, so we are seeing fewer physicians who are even generalists in their own sub-specialties (such as cardiology). The goal should definitely not be to increase slots only for primary care, but to target those specialties in which there is a mismatch between the number of doctors being trained and the number needed by the community.

Considering primary care, however, there are several problems with the current AAMC proposal.

1. The proposed bill is about expanding residency slots, not about defining the content of a primary care practice. Yes, there are subspecialists who provide comprehensive patient-centered care for their patients. Particularly in pediatrics, but also in adult internal medicine; people who have mainly one serious chronic disease (kidney failure, cancer, heart disease) sometimes receive most of their comprehensive care from nephrologists, oncologists, or cardiologists (more often in pediatrics because having only one chronic disease is the norm in children, but much less common in adults). Many of these subspecialists do not. In identifying practices as providing primary care for, say, increased reimbursement, looking at services provided is quite reasonable. However, in looking at a strategy for creating greater primary care capacity, what makes sense is to expand the residency programs in specialties that are particularly about training physicians to practice primary care, and whose graduates actually do so – family medicine, general pediatrics, and general internal medicine. This is especially true when looking at how we can provide comprehensive primary care to communities, not simply to selected individuals. To say “let’s just train more doctors altogether, and some will probably do some primary care" (radiologists? anesthesiologists? ophthalmologists?) is a nonsense strategy.

2. The significant impact on the health of the population that is related to increased primary care capacity only occurs with more primary care doctors. It does not occur with just more doctors, some of whom might do some primary care. (This is the point of the Brownlee and Goodman piece cited above.) These results have been documented repeatedly, in a variety of geographic areas and populations. Yes, there is also a contribution made by “non-physician” primary care providers including nurse practitioners and physician’s assistants, but they are not the concern of the AAMC, and, moreover, are increasing not practicing primary care. (See “myths” 2 & 3 in Dr. Bowman’s guest blog of January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future.) I addressed the issue of specialty choice in More Primary Care Doctors or Just More Doctors? (April 3, 2009). Of note, Dr. Richard Cooper, whose positions I criticize in that piece, has more recently been advocating for the needs of poor and minority communities, a good thing. His main point is that the Dartmouth Atlas data on geographic variation do not account for socioeconomic differences (debatable, certainly); however, I have not seen any retraction of his AAMC-type support for “more doctors” rather than more primary care doctors.

3. There are not enough students currently interested in entering primary care to fill currently existing positions. Thus, even if a greater priority were given to family medicine and other primary care residency positions, the new positions would, barring a major change – that would, as discussed in many previous pieces, have to be systemic and involve large, not simply cosmetic, changes in reimbursement – also be unfilled, at least by US graduates. Then, of course, the teaching hospitals and medical schools would use them for other specialties. Indeed, a big reason even more students do not enter the “ROAD” specialties described by Pauline Chen (“Primary Care’s Image Problem”, New York Times November 12, 2009, and discussed in this blog November 17, 2009, as Primary Care’s Image: A Problem?) is the limited number of slots; increasing slots without increasing the attractiveness of primary care as a career option will just increase the mismatch between the proportion of primary care doctors needed by the society and that being produced by medical schools. To the extent that primary care residency positions are filled by international medical graduates, it continues to contribute to the “brain drain”, where third-world countries bear the cost of educating physicians to provide care to first-world citizens.

The only way an increase in the number of GME slots could be beneficial is not only if a majority are targeted at primary care, but are required to be primary care, or they don’t happen. And that only specifically primary care internal medicine residencies count, and that the slots are withdrawn if, after 5 years, more than 25% of graduates have entered subspecialty training.

In greater detail, Patrick Dowling, chair of family medicine at UCLA, comments on the AAMC letter:

“Granted these are complex issues but in the end I read this as: ‘give us more of the same—we need more doctors, more funding for academic centers and we need to get reimbursed better!’ I think the AAMC would have much more credibility if they stepped up to the plate and said:

‘The US health care delivery system is terribly flawed and we are a significant part of the problem. We have terrible geographic and specialty maldistribution of physicians, our costs continue to be way out of line compared to any other industrialized country and we have unacceptable racial and ethnic disparities in outcomes of care.

