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.

Grand Frowns at the VA

I’ve been on my Internal Medicine rotation at the local Veterans Association (VA) hospital. I’ve really enjoyed it – the Veterans are almost all super appreciative, friendly people and make great patients to learn from. They’re used to medical students and mostly don’t mind our repetitive and lengthy interviews and exams. In fact, many seem to enjoy being part of future doctors’ educations and often wish me good luck after I see them. Maybe it’s the culture of service and commitment to their country that the Veterans really seem to take to heart (despite the shady deeds of the US military in the name of “protecting” Americans but in reality pushing imperialism and exploiting other less powerful countries – but that’s way beyond the scope of this post!) One Veteran told me the other day, “The VA is a great place to learn! You’re going to see some really sick patients!” As morbid as that sounds, it’s true. The patients at the VA seem to have a disproportionate amount of medical complications and coexisting conditions that are generally highly predominant in the working class (and, well, all of the developed world)– COPD, heart failure, obesity, diabetes, often all at the same time. I’ve found them to be extremely trusting of and grateful to physicians and even medical students. Like many patients with complicated medical conditions affecting multiple organs, they can be shuffled from specialist to specialist. They sometimes will start explaining a medical problem only to be told by that particular doctor that they are there to manage only a certain organ system. I’ve seen them often leave appearing pretty frustrated and confused.

I feel compassion for all patients I see, but I find myself feeling extra protective towards the VA patients. They require much care and coordination and it’s no surprise the VA is an expensive system. It highlights the importance of a large, motivated, talented primary care workforce and having a single competent person overseeing the care and referral to specialists. Yet, our American healthcare system rewards specialists with more money and prestige.

Often, I’ve heard residents and fellows talk about how inefficient the VA is and how much better private hospitals are. I’m not exactly sure what experience they have with those hospitals as the other training hospital for the program is a large public tertiary care center, taking on a ton of disproportionately uninsured patients. If you qualify for the VA and choose to use this service (as I understand it, Veterans can also choose to be privately insured through a job or otherwise), you have to use only VA facilities and doctors unless the technology isn’t available at the VA, in which case they will refer you to a place that has the appropriate services. Some of the patients end up traveling hours to get to the clinic. I can’t help but think this problem would be solved if the veterans’ care extended to any hospital or doctor. If we had single payer, national health insurance.

This past Friday, the day I leave for the Students for a National Health Program summit, we had a Grand Rounds presentation from a senior staff attending about the ACA and Medicaid in Virginia! For the most part, the presentation was mostly numbers about how coverage in Virginia would change if Medicaid expansion was implemented and the state of Medicaid in Virginia. It seemed pretty nonpartisan until he began to use buzz words like “large government program” and it started to become clearer which team he was batting for. When he mentioned Delegate John O’Bannon’s position on the panel involved in deciding whether and under what conditions Medicaid expansion will occur in Virginia, it seemed pretty apparent. He said that Virginia was set to become one of the states that did not accept Medicaid expansion until “the Left” colluded to put the transportation bill in jeopardy. He did not mention how an independent economic study determined that Medicaid expansion would cost less than not expanding it, which I’ve written about in previous posts. He also didn’t mention the terms of the Medicaid expansion. I was feeling pretty irritated. I’m in a pretty vulnerable position though, since I’m interested in going into general Internal Medicine, it’s to my advantage to not do anything that would negatively stand out and might result in a bad evaluation. No one wants to hear a med student get ornery during Grand Rounds when people by and large just want to get on with their day.

But the temptation was too much. After the presentation, I couldn’t pass up the opportunity to ask a single question which I attempted to frame as diplomatically and non-confrontationally as possible. “One of the criticisms I’ve heard about Medicare and Medicaid is that as soon as they are contracted out to private insurance companies, they become more expensive. What’s going to happen with the Virginia Medicaid expansion – will it get contracted to private companies and will it become more costly then too?” He replied that whether it was more expensive was a matter of some debate (it’s not), and that the commission was trying to make certain that every person’s Medicaid was contracted out to private insurance, and that would be a very good thing. He did not elaborate why, and I didn’t think it wise to keep pressing him.

a sampling of privatized Medicare logos

 A few minutes later, as I was reviewing charts for the morning, one of the attendings in the presenter’s own department (and an attending that I had worked with!) came to the exam room I was working in and told me he thought the presenter should have included some information about Medicare Advantage (the version of Medicare that’s contracted to private insurance companies) to the presentation. He said it was proven that Medicare Advantage cost more than traditional Medicare and didn’t have any proven better outcomes, which is true. He then gestured around and said “For all the imperfections of a single payer system, it’s what we need.” Comrades! Sometimes taking a tiny risk and speaking out helps people reach out to you. I just wish he had given the Grand Rounds.

It bears mentioning how harmful it is to present biased and only partially accurate but incomplete information to groups of physicians. A senior attending is a trusted source of material, and doctors are often too busy to do primary research about every issue. Grand Rounds exists to educate with facts, not half-truths. It was an informative and well-researched presentation in many ways that happened to conveniently neglect some key data.

