SCOTUS shows us we need to take a BIG step back

Let’s say you are a smart high school student who is learning about the American healthcare system for the first time in a civics/social studies class and considers herself unbiased, non-partisan, and open to a variety of perspectives and solutions. You are given an assignment to read this article about how we aren’t getting what we pay for in healthcare – we have the most expensive healthcare system in the world, yet we aren’t any healthier than other developed countries.  You learn about the ACA and all the workarounds that have been implemented in its wake (voluntary Medicaid expansion for states, for example) and finally, today’s Supreme Court decision. That a private corporation that provides health insurance to its workers is exempt from having to provide coverage for birth control – a basic preventive form of health care that allows women to decide when/if to start families, even though birth control is included in the required forms of mandatory minimum coverage.

Would you look at this law and think:

A: “Wow, glad that’s settled. No one will ever challenge the ACA again and this is a great example of religious freedom in America.

B: “This system just allowed a small group of people exemption from the law because these people held an opinion that other people that they have power over (ie., their employees) shouldn’t do something (in this case, take a medication) that they disagreed with.”

It doesn’t take too much imagination to think that this is just one of the many future battles to be waged on the ACA. Because special interests (ie., certain employers) are still intimately involved in seeing that a good deal of the public has access to healthcare thanks to the ACA, the implication is that our system is going to get more and more complicated, exemptions for special groups will continue to be made, and as a result, the public will NOT have the expanded access to affordable, comprehensive healthcare the ACA was (supposedly) designed to promote.

If I were that high school student, I would say – scrap the whole thing and start over.

I would want a system that provided certain mandatory minimum coverages to ALL people, regardless of their bosses’ religious and political inclinations. I would want a system that didn’t jeopardize my ability to plan a family because of my employers’ convictions.

When we have these arguments about whether certain groups should be exempt from certain parts of the law, we are getting mired down in details and missing the bigger picture – that we have “designed” a bizarre and perverse system that has now incentivized employers to take such interest in our sex lives that the SUPREME COURT has to get involved.

A solution – get rid of employer-sponsored health insurance and extend Medicare (with mandatory minimum coverage requirements!) to everyone.

 

Good article about some more philosophical considerations…

Income Inequality is Everyone’s Problem – Including Physicians

A group of medical students (myself included!) rally to support Single Payer – one of the most important campaigns health professionals can participate in to combat income inequality.

The publication of Thomas Piketty’s book Capital in the Twenty First Century has really shook the economics community, and along with Robert Reich’s documentary Inequality For All has thrust the debate about income inequality into the spotlight. I haven’t yet read it, but it’s hard to ignore all of the publicity it’s been getting from highly influential people. Bill Moyer’s interview with Paul Krugman as he discusses the book and its importance is well worth a watch. As I understand it, the thesis of the book can be summed up in the Intro (available to preview for free on Amazon!),

When the rate of return on capital exceeds the rate of growth of output and income, as it did in the nineteenth century and seems quite likely to do again in the twenty-first, capitalism automatically generates arbitrary and unsustainable inequalities that radically undermine the meritocratic values on which democratic societies are based. There are nevertheless ways democracy can regain control over capitalism and ensure that the general interest takes precedence over private interests, while preserving economic openness and avoiding protectionist and nationalist reactions.

 

I don’t think this book could have come at a more important time. With the following egregious facts coming to light (CEOs now making 354 times the amount of the average worker), nicely summed up by John Case’s article for People’s World:

The wealth of the 1 percent, and even more the .1 percent, is increasing at 2-3 times the overall growth rate of the economy (GDP). The median income worker, on the other hand, received virtually no gains from increased productivity. And workers who fall below median income have seen their share of national wealth and income dramatically cut.

It seems that Americans are more open to realizing that the super-rich didn’t necessarily do anything of value to earn that money, and that it is harmful for everyone for wealth (and increasingly, political power) to be concentrated in the hands of fewer and fewer.

As a member of the Millennial generation, I grew up being told I could be anything I wanted to be. Inherent in that statement is the idea of upward mobility. The idea that working hard is a surefire way to success in America. Yet, increasingly, this is a myth, and reviews of this book indicate this is something that Piketty addresses. In a review by Christopher Matthews for CNNMoney, he writes,

[Joseph] Stiglitz was equally taken by the work, arguing that Americans would not be bothered by increased inequality if it were based on merit within a society that enables class mobility. But the U.S. is near the bottom when it comes to social mobility [emphasis added].

 

Now we see a student debt crisis and the related social and economic effects of this on our generation, yet we are blamed for being lazy and entitled when we can’t find meaningful work that allows us to support ourselves as well as generate new ideas and technology.

Why should physicians care?

• Medical students are a privileged few who have managed with a hearty dose of luck and generous social support to forge the beginnings of meaningful careers, but we face financial and occupational insecurity never before faced by the profession.  According to the AMA,

AAMC data show that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period. 