‘Moreover, because the graduates of our medical schools have overwhelming chosen to practice subspecialty medicine in green leafy suburbs we must import international physicians, to staff our inner cities and rural towns in exchange for visas. Although we are fortunate to have someone to send, these docs face overwhelming linguistic and cultural barriers, especially in the provision of care to low income minority populations. And in some instances they represent a “brain drain” in from the donor countries

‘Further, as the baby boomers begin to hit age 65 at the rate of 5,000 per day on Jan 1, 2011, the epidemic of chronic diseases linked to aging will soar. We would propose the following new innovative steps to insure that we have a geographically dispersed physician workforce that delivers cost effect, high quality care with a physician workforce that is optimally balanced by specialty.

‘If you provide $X billion in extra funding for Academic Medical Centers (AMCs), enhanced funding for NIH budgets and thousands of more Medicare funded GME spots we will insure that the number of HPSAs will be reduced by X, that the actual number of USMGs choosing bona fide primary care specialties will increase by Y number which will result in a primary care to specialty ration of A to B, a ratio which works very well in other industrialized democracies.

‘Finally, if we are funded we promise to bend the unacceptable curve of increasing costs so that average yearly increases are less than X% of CPI. If we fail to meet these objectives we agree to decreased funding over the following years of $Z billion.’

“If I was in the US Congress,” Dr. Dowling concludes, “I would tell the AAMC that rather than stuffing their pockets it is time to put some skin in the game and actually become the leaders in the science of health care delivery and solve these problems.”

Hear, hear.
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Health Care Needs Should Guide Health Reform

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As the debate over health care reform proceeds in the Senate, and in the nation, it is important to take stock of the key assumptions of those planning the changes. The Democrats have chosen to combine increased regulation and requirements for insurance companies with economic incentives, in an effort to cover more people and reduce skyrocketing costs. The Republicans have chosen to combine a core opposition to any proposal originating from the Administration or the Democratic leadership (articulated by New Hampshire Republican, and almost-Obama-cabinet-appointee, Judd Gregg) with cynical attempts to portray themselves as the defenders of currently-insured Americans by opposing cuts while criticizing the proposal for not saving enough money. The classic here is John McCain, who campaigned on a platform of quite draconian cuts in Medicare, screaming that the much more modest cuts in the Democratic proposal will, essentially, kill old people.

While the Democratic proposal does resemble an effort to patch the chinks in a leaky old house as winter approaches, leaving lots of holes and at cost greater than fixing the whole thing, the Republican scare tactics should be seen as what they are. Across the board cuts in Medicare would be a bad idea, as are almost all across-the-board cuts in any organization, but cuts which reduce the over- and unnecessary use of expensive tests and procedures, while increasing access to primary care, would save a lot of money. To be sure, the doctors and hospitals who provide those tests and procedures would take a financial hit, but it is unlikely to lead them to food stamps. A colleague who is in the health care field, but not a physician, told me that he had been at a meeting in which a Canadian doctor talked about the structure of their payment system, which pays subspecialists less than they make here, and observed that such change would be opposed by the specialists who would not welcome their income being reduced from, say, $600,000 to $400,000. What is there to say? Life is tough? It is hard to see the American people, worried about their jobs and future, increasingly (as I have recently discussed) on food stamps, fighting to prevent such losses. And, more important, I am sure that we will find doctors in those subspecialties who are willing to work for the $400,000.

The bigger problem with the Democratic proposal is that most of its solutions are based on creating business and economic incentives to try to get insurers to do the right thing, or at least a little more right and a little less evil. This is, I suppose, good insofar as it goes, and seems to be convincing even progressive economists such as Paul Krugman (“Reform or else”, New York Times December 4, 2009). But the idea of patching the house of health care using economics is intrinsically flawed, when the model should be based on social justice, morality, and doing the right thing for our nation and our people. Sophisticated businesses, whether Wall St. banks or health insurance companies, will always find ways to “game the system”, to find profit by reducing service, no matter how the economic incentives are structured (although surely they can be structured better than they are now). Even organizations that are intended to meet the health needs of the underserved can, because of the way incentives are structured, find that they can do better (or even simply survive) by caring for some needy in preference to others.