 When reading info about the superiority of single payer over existing systems, I am often struck by how obvious of a solution it becomes from all angles – reduction in bureaucracy, centralization of records, marketing power to bring down pharmaceutical and medical device costs, thus providing incentive for pharmaceutical companies to develop truly innovative drugs instead of  “me-too” substitutions that are guaranteed to make money, just to name a few. And when one simply steps back, how much sense could it ever make to rely on companies whose main goal is to produce profit for shareholders to reduce healthcare costs? It’s a fundamental conflict of interest. Yet, in the face of presentations like today which I’m sure are a common occurrence, physicians are given biased views and told about the bloated, complicated Medicaid system that covers millions of US citizens and costs taxpayers billions of dollars (with a special emphasis on the low provider reimbursement rates) without explaining how much more inefficient and wasteful private insurance is.

We have much work ahead of us and much misinformation to put to rest, but every day the road becomes a little clearer and the facts speak more loudly for themselves.

Role of Profit in Virginia’s Medicaid Expansion Drama

Since I last wrote about Virginia’s foot-dragging on expanding Medicaid back at the beginning of January, a number of interesting developments have taken place. Fortunately, after what can only be described as a beating with evidence, public outrage, politicking, manipulation, and extreme waste of resources, it looks like Virginia is starting to consider accepting the expansion of Medicaid and joining the ranks of such progressive states as oh, Florida.

There is a back story to why this is happening now, and why Virginia’s uber-conservatives are allowing it at all. It involves the opportunity to profit. To understand why, let’s go through a quick summary of the events of the past couple months.

When the House of Delegates and Senate worked on their budget bills, the House agreed to accept Medicaid funding only if Virginia could have authority to “reform” Medicaid, and only after a likely special session meeting. The Senate bill was slightly less strict, saying Medicaid expansion would happen without approval from the General Assembly, but that “reforms” were still necessary.

Earlier this week, McDonnell really gave us a good scare by implying that no matter what kind of reforms Washington allows Virginia to make, it was unlikely Medicaid would be expanded. He wrote a letter to the chairmen of the House and Senate budget committee on Wednesdays, including the following, “Please understand that I cannot and will not support consideration of an expansion of Medicaid in Virginia until major reforms are authorized and completed, and until we receive guarantees that the federal government’s promises to the states can be kept without increasing the immoral national debt.”  It’s worth noting that McDonnell vehemently opposed cuts to the national “defense” budget, yet the US spends, as this article very nicely elaborates, “nearly as much on military as the rest of the world combined.”

Virginia’s Democrats in the House, seeming to recognize how ridiculous this was all starting to get, started to talk about blocking the Transportation Bill if the Medicaid expansion didn’t happen*. So, yesterday, the Senate and House voted to, uh, if not exactly accept federal money and expand Medicaid, then to pave the way towards accepting it in July with the stipulation that there be major reforms to the way Medicaid is handled in Virginia. Completely and utterly confusing, I know. This article in the Richmond Times-Dispatch reported, “The budget actions give a green light to negotiations already under way between state and federal officials on flexibility in how Medicaid is administered in Virginia — from the benefits that would be provided to newly eligible participants and their share of the costs, to the eventual use of managed care for all Medicaid services to control costs.”

Aha! Virginia wants to have more flexibility to use managed care for Medicaid. Read this as : Virginia wants to contract out the administration of Medicaid to private companies, like in Florida. They want reassurance that the federal government will allow this. With Florida setting precedent earlier in the week to move forward with increased privatization of Medicaid, Virginia was able to breathe a little sigh of relief. We might get the government out of our Medicaid after all! Florida state representative Mark Pafford remarked, “Whenever you inject the profit motive into medical decision-making, there’s a tension between patients’ interests and stockholders’ interests…We haven’t seen any hard evidence that privatizing Medicaid will actually help people.” Well said. So why is the federal government allowing this?? Well, it’s giving lip service to critics like Pafford, saying that Florida has 3 years to prove that privatization provides effective coverage and keeps costs down. On Wednesday, when Florida Gov. Rick Scott announced Florida would be expanding Medicaid, he stated, “Quality healthcare services must be accessible and affordable for all, not just those in certain zip codes or tax brackets.” It’s interesting how quickly Republican governors take up the language of real health reform advocates when the opportunity presents itself to make a profit off Medicaid.

It is well-documented how privately administered Medicare Advantage programs increase costs to taxpayers and lower quality of health services delivered. These programs have wasted $283 billion dollars in taxpayer money from 1985-2012. It’s a complicated story, but just one of the ways this happened is because the programs select for the healthiest seniors, leaving the sickest, poorest, and most expensive seniors to the standard Medicare program. Private corporations that administer these programs go home with a profit; American taxpayers literally get sold out.

The always-eloquent health justice activist, pediatrician, and role-model Dr. Margaret Flowers put it best in 2011 when she wrote about privatization of publicly-funded healthcare. “Medicare and Medicaid must be left out of the discussion entirely until leadership has the courage to address the real reasons why our health care costs are rising, the toxic environment created by investor owned insurances and the profit-driven health care industry.”

*Transportation funding plans in Virginia are particularly near and dear to my heart as there was serious discussion about re-adding a toll to I-95 South effectively throwing poor, rural southern Virginia – where I am originally from – under the bus. Making the poorer areas of the state subsidize the wealthier parts is NEVER a good idea. Ultimately this didn’t make it into the transportation bill, fortunately, but it bears mention that it was McDonnell’s idea, and given his high-falutin’ talk about “morality,” it’s interesting how selectively morality can be applied.

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.