 

• Accelerating consolidation of hospitals and insurance corporations, leading to huge behemoths of systems with unprecedented power and exploding costs. The ACA has been a driver of this trend, and this is a HUGE topic that’s worthy of much closer examination that I only superficially address here. Yet there is no doubt this relates to concentrations of influence.

• Concurrently, physicians are changing from an employing to an employed class. This is also related to many other factors, such as the fact that employed physicians typically have more predictable work hours, a guaranteed salary, and maybe a better work-life balance. But, because they are employees, they have a boss that they are accountable to, who may or may not possess an MD and understand the challenges of the profession. Will this mean that doctors’ voices will be less influential in healthcare in the future? In a 2014 Medscape survey asking what doctors dislike about being employees, 45% of employed doctors reported limited influence in decision-making, and 30% reported “being ‘bossed around’ by management. If this doesn’t sound like the classic worker-boss struggle… Yet as a “profession” instead of a “trade,” doctors generally do not participate in typical collective bargaining efforts like strikes (and many, including myself, have ethical concerns with doctors striking).

To me, the direction this is pointing is that physicians no longer have the power and influence they once did, and they will likely continue to experience declines. I don’t think this is entirely a horrible thing in itself; like all groups, physician self-interest has not always aligned with what’s best for the public (ie., the AMA was one of the biggest opponents of Medicare for all back in the day, and its official position does not support single payer still.)

This change in status will force physicians to pay attention to the concerns of the working class – because physicians now belong to it. 

Our organizing strategies will have to reflect this emerging reality. The good news is that tons of groundwork of labor movements has already been laid. Once physicians join the voices of other allied health professionals and working people, all of our voices will be much stronger. This means physicians must publicly support the struggles of much lower-income workers in living wage campaigns (as these health professional students did, this physician did, and this group of physicians did), attempts at better working conditions, and yes, single payer healthcare.

• Finally, and probably most importantly, physicians should care about income inequality because it drastically affects the health of our patients. Check out these graphs charting life expectancy by income.

If true democracy is the key to solving the problem of income inequality, physicians can play an integral role. Now, more than ever, we’re in this together.

Anyone Can Serve

I don’t think I’m alone in occasionally feeling discouraged in my ability, as an individual, to make some positive change in the face of powerful corporate interests. A few recent events have allowed me to reflect on this feeling and given me some guidance in how to proceed.

The first was a recent lobby day organized by some very inspiring, intelligent, and thoughtful first and second year med students at my school. It was organized by VCU‘s chapters of Physicians for a National Health Program (PNHP) and American Medical Student Association (AMSA), with some help from National Physicians Alliance. The goal was to advocate for closing the coverage gap in Virginia – expanding Medicaid. They set up appointments for us with some extremely difficult targets, so I knew it had the potential to be tougher than some other lobby days I’d participated in. Having grown up in the South, I wasn’t surprised at the undertones of sexism and condescension (ie., referring to adult, professional women as “honey” and “girls,” etc.) I even expected the ideological arguments grounded not in published research or testimony from health policy experts, but in pure opinion. Del. Orrock, an otherwise friendly, likable man who probably is great at his job as a high school ag teacher (bet you don’t have those up North!) remarked that he wouldn’t support Medicaid expansion because the program didn’t adequately ensure “personal responsibility” in enrollees. Never mind the economic arguments (Virginia is losing $5 million dollars a day for a projected total of $2.8 billion), the health outcomes arguments (over 7,100 deaths attributable to consequences of no healthcare access), or the fact that Medicaid expansion is primarily targeted toward people who aren’t (obviously) already covered by Medicaid – mostly the working poor. I tried emphasizing that I have seen many patients with illnesses that aren’t a result of lifestyle, and that we are all vulnerable to disease and death. The idea that people don’t value health care because it’s free and visit the doctor – what, for fun? – on a whim is not really even worth entertaining as a serious reason to inform public policy. I wonder whether people even believe that, or if they just latched onto that idea as a way to resolve their cognitive dissonance about how doing the morally and economic right thing would jeopardize their position as a Republican legislator. Then there was the meeting with Del. O’Bannon, a member of the Medicaid Innovation and Reform Commission (MIRC), the group currently charged with making the decision to expand Medicaid. He also refused to support this expansion without “significant reforms” though didn’t specify what, exactly, those reforms would be. It was a tiresome meeting. 

We did meet a well-dressed, attractive young woman who answered some of our questions about the general assembly process though – she was a lobbyist for Pfizer.

One thoughtful grad student in another profession remarked when I described my lobby day experience to her that it can be useful to talk to representatives just to remind us that there isn’t but so much that can be accomplished inside of the system. It’s true – I was pleasant but serious, balanced listening with speaking, and did all of the “right” things during the lobby day, but I’m not sure how much difference it made. It is very useful for these representatives to know that future physicians are paying attention and educating themselves on these issues; it’s clear we care deeply. But that may be more of a long-term strategy. Using a variety of tactics to accomplish change is something that I continue to grow increasingly respectful of.