A case in point is one of our local Federally-Qualified Health Centers (FQHCs), also known as Community Health Centers (CHCs). I discussed these entities nearly a year ago, on December 30, 2008 (Community Health Centers, and more recently on September 3, 2009, Public/Private funding: We’re all in this together). These clinics are financially supported by the federal government largely because, in return for caring for the poor and meeting other federal service and reporting requirements, they receive cost-based reimbursement for Medicare and Medicaid patients, leading to Medicaid payments that are usually several times that paid to private doctors. They also usually receive a federal grant that helps support care provided to the uninsured. However, that money is never enough, and the additional funds from Medicaid and Medicare help subsidize that care for the uninsured.

One branch of the local FQHC located in northeast Wyandotte County, KS, where I live, served a desperately poor neighborhood. Indeed, most of the people are not on Medicare (because they are too young) or on Medicaid (because, while many are unemployed and others work for low wages at businesses that do not provide health insurance, either they are not families with young children or, if they are, they are often undocumented and ineligible). So the clinic was financially unable to support itself, and has solved its problem by moving to another part of the county, where the percentage of poor people with Medicaid is much higher. Still poor, to be sure, and in need of providers, but a good business move for the FQHC.

The problem, of course, is those people living in their old community. They did not go away, become more prosperous, or become more likely to be insured. They just lost their only source of health care. It’s hard to completely blame the FQHC, for all other providers left that community long ago, although the FQHC was specifically designed to fill these gaps. It is possible, and popular, to blame the “illegals” who make up much of this abandoned population, but while this works for propaganda, it is not so smart in reality. These people are here, and absent access to primary and preventive care they will continue to show up in emergency rooms to receive care for advanced disease that could have been treated more cost-effectively.*

Fortunately for this community, an independent, non-federally supported, safety net clinic (disclaimer: I am on its Board) has opened a small satellite in the basement of a church in that community. In doing so, it is not employing a traditional business plan; it is going where the need is, rather than where it can expect to make money. This will be a good thing for the people of that community, but it is no solution to the health care crisis, and cannot be expected to be replicated everywhere as a means of patching those chinks in our system. Not only does it depend upon funding from private foundations to exist, it depends upon enormous “in kind” contributions from its health care providers, doctors and dentists and nurses, who all receive the same wage as every other worker in the clinic, currently $12/hour.

But it could work on a national basis; not the part about doctors and dentists earning $12 an hour (we’re not talking here about $400,000 instead of $600,000!), but rather a national plan for a system that is predicated not on profit but on caring for people. A health care system which did not discriminate among people, but ensured that providers caring for everyone could survive and make a living, so that there would not be big parts of our population left out. Like a single-payer plan. Like Medicare for All.

Our system is upside down. Every other first world country has a health system built upon the idea that everyone is entitled to access to health care. Financial incentives to providers and insurers may work to fill some gaps. Ours uses financial incentives to provide care to a majority of our population, but it is a shrinking percent and even for them the coverage is decreasing and the cost is rising, and volunteerism and sacrifice are relied upon to fill the holes.

A health system for our country should start with ensuring access to high-quality health care for all our people. As I have discussed before, it may actually save money, but the reason to do it is that it is the right thing to do.

*This is not to mention that they work and pay taxes – often payroll, but certainly sales taxes – for low wages. What happens when they really leave – see “Arizona” – is there aren’t enough people to do these jobs, and aren’t enough people to rent housing – causing a major negative financial ripple effect.
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HR 3962 is still a bad bill, and Stupak-Pitts is a scandal

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After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.

I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.

HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.

Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site, http://plannedparenthoodaction.org/healthreform/668.htm.

The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.

A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.

President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.

