Sunday, January 24, 2016

Flint, lead, medical heroes, O-rings and guns

In January, 1986, 73 seconds after lift-off, the space shuttle Challenger exploded, killing all 7 astronauts on board, including one of the first civilians to go up, New Hampshire teacher Christa McAuliffe. It was a disaster; indeed the words are now paired so that we always say “Challenger disaster”. The cause was a flaw in the design of the solid rocket boosters (“SRB”s) and in the now famous “O-rings”, flexible rubber seals, like max versions of the ones we see on a lot of home tools. It was perhaps the worst domestic disaster of its time, nine years before the 1995 domestic-terrorist white-power bombing in Oklahoma City, almost 16 years before the attack on 9/11. It was a disaster in two ways; the obvious one, the explosion, and in that it could have been prevented; NASA and the company that produced the SRBs, Morton Thiokol, knew about the problem.

Morton Thiokol engineers, and particularly one named Roger Boisjoly, had been worried about the problem for years; Boisjoly had expressed his particular concerns in 1985. Morton Thiokol managers considered telling NASA to scrap the launch, and then decided not to. After the disaster, Boisjoly testified before a commission about the problem, and about the warnings that he had sent to his bosses. In 1988 he was awarded the Award for Scientific Freedom and Responsibility by the American Association for the Advancement of Science. He was shunned and at Morton Thiokol, and resigned. He was right; Morton Thiokol and NASA were wrong, and it led to a disaster. And he was out of a job.

In 2014, Michigan Governor Rick Snyder appointed an emergency manager named Darnell Earley, for the bankrupt city of Flint. One of his cost-cutting measures was to stop buying treated Lake Huron water from the Detroit system and instead supply water from the Flint River. The river was full of corrosives, from decades of industrial discharge, and one effect was to degrade the old lead pipes in many Flint homes, dramatically increasing the lead levels in the water. And in the bodies of Flint’s children. The politics of the decision are continuing to play out, with calls for Snyder’s resignation, and it would have been corrupt and evil even if the problem had been identified and remedied earlier. It wasn’t, and thus became a disaster. Good piece on it in Rolling Stone.

Again, we have a hero, a Flint pediatrician named Mona Hanna-Attisha. Dr. Hanna-Attisha had heard that a team from Virginia Tech had found high lead levels in Flint’s water, and noted that she was seeing a rise in the number of children with high lead levels. She led a team doing “the easiest research project I have ever done”; because Medicaid requires children to be tested for lead at 1 and 2 years of age, she was able to compare the prevalence of high levels from 2013 to 2015.  The percentage of children with elevated lead levels “doubled in the whole city, and in some neighborhoods, it tripled. And it directly correlated with where the water lead levels were the highest” she noted in an interview on “Democracy Now”. She announced it at a press conference, and was immediately attacked by the powers-that-be (I call them the “PTB”); in this case both the political leaders of the state and the state health department.

Well, that evening, we were attacked. So I was called an "unfortunate researcher," that I was causing near hysteria, that I was splicing and dicing numbers, and that the state data was not consistent with my data. And as a scientist, as a researcher, as a professional, you double-check and you triple-check, and the numbers didn’t lie. And we knew that. But when the state, with a team of like 50 epidemiologists, tells you you’re wrong, you second-guess yourself. But that lasted just a short period, and we regrouped and told them why, "No, you were wrong." And after about a week and a half or two weeks, after some good conversations, they relooked at their numbers and finally said that the state’s findings were consistent with my findings.

There is a long and distinguished tradition of doctors making breakthrough discoveries that helped cure or prevent disease in thousands or millions of people. Some of the most storied are Edward Jenner, the 18th century physician who invented the vaccine to prevent smallpox, 19th century physicians John Snow, who discovered that the contaminated water from a particular pump in London was the cause of a cholera outbreak, Ignaz Semmelweis, who showed that doctors washing their hands could prevent deaths in post-partum women, Rudolf Virchow, the “father of social medicine”, who showed an outbreak of typhus among miners was the result of the social conditions they lived in, Louis Pasteur, Robert Koch, and Joseph Lister who proved that germs caused those diseases, and 20th century doctor Jonas Salk, who found the vaccine against polio. Does Mona Hanna-Attisha’s work rise to this standard?