The second is my participation in an elective at my school that is designed to introduce students to the workings of a large health insurance corporation (I won’t mention which one it is, but it’s probably not too difficult to figure out.) I signed a non-disclosure agreement to not report their proprietary information, and I won’t do a huge med student expose on my experiences because a) I don’t want to jeopardize the chances of them not offering the elective for other med students and b) my integrity is very important to me – I said I wouldn’t reveal specifics in exchange for the incredible opportunity to spend time learning what goes on there (or more likely, how they present what goes on there), and I won’t do it. So, very generally, I will say that it is difficult to envision disengaging our health care system from these huge, entangled webs of companies that offer very little value outside of what is being accomplished already by CMS. That isn’t to say the employees aren’t talented, thoughtful people who have much to offer to society – and who could easily offer it in the public sector instead. Very often when meeting with them I feel extremely sad that such bright people are being used by the company for the ultimate aim of keeping them ahead of their competitors. If this results in great patient care, that’s wonderful, but if not, money is what matters. Publicly-traded for-profit companies have but one obligation – to increase the wealth of their shareholders.

One common misconception about those who seek to limit the overreaching powers of corporations – It’s not that these companies can NEVER benefit society, it’s just that in instances when benefiting society conflicts with making money, the bottom line always wins.

I’m currently working on a review article about the impact of cost-sharing (deductibles, copays, etc) on low-income Americans, ie., the people targeted via Medicaid expansion. Getting acclimated with the literature in this area has been a combination of frustrating and inspiring. On the one hand, there’s so much clear evidence that imposing extra costs on poor people doesn’t improve their health or save money that it’s unbelievable there is still so much support for these types of policies. On the other hand, it’s incredibly inspiring to read about the brave actions that researchers have taken in conservative states. Some people have really aligned themselves with the poor, putting their reputations and careers on the line. They’re not really famous, they don’t have movies coming out, they’re not on “The Doctors” or anything like that, but they are worthy of recognition and admiration.

A few examples:

Gordon Bonnyman: A lawyer and advocate of Tenncare, an innovative and controversial experiment in Tennessee that aimed for universal coverage. It ultimately failed due to budget cutbacks and a variety of other reasons.

Teresa Coughlin: A senior fellow at the Urban Institute. Among many other things, she conducted research about how well Florida Medicaid recipients understood the extremely complicated reforms that occurred in 2006 under the premise of increasing choice and benefit variation and providing incentives for healthy behaviors (personally, the only thing I’m confident I understand about Florida Medicaid reform is that it involved a lot of paperwork). She and her colleagues demonstrated that, unsurprisingly, people had great difficulty understand the details of the plans, or even knowing that they were enrolled in the plans.

One of the core issues in assessing consumer-choice models is the degree to which individuals have the ability to make informed choices among different plans, which is central to the success of a competitive model. Informed choice presumes that key information on enrolling in and using a plan are communicated in a way that is easily accessible. It also presumes that sound plan information (for example, information on provider networks and prescription drug formularies) is readily available. Equally important, people must be able to use the information to make the complicated decisions required to ensure that they select a plan that meets their needs and preferences. Previous studies, however, indicate that understanding and acting on health care information is a problem for nearly half of the general population. Making sound decisions may be an even greater challenge for Medicaid populations, as research indicates that advanced age, limited formal education, and poor health status—characteristics common among program recipients—are associated with poorer health literacy.

Robert Reich: Ok, this guy is famous, and he DOES have his own movie (check it out – it’s great!) But take a look at this facebook status he posted today:

Behind the political theater over Obamacare – from the botched rollout to yesterday’s false claim it will increase unemployment – is a reality that’s barely mentioned, not well understood, but the most important of all: It’s leading to the biggest consolidation of insurers and health providers in history. Giant insurers like WellPoint are taking on an ever-greater share of enrollees, hospitals are merging into huge systems, and physicians are fast becoming system employees. Last year alone 247 hospitals merged, three times as many as in 2008. A decade ago, hospitals owned a quarter of all physician practices; by 2011 they owned half. Why? Because large insurers and giant hospital systems are each racing to increase economies of scale and market power over the other — in order to capture more of the revenues from the Affordable Care Act as well as an expanded Medicaid and, not the least, the surge in baby-boomer Medicare.

The endgame here is either (1) huge healthcare monopolies that rake in tens of billions of dollars a year while delivering mediocre services, or (2) a single-payer system with regulated prices that turn on healthy outcomes. I predict (2), within the next decade. Which do you predict?

It’s these people that remind me that we are in class war, for lack of a less divisive term, and it’s composed of everyday, local battles. We can’t fight them all, but we can choose an aspect of to gain expertise in. We can support each other through diverse causes, recognizing that many struggles fall under the same umbrella. And eventually, I still think, we will succeed in holding the flood gates against special interests and will be able to forge a more just society.