Health Care Shoutdowns: Liars and Demagogues

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One of the striking new developments in the health reform debate is the occurrence of “shoutdowns”, where opponents of health reform, in events that obviously orchestrated, show up at appearances by Democratic Congressmen to scream against health reform (addressed by two recent articles in the NY Times, August 8, 2009, “Beyond Beltway, Health Debate turns hostile”, http://www.nytimes.com/2009/08/08/us/politics/08townhall.html?ref=weekinreview, and “Where have you gone, Joe the Citizen?” http://www.nytimes.com/2009/08/09/weekinreview/09stolberg.html?ref=politics).

According to these articles, many of the demonstrations are organized by Freedom Works, Tea Party Patriots, Sean Hannity and other well-funded right-wing groups. While freedom of speech is a good thing, preventing others from speaking, and preventing the events from occurring, is more suggestive of Brown Shirts than Americans. The conservative radio commentators, such as Hannity, O’Reilly, and Limbaugh, the right wing think tanks and activist groups, and the reactionary billionaire individuals and corporations that fund them, are bankrupt when it comes to health reform ideas, but are clear what they do not want. Coverage for all. A public option. A single payer system. Anything that will limit the profits of the insurance and pharmaceutical industries. But how do they get regular people out to yell and scream?

Well, some of them are ideologues themselves. Some of them have drunk the Kool-Aid of “no government” (except when it benefits me), or no socialism. There are always, in every country, multiple groups arrayed across the political spectrum. But the other way to get these folks out is to lie to them, to make them believe that health reform will take away their health care, limit access to their doctor, take away their current government benefits (“Keep the government’s hands off my Medicare!” is a nonsense chant heard all too often, and not nonsense to the chanter.) Misinformation is everywhere. A member of my family received an email containing the following nonsense: “…you will see that after 65 all Health Care will be limited and the people (SEC. to be specificied) will make our health care choices for us. Also the community service people will be in on the act to deny and/or approve (this is ACORN) OBAMA and his crew are denying what this plan is and they keep saying you get to choose, however, if you persist in reading you see that in 2013 all other plans are frozen out and only the public plan remains. Then the government wants access to your bank account so that after you are dead they(the government) can and will seize assets.”
What? Are these paranoid nuts, or just liars?

CJ Janovy, editor of the Kansas City Pitch, recently attended an “event” of this sort in a KC suburb which she describes on her blog, “Saturday morning's protest: Coffee and crabbiness with Cleaver in Lee's Summit”, http://blogs.pitch.com/plog/2009/08/saturday_mornings_protest_coffee_and_crabbiness_with_emanuel_cleaver_in_lees_summit.php : “Most ridiculous thing anyone said -- and more than one person said it ‘I'd rather have no health insurance than government health insurance.’” *

More disturbing yet are the threats of violence, so far only involving fistfights. However, as reported by Rachel Weiner in the Huffington Post, http://www.huffingtonpost.com/2009/08/10/gabrielle-giffords-town-h_n_255656.html, “…one visitor dropped a gun at the meet n' greet held in a Douglas Safeway,” by Congresswoman Gabrielle Giffords (D., AZ); and these opponents were not only unhappy with the Congresswoman, but with the fact that trade unionists were present to support her. “One of the callers to the Service Employees International Union said, "I suggest you tell your people to calm down, act like American citizens, and stop trying to repress people's First Amendment rights... That, or you all are gonna come up against the Second Amendment."

OK. So I’m upset. Like a lot of pointy-headed intellectuals, I would rather argue the issues than shoot them out in the middle of the street like a hero in one of my beloved Marty Robbins songs (although Rep. Gifford might end up needing the services of the Arizona “Ranger with a big iron on his hip” http://www.cowboylyrics.com/lyrics/robbins-marty/big-iron-11880.html [1]). I do believe that supporters of health reform need to start turning out in massive numbers. But people who want to read more about this, including incisive commentary, have a lot to choose from. In addition to the sources cited above, there is an excellent piece from Robin Wells in the Huffington Post August 8, 2008, recommended by Paul Krugman, http://www.huffingtonpost.com/robin-wells/what-obama-needs-to-learn_b_254714.html, who notes that “Our uniquely noxious blend of racism, right wing politics, and moneyed interests exploiting racial fears and economic insecurity have hollowed out the core of moderation in American politics. In an unbroken line from Goldwater to Limbaugh and Palin, the Republican party has committed itself to scorched-earth tactics that have shredded the economic, political, and moral fabric of this country.”