Well, it may not in terms of the total lives saved, although it is worth noting that, like the work noted above, it is about public health, about populations, not individual interventions, and thus has a great impact on so many (despite the fact that in the US at least 95% of all “health spending” is on individual medical care, not public health). But she is heroic in that she stood for the truth and for the health of the children in defiance of the powerful who were trying to minimize or cover up the problem, and who tried for a while the “best defense is a good offense” strategy of attacking her, shamefully. Indeed, this is what it takes to be a hero, to not only do something important that has an impact on many, but even more to do it when you have to stand against the establishment, the PTB, the powers-that-be. This takes a great deal of courage, as well as commitment.

In Kansas, the legislature legalized concealed-carry of guns a couple of years ago, but exempted schools and hospitals until July 2017. As that date approaches in 18 months, there is little indication that the exemption will be extended, and there is great concern. A recent survey found that 70% of faculty and staff at the 6 state Regents universities oppose the law. Faculty are worried about telling students that they are failing them while they sit in their offices armed; doctors worry that if a crazy person pulls a gun in clinic, several others will draw down and make it more dangerous, police worry that they won’t even know who created the original threat. The data shows that there is a real risk of more homicide with more access and carriage of guns; “natural studies” of homicides showed a marked increase after Missouri eliminated its permit laws in 2007 and decrease after Connecticut tightened its laws after Sandy Hook.[1] [2] Moreover, 60% of gun deaths are suicides, and these are also dramatically decreased by making guns less easily accessible.[3]  Doctors and researchers need to speak out about the public health implications of easier access to guns. Luckily, many are; others are worried that perhaps the notoriously-vindictive Kansas legislature may respond by cutting funding for the university. These people will not become heroes, but they may keep their jobs and their funding.

Being a whistleblower is not easy. It is not a way to have a calm, peaceful life. Some folks have made a lot of money and retired far from those they blew the whistle on, but many more I know of are, like Roger Boisjoly, are shunned, forced out of their jobs, threatened, and may even suffer PTSD. It is not easy to take on the PTB. Better to work in their interests; for his great work as emergency manager in Flint, Darrell Earley has just been named emergency head of the Detroit Public Schools!

The full impact of the Flint lead-poisoning disaster is not yet known, because the full impact of these elevated lead levels on the brains and bones of Flint’s largely poor and African-American children will take years to take their toll. Even then, and even if, because they are treated the damage is limited, we will never know what kid who grew up seemingly ok and normal might otherwise have been brilliant.

She might have become a doctor, maybe even a heroic one like Dr. Hanna-Attisha.

[1] Rudolph, KE et al., Association Between Connecticut’s Permit-to-Purchase Handgun Law and Homicides Am J Public Health. 2015;105:e49–e54. doi:10.2105/AJPH.2015.302703
[2] Webster D, et al., Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 91, No. 2, doi:10.1007/s11524-014-9865-8
[3]  Crifasi CK et al., Effects of changes in permit-to-purchase handgun laws in Connecticut
and Missouri on suicide rates, Preventive Medicine 79 (2015) 43–49

Sunday, January 17, 2016

Are primary care practices prepared for complex patients? Is this even the right question?

The goal for our national policy should be that every person have the best health status that they can. One component of this, although certainly not all of it, is access to high-quality appropriate health care services. This means that people can receive the care that they need, when they need it, and do not receive unnecessary or harmful care. Access includes both financial and physical (geographic) access, and also access to high-quality care (see, for example, "Et qui vendit pellucidum", a recent blog post by my friend Dr. Allen Perkins).