Expanding Medicaid is important; keeping an eye on Managed Care corporations is more so

It’s no secret that the ACA is experiencing growing pains at best and is in crisis at worst. Plagued by website concerns and the fact that many states are not committed to the Medicaid expansion, actually manifesting the increased coverage that is so central to the bill is proving to be much more difficult. Robert Reich recently remarked on his Facebook page regarding the problems with ACA implementation, “…if the problems continue, it won’t be only Democrats in trouble but the entire idea that government can do something complex and well. Yet, ironically, it won’t be the government that determines whether or not the system works as promised; it will be an array of private for-profit contractors and insurers.”

Again we see private industry creating problems but our government taking the blame in the public’s eye.

SCOTUS’ decision to allow states to choose whether to expand Medicaid created a new “donut hole” that’s particularly worrisome – people who do not qualify for Medicaid as it currently stands, but who make less than 138% of the poverty line (and thus do not qualify for the federal subsidies to purchase insurance through the exchange) have absolutely no options for health insurance! Because they were supposed to be covered under the new expanded Medicaid, no other provisions for their coverage were made.

It is extremely important that Medicaid expansion happen in every state, but we need to keep a close eye on how it’s done.

In some previous posts I’ve talked about states’ ideas for implementing Medicaid expansion and how Virginia, like many other states, seems to be leaning in the direction of increasing managed care. This basically amounts to awarding contracts to private insurance companies to handle the administration of Medicaid, with the idea that private companies will know how to better decrease costs as well as increase efficiency. Generally (but not always) this means that private companies are paid a fixed rate per enrollee, which is usually a percentage (usually around 95%) of what patients are costing the state, on average, under the prior fee for service system. Good data exists regarding this tactic in Medicare. Contracting to private companies via Medicare Advantage increases costs because programs have consistently found ways to cherry-pick for the healthiest seniors, thus minimizing risks, and have higher administrative costs than traditional Medicare.  It is estimated that Medicare private plans have resulted in overpayments of over a quarter-trillion dollars from 1985 – 2012!

However, the impact of Medicaid Managed Care on cost, access, and quality of care is more difficult to assess on a national level because Medicaid is a state program and significant variability exists between states. The patient population of Medicaid is also significantly different than Medicare. Yet there is some emerging evidence that the impact is negative, especially when for-profit companies handle care:

1) A recent study by McCue and Bailit directly compared publicly-traded with non-publicly traded Medicaid Managed Care plans and found “publicly traded plans that focused primarily on Medicaid enrollees paid out the lowest percentage of their Medicaid premium revenues in medical expenses and reported the highest percentage in administrative expenses across different types of health plans. The publicly traded plans also received lower scores for quality-of care measures related to preventive care, treatment of chronic conditions, members’ access to care, and customer service.”

2) The state of Connecticut recently ended their contracts with multiple managed care organizations (MCOs) after an independent investigation, citing concerns about insufficient transparency regarding allocation of funds and burgeoning administrative costs.

I spoke with a few physicians who provide care to a large population of patients with Medicaid about differences they’ve noticed with the Managed Care companies vs fee for service. These companies seem to increase administrative burden on physicians by ensuring “quality measures” are met. A few examples – reminders to place patients on ACE inhibitors (when many of the patients are already on these medications, but just not registered by the company), or “Members who turned 15 months old during measurement year and had at least 6 well child visits since birth.” While important aspects to consider, it’s easy to see how satisfying them may not necessarily lead to better outcomes (but give the appearance of such to policymakers). It’s even easier to see how these may balloon into huge administrative bloat for already busy doctors.

Still, many states are expected to increase their involvement with private insurance companies in expanding Medicaid.  Why? The myth persists that private companies, because they are subject to the invisible hand, will streamline administrative costs and improve quality or risk failure. All available evidence points to the contrary, because healthcare does not function like other markets. 

 

Medicaid Managed Care proponents say that coordinating care of people with chronic diseases/conditions is necessary to help them navigate the confusing system and keep them out of the hospital living longer, healthier lives. How could any multi-payer system possibly do that better, and with less administrative burden, than a single payer one? That would allow for the optimum, most efficient coordination of care, as well as quality evaluation.

Let’s work to keep an eye on further privatization of Medicaid. An example of an organization doing just this is Community Catalyst, a consumer advocacy group that conducts research and writes publications about healthcare reform, including Medicaid Managed Care. 

When these market-based experiments fail, we need advocates to step in swiftly with evidence-based explanations in order to prevent the needless suffering of patients and further waste of taxpayer money.

Price-posting: Oh Look! Another Healthcare Cost “Solution” Gimmick.

The Surgery Center of Oklahoma has been in the spotlight recently because of its decision to post all of its prices for its procedures online. This has been heralded as increasing transparency in healthcare costs and implicitly demonizes other hospitals in the area that haven’t followed suit, like traditional academic centers.