What I can do is to address some of the concerns that people, such as my relative who sent me the anonymous email quoted above, may have after this right wing onslaught. The ones making these assertions, from Palin to Limbaugh to Hannity to O’Reilly to Mitch McConnell to John Boehner to Freedom Works are evil liars, but regular folks hearing these lies may legitimately be worried. OK, here goes:

No, the plans being put forward by the Democrats, President and Congress alike, are not going to euthanize your grandmother. They are not going to leave you naked, without health insurance. They are not going to cost you a lot more – in fact they are likely to cost you less, unless you are very wealthy. (Note: this descriptor, “very wealthy”, generally applies to the folks mentioned above and the owners of the big insurance companies and their lobbyists, but not to the folks actually showing up and yelling.)

These plans are not what I have been advocating for, a single-payer system where one payer would cover everyone, and save lots of money at the outside by elimination of not only insurance company profits but the massive inefficient billing and collecting infrastructure (see previous blog entries), but it is to the extent that they would come a little closer that is (to put it mildly) agitating the right.

No one will lose their Medicare. Indeed, much of the “public option” being discussed would be expanding Medicare, the most popular, and one of the most successful, government programs ever implemented, to more people. HR 676, the single-payer bill sponsored by Rep. John Conyers and cosponsored by nearly 100 house members, is in fact called the “Improved and Expanded Medicare for All” bill. HR 3200, the current house bill, is not single-payer but does expand Medicare. The costs will be higher than I would like, not because of any “government involvement” but specifically because of the retention of private health insurance, which will necessitate maintaining the huge and costly billing and collecting infrastructure. However, currently direct government funds account for nearly 40% of our health care spending (Medicare, Medicaid, insurance for government employees and retirees at all levels) and when the taxes not paid on employer-sponsored insurance are added in, it is almost 60%. That 60% of OUR healthcare spending, which leaves 47 million people uninsured and tens of millions of more poorly insured, is more than that spent, per capita, to cover everyone in any other industrialized country. Yes, multimillionaires might spend about $10,000 more per year under HR 3200. What is wrong with that? Regular people would not.

And no one is going to euthanize your grandmother. In fact, your grandmother, your mother, you, and your children will get better care. This is a “red herring”, a complete distortion of a discussion about efforts to control costs by not doing procedures that do not benefit people but still have the potential to harm them. This makes perfect sense, and is the way it should be, and is the way I want it to be, and is almost certainly the way everyone would want it to be for themselves and their families, but is not the way that it is now. The reimbursement system that we currently have rewards doing procedures, even procedures that are not proven to benefit anyone, that will definitely not benefit the patient affected, may do them harm, and often are expressly against a patient’s wishes (e.g., your grandmother who has expressed her desire to not have any interventions except those that increase her comfort). I have discussed this at length in various columns, including Feb 13, 2009, Jun 22, 2009 and especially “Clinical Guidelines and Technology Assessment”, May 12, 2009 http://medicinesocialjustice.blogspot.com/2009/05/clinical-guidelines-and-technology.html.)

The people who are stirring up the pot are liars and demagogues, looking out, at bottom, for the financial interest of the billionaires and insurance companies that fund them. Regular people should not believe them. We are better than that. We need to support a health reform program that covers everyone. And reject these scare tactics. And be vocal about it. And make sure that we don't allow Brown Shirts to set the tone of the debate.


[1] As best as I can find, copyright Elvis Presley Music, Inc., Unichappell Music Inc.

* I had an idea for a bumper sticker that was made for these people: "We don't need to provide health coverage to everyone. If you think it's wrong, we can leave YOU out!". Of course, the problem would be that they would turn it down when healthy and then coming asking for it when they got sick and needed it. We would have to make them sign waivers that they would never ask for it. Maybe their billionaire friends in the health insurance industry would take care of them.
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