Why haven’t hospitals done this a long time ago, so the uninsured can bargain shop for their knee replacement  instead of being stuck with a huge bill they’ll have to go into bankruptcy to afford? It’s an attractive idea, especially when presented as oversimplified as it has been to the public.

In isolation, price-posting is just another market-based artifice, more zeitgeist of our accelerating entrenchment in our broken, healthcare-as-commodity model than any real solution. Nothing illustrates it better than this quote in the NYT opinion piece from the co-founder of the Surgery Center himself, “Patients are holding plane tickets to Oklahoma City and printing out our prices, and leveraging better deals in their local markets.”

HOLD UP DOC. There are a few BIG assumptions here:

1) The medical procedure you need is known to you in advance – that is, it isn’t an emergency.

2) You have the ability to pay SOMETHING ,but either don’t have insurance or lack specific coverage for the procedure, etc.

3) You are physically and mentally able to bargain shop for the healthcare you need. There are many people who need healthcare services who aren’t able to do this – people with dementia requiring long-term care, a person in a coma from a car accident, a person with a debilitating psychiatric problem – it’s not hard to bring examples to mind.

We find that what this really represents is a very specific marketing tactic to a targeted audience – mostly healthy people who need an elective surgery to improve their quality of life. Clearly a very important demographic, but it by no means representative of everyone seeking healthcare.

This approach might works for certain places, like outpatient surgery centers, because they don’t have to deal with people who can’t pay. They can throw their hands up and say, “Don’t blame us! This is a fair deal. Our prices are listed with no small print – pay or don’t receive services.” These are not hospitals – they are centers that offer specific, non-comprehensive services.

Meanwhile, other hospitals in the area, like Oklahoma University Medical Center, take care of people who can’t pay.

The NYT opinion piece basically sums the problem of healthcare costs as a lack of knowledge on the part of the consumer.  That IS a problem, but the real problem is summed up simply in one word: profit.

When there is a market-based healthcare system like there is now, we get comical (but tragic!) comparisons like the NYT piece where finding cheap airline tickets through Kayak is used as analogy to “shopping” for health care.

Anyone without a stake in the current system, any American that needs life-saving services, anyone with the presence of mind to take a step back and examine things in context will see this is just. another. tired. gimmick.

The beginning of a real solution to the healthcare cost problem requires the following steps, in order:

1) Recognize every single person’s fundamental vulnerability to disease and death.

THEN

2) Affirm healthcare as a human right, NOT a commodity that is only available to those that can afford it.

THEN

3) Change the system into an “Ultimate Public Utility” model – because it’s something that we ALL benefit from, and are (mostly) unable to predict when we will require.

THEN

4) Realize that a publicly-funded, Single Payer model – improved Medicare for everyone – is the NECESSARY BUT NOT SUFFICIENT next step.

I’ve noticed some Single Payer advocates start to falter when they present Single Payer as the ipso facto solution for every healthcare-related problem. It will not be like that. Very little will change for the average person if we just decide tomorrow to extend Medicare to cover everyone. A Single Payer system’s REAL power is providing the  ONLY framework that will allow us to collate our bloated, fragmented system into one that can be examined and systematically changed in response to population needs. More fundamentally, it is the only one in which population needs can be accurately assessed in the absence of profiteering. It will be a quicker, more centralized, more responsive system because it is structured to be resistant to conflicts of interest. The goal of a Single Payer system is to provide necessary healthcare to everyone, NOT quibble about piecemeal, temporary gimmicks like price-posting.

Students for a National Health Program Summit

Over the past few months, I’ve been helping to organize the 2nd annual Students for a National Health Program summit – a conference designed to help health professions students learn more about how to advocate for single payer national health insurance. It’s getting down to the wire – the conference is this Saturday, May 11 at Physicians for a National Health Program headquarters in Chicago. It’s been a pretty sizable amount of work – I feel like I’m sending a million emails a day – but it’s shaping up to be a great conference. This is the first time I’ve helped to organize something like this, and I’ve actually kind of enjoyed it, despite never considering myself someone who was particularly good at logistics or details. I’ve been incredibly impressed with the other organizers who are all busy med students too. It seems like this has run WAY more smoothly than I anticipated, and it’s no doubt because the other students are doing it because they believe strongly in the cause (not to mention they’re super smart and talented!). I’ve noticed that when counting on people who are volunteering their time, you can unfortunately expect about a third to half of them to flake on some tasks, even if they specifically said they would do them. It just seems to be the nature of the beast. These guys have not only NOT done that, but they’ve been incredibly proactive in volunteering to take on extra work during our organizing conference calls. It’s made me work even harder to ensure we provide a good conference for the other attendees.

One of the things I’m really excited about (which was also true last year when I attended the first conference) is that the group chose to invite other health professions students, and I was able to meet with people in different training programs – nursing, public health, etc. We have several other professions represented this year too, including some premeds, which is great! I think interacting with other health professionals is something that my school has been a bit weak on so far. We’re all working towards the same goal and we’re all in the same system, yet sometimes we don’t even understand what the other’s role is.

We’re going to start the day with an introduction to single payer and a presentation about the role of advocacy that health professionals have played in the past, and what we can do in the future.Then we’re going to talk about HR 676, the House single-payer bill. From there, we’re giving students options of attending one of two breakout sessions which are designed to be more interactive. I’m helping with two of them. The first is a co-presentation with Paul Demos, a former drug rep who is now a medical student. We’re giving a presentation about – my favorite topic – the role of privatization and for-profit corporations in health care! And who better to speak about this than someone who has been in the trenches and really knows what it’s like as a former drug rep. The next presentation that I’m giving is really going to be an interactive session about communication/conversation skills and responding to difficult questions about single payer. I was feeling a bit uncomfortable giving this, to be honest! I was wondering if I even have these skills – sometimes I feel after walking away from someone who disagrees with me we’ve both just annoyed the other. I kind of tried to get out of this presentation or at least get someone to help, but then I realized that it’s completely fine to admit that effective communication skills are a constant learning process. Expecting to always be perfectly poised, articulate, and calm when speaking with someone about something you feel passionate about is unrealistic. The healthcare system is complicated (to say the least), and understanding the economics behind it is something I feel like I’m only beginning to grasp. Instead of giving a presentation, I tried to come up with a framework where we could all learn from each other. There is no doubt that some of the people attending will be much better at this than me, naturally, and I hope that we’ll be able to learn from them. So I designed a couple of scenarios for people to act out. I hope this will be a good experience for everyone, but we shall see! Other presentations/breakout sessions focus on transitioning from sympathizer to activist, a workshop on writing letters to the editor/speaking out, healthcare economics, and more! I have really high hopes for the conference and I hope that I can learn to better convey my optimism that single payer is the most realistic, humane goal for a better future.

A criticism of my own criticism

Based on a conversation yesterday, I began to consider the problems inherent to criticism that only seeks to expose problems in a system without proposing solutions. Such criticism, – well-founded, researched, and presented – would at its best leave informed people galvanized for action. But what action? Action should be organized and directed in order to be effective. At the worst, the criticism would leave people feeling hopeless and helpless, especially for those less familiar with the inner workings of health care systems. It could potentially discourage a growing sense of empowerment that would encourage people to learn more and fight for a better future. That is of course the last thing I’d want to do.

Presenting problems in any system, then, brings up the question of whether we have an obligation to provide some form of hope. This could be as concrete as a suggested action or as abstract as a vision of what a better system would look like. Kind of in the vein of “a journey of a thousand miles begins with a single step” – should we provide a step, any step? Without entering in a rigorous philosophical and ethical discussion, in short, I think we should. From now on, when I speak and write about the problems in the system, I’m going to endeavor to provide at least the framework of a potential solution.

Of course, a potential solution to the problems in American health care is a HUGE undertaking (and one that I am only beginning to realize the magnitude of as I sat down to write this post!). Considering a theoretical perfect system seems more proactive than reverse engineering the current system.

It seems 3 main goals/themes start to emerge when I imagine a just and sustainable, prevention-oriented health care system. The specifics of these  will change as our collective knowledge improves, yet the over-arching principles should remain.

1) keep healthy people healthy

2) heal the sick quickly, efficiently, and effectively

3) provide compassionate, human-centered end of life care.

Such a system would prioritize these goals above all others. There does not seem to be any room for the pursuit of profit within this framework, yet there is a clear role for continued research into cost-effectiveness. These goals necessitate that we consider an individual as a collection of smaller systems (individual organs down to cells) but yet a part of larger systems (families up to societies and species).

Obamacare and Virginia

My privilege is this much bigger than yours!

The ACA/Obamacare is a flawed piece of legislation. It will not provide universal coverage, and there is little reason to think it will control costs. I find arguments against incremental reform in health care (and indeed, almost all systems) very compelling. While the debate of incrementalism vs. true reform/revolution is deserving of much reflection, that isn’t the intention of this particular post. I want to talk about how the implementation ACA/Obamacare is playing out in Virginia and what the implications of this are for the 99%.

There are two large issues in the short term regarding how the ACA will affect Virginia. The first is that Gov. McDonnell has said Virginia will not be setting up its own health care insurance exchange, and as a result will not be getting the federal money for Medicaid expansion.

Go ahead and skip this paragraph if you know what the exchanges are – this is just a refresher. The exchanges are based on the idea that by pooling small businesses and individuals together to function as a large company, they can buy insurance at rates comparable to what big businesses already pay. It was in recognition that because of less bargaining power, small businesses and people buying insurance on their own often pay far higher than what large businesses are able to negotiate. —States can lump individual and small business together in the same pool or they may be separate. There are four levels of benefit packages offered with varying percentages of health care costs covered (certain minimum coverages included) – from bronze (pays 60% of actuarial value of plan benefits) to platinum (pays 90%). People under 30 who would not be required to purchase insurance because it exceeds 8% of income will be able to buy “catastrophic” coverage. The exchanges must limit cost-sharing, with no annual or lifetime caps in coverage, and a maximum of $2k for premiums of individuals and $4k for families (the actual number is subject to change in the future). Yeah, it gets really complicated. The exchanges are supposed to be in place by 10/1/13 so people can start shopping, buy their plan, and have their coverage start on 1/1/14.

The states were given the option of setting up their own exchanges, or they could default to a federally-operated exchange. The catch is that by defaulting, they lose the federal funds to expand Medicaid.

The Medicaid expansion is a tricky subject. In order to get an idea of what Medicaid currently is like in Virginia, consider these facts: Unemployed parents in a family of three with incomes over $4,772 make too much to receive Medicaid coverage (25% of federal poverty line), while employed parents in a family of three who earn over $5,744 make too much to receive Medicaid coverage (31% of federal poverty line). Obamacare expands Medicaid eligibility to 133% of the federal poverty line. In 2014, that corresponds with an income of  $14,856 for a single person and $19,378 for a family of three. This would result in about 420,000 more Virginians covered, 84,000 of them kids.

The Supreme Court ruling that upheld Obamacare in June 2012 also said that states could not be forced to use their money to expand Medicaid. This was still decided even though care was taken during the crafting of the bill to not impose excessive burden on the states which tend to have more variable expenses and incomes. In fact, the federal government would pay 100% of Virginia’s Medicaid in 2014, and gradually reduce to 90% starting in 2020. However, if Virginia waits until 2016 or 2020, that drops to 95% or 90% immediately.

There is absolutely no reason to refuse this money from the federal government. It is especially important to take this money because the amount of federal dollars given through the Disproportionate Share Hospital (DSH) program for hospitals serving lots of uninsured patients is decreasing.  This means that in states like Virginia that won’t be receiving federal money for Medicaid expansion, hospitals serving the poor will be disproportionately hurt. Even the argument that McDonnell is using regarding the instability of the federal money holds no weight:

“I don’t believe the federal government can possibly deliver its commitment to fully fund the program, and I don’t want to be part of contributing trillions of dollars to the national debt.”

If in subsequent years Virginia found that it was unaffordable to continue the expanded Medicaid, it could withdraw from the program (and lose federal funds). The Virginia Chapter of the American College of Physicians, an organization of Internal Medicine specialists and medical student members (including yours truly), recently released a report detailing how the Medicaid expansion will benefit Virginia. It’s pretty compelling stuff. Basically, Medicaid saves lives, and reduces racial and ethnic disparities in health care, with over 40% of the those affected by the Medicaid expansion being people of color.

Let’s review what happened immediately after Obamacare passed in March 2010. The Virginia General Assembly passed the “Virginia HealthCare Freedom Act,” which was basically written by the corporate-backed American Legislative Exchange Council as the “Freedom of Choice in Health Care Act.” This made it illegal for the government to require the purchase of insurance.  Our Provocateur-ney General Ken Cuccinelli then used this as the basis to file suit against the federal government, which, of course, ultimately failed.

What is the purpose of fighting the Medicaid expansion so hard if it would genuinely help the poor of Virginia? The purpose is to chip away, undermine, and sully the reputation of publicly funded and administered health care. If Medicaid works for the people of Virginia, then that is yet another weak link in the argument that complete privatization of health care and voluntary coverage is the only “right” way (never mind that Obamacare essentially ensures this anyway).  Conservatives love to demonize Medicaid, continuously underfunding it and fighting attempts to improve it. Medicaid, like the current Medicare, is highly flawed, pays much less than private insurance, and is mostly inaccessible for all but the poorest of the poor. (But people with Medicaid are still better off than with no insurance at all!)The reason is because the powers that be have vested interests in profiting off health care, and Medicaid stands in their way.

Take action to help the Medicaid expansion happen in Virginia. Contact your state senators and delegates.

Market-based ideas: option or coercion?

I recently saw the new film Escape Fire and felt like it provided a pretty good introduction to the problems with American health care at the moment. It was up to date in detailing why Obamacare is an imperfect solution, and it did explore the issue of why for-profit corporations might not be in the best position to reduce health care costs. Just because of the wide variety of issues the filmmakers chose to look into, it was naturally limited in the depth it could go, but it seemed to provide a reasonably fair assessment overall.

I was struck by one example of lowering costs and improving health that I hadn’t heard about before – that of the grocery store Safeway. Faced with rising health insurance premiums like most companies, Safeway decided to implement a behavioral motivation program where it based the costs of its (non-union) employees’ premiums on a variety of health indicators: “tobacco usage, healthy weight, blood pressure and cholesterol levels” according to an article written in the WSJ by Safeway CEO Steven Burd in 2009. He claimed that insurance costs almost immediately stabilized after implementation of the program in 2005 and that they were “building a culture of health and fitness.” The idea, of course, is that if people are financially motivated to behave themselves in a way that will reduce their future need for health care utilization, everyone will benefit.The movie showed happy-looking employees jogging around the building.

I got a feeling of unease when I heard this story, although I couldn’t immediately figure out why. What’s wrong with giving people an extra reason to improve their own health? After all, they’re the ones who are benefiting from losing weight, quitting smoking, etc. It took me awhile, and I had to dig into it a little bit, but I think I have an explanation.

Burd’s tone in the article struck me as condescending and infantilizing to the workers, although I’m sure he didn’t see it that way. To me, the subtext was, “if only these fat smokers would just QUIT IT ALREADY, they would save us all a ton of money.” He emphasized that 70% of health care costs are the direct result of behavior. (I wasn’t able to find sources in his article, but it very well may be true.) Regardless, such statements are oversimplifications that grossly devalue the truly transformative experience of changing an unhealthy habit. And it shames and punishes people who are unable to make the changes.

Why is that a problem? If 70% of health care costs truly are the result of unhealthy behaviors, then that must mean those behaviors are probably pretty hard to change. I don’t think that people were totally ok with making themselves ill and just looking for an insurance discount to provide that final incentive to get rid of their pesky congestive heart failure caused by a combo of uncontrolled hypertension, high cholesterol, and diabetes-induced heart attacks.

What seems to be difficult for most super-rich people to grasp is that behaviors aren’t just about an individual’s choices. An individual isn’t isolated from the influences around them, but certainly does suffer from them. Not having a car because you are poor, work a low-paying job with weird hours, take a bus home to a neighborhood where there aren’t any grocery stores, and as a result end up eating crap from the local corner store which contributes to your early-onset diabetes certainly could be considered a “behavior” but I think it’d be more accurate to call it a “complete failure of our unjust society.” Granted, most people’s situations are not that drastic, but it’s an illustration of how even calling something a “behavior” neglects the complexities inherent to real people’s lives.

I’m reminded of a (by all accounts middle-class, relatively privileged) person I met whose weight-loss efforts had stalled recently because of severe depression accompanied by some pretty terrible family and social circumstances through absolutely no fault of their own. Any one of us would have found it difficult to continue losing weight in their shoes, despite this individual being highly motivated. It seems incredibly uncompassionate to just toss that person into the policy. It contributes to the myth that meeting these objective, population-based benchmarks are possible for every person at every time if they’d just work hard enough and take personal responsibility, dammit!  It pits workers against each other – hey, fatty 2 cubicles over! Put down the donut and take a walk around the damn building to get your blood pressure down! I don’t wanna have to pay for your expensive, fancy diabetes drugs!

And perhaps most frustrating of all, it’s based on the premise that absolutely everything, even our own health and well-being, has a price and can be commodified.

I should note that in no way am I attempting to minimize the accomplishments of Safeway employees who actually did make these changes and come out far healthier. I have no doubt that such a program was just what some people needed to provide that extra oomph to get the exercise ball rollin’. But even if that were the case for every employee, isn’t it a bit creepy and invasive that your boss cares so much about your waistline and your cholesterol level?  A “culture of health and fitness” starts to look a little more like a culture of coercion, shame, and anxiety.

And what does this market-based solution do to fundamentally address the inequities in accessing health care? That is, even if every employer had a similar program, what would that mean for people who are unemployed due to say, chronic illness? Would they be further shamed and isolated from society? The program is based, by definition, on employees, so that means the people participating were at least healthy enough to work. Almost certainly this would mean that the care of the very sick would continue to fall in the public domain, decreasing private, corporate health care expenditures, but further increasing publicly funded healthcare (ie., Medicare). Though this type of system, Medicare will continue to be fantastically expensive, making it easier to demonize until we finally move toward a total privatization of health care, dissolution of Medicare and Medicaid entirely, with safety nets only being provided by voluntary, charity care.

Well, it turns out that even though Safeway medical costs did stabilize from 2005-2009, it may not have really been related to the incentive program at all and was heavily weighted towards the early years. That is, costs dropped 12.5% in 2005 when the company drastically changed the benefits it was offering. However, 2009 was the first year that insurance premiums were tied to test results at Safeway. According to David Hilzenrath in the Washington Post, “Even as Burd claimed last year to have held costs flat, Safeway was forecasting that per capita expenses for its employees would rise by 8.5 percent in 2009. According to a survey of 1,700 health plans by the benefits consultant Hewitt Associates, the average increase nationally was 6.1 percent.”  When Safeway Senior Vice President Ken Shachmut was asked why premiums rose so much despite their terrific program, he said “we frankly did not have as much control over things as we should have.”

Maybe they had too much control.

Of note, the idea of financial incentives being not only ineffective in reducing health care costs and improving societal health, but actually impeding these goals is one that I intend to explore in future posts!