One part of having access is that there need to be sufficient numbers of providers, appropriately trained and distributed to meet those health needs. It also means that those providers should have no reason or incentive to preferentially provide certain types of care rather than others, or care to certain people rather than others. Unfortunately, the profit motive skews this in the US; we have redundancy of profitable services like “cancer centers” and “heart centers” in major metropolitan areas, with hospitals competing for the same pool of patients, while in other areas even primary care is unavailable. We have excess capacity in some areas (every hospital, for example, needs an MRI or patients might go somewhere else, even if the number of MRI scans the population needs doesn’t justify it; providers prefer to take care of less-complex patients – a single joint replacement in an otherwise-healthy 45 year old with an athletic injury is more profitable than, and thus preferable to, doing a joint replacement in an 80 year old with multiple medical problems).

A recent survey of primary care providers in 10 countries by the by Robin Osborn and colleagues from the Commonwealth Fund, “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”[1], published in the December 2015 issue of Health Affairs (only the abstract is available free on line) sought to determine whether primary care physicians (there are, at least in the US, other providers like NPs and PAs who are not physicians) feel competent to provide various types of care. The 10 countries were all wealthy and highly developed (Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). All but the US have some form of universal health care, although the way that it is organized (e.g., single-payer government health insurance in Canada, a national health service in the UK, multiple non-profit insurers in several others) varies from country to country. In most countries, “primary care” meant family physicians or GPs, but in others (including the US), it also included general internists and general pediatricians.

The researchers found both similarities and differences by country in the percent of primary care practices that had confidence in their ability to adequately address population health needs, especially those that are increasing because of the aging of the population. For example, the confidence of these practices in managing patients with multiple chronic conditions was generally high (from 70% in Canada to 88% in Germany and the Netherlands; the US was at 76%). Fewer practices were confident in other areas, and there was greater variance. For example, 92% of practices in the Netherlands and 81% in the UK had high confidence in providing palliative care, while Sweden (25%), the US (41%), and Canada (42%) were much lower. Similar variations existed for other services (see table); for example, confidence in dealing with patients with substance use related issues were much lower (from 16% in the US to 41% in the UK).

The authors also surveyed whether practices had a number of characteristics that many experts think are important for being able to effectively and efficiently manage complex patients. These included use of electronic health records (European countries were ahead, but the US and Canada, late adopters, are catching up), team based care, after hours care not requiring visiting the ER (the US is very low), access of patients to their medical records (the US is very high as this is one of the criteria for “meaningful use” payments from the federal government), communication between different hospitals, specialists, and ERs with the primary providers (all over the board including in the US), and many other areas.

Of course, these surveys reflect the experiences of physicians in different countries, and are thus subjective rather than compared to some iconic “gold standard”. People do not know what they do not know, or haven’t experienced, or cannot even imagine; their experiences are context-dependent, and so cannot be directly compared. For example, the survey asked whether physicians thought that (their) “system works well; only minor changes needed”.  Only 16% of US doctors answered positively, with the high being in Norway, 67%. However, in the UK the number was also very low – 22%. How can we interpret that? In all of these countries, save the US, including the UK, everyone is covered. 78% of UK physicians may not believe that their “system works well; only minor changes needed”, but what would they think if the alternative was a non-system like the US where there are large numbers of uninsured people? Would they think that a better system? Probably not, but can’t tell from this data.

Finally, and perhaps most important, the survey does not look at whether there are a sufficient number and appropriate distribution of primary care providers to meet a country’s needs even when the practices are well-organized. It is my impression that the answer to this question is closer to “enough” in most of these other countries; I am certain it is not in the US. In our country, the financial rewards for subspecialization and the “lifestyle” (and sometimes financial) rewards for urban location are major determinants in our distribution of providers across specialties and geography. There are far too few primary care providers as a percentage of all physicians, and while family physicians are far more equitably distributed than other specialists, there are still big geographic disparities. Among the many “solutions” that have been suggested, I believe that only one will work: eliminate, or at least dramatically decrease, the income differential between primary care and subspecialties. This is not as far-fetched as it seems; as I have discussed before, high income for some specialists and procedures are not market-drive but are set by policy; Medicare sets these rates.

As far as geographic disparity is concerned, this is an issue that most effects primary care and a few other specialties (psychiatry, general surgery) since most subspecialists practice only in urban areas where there are sufficient populations to use their services. This also can be addressed by money: pay providers differentially more for more rural practice. We also need to provide financial resources to support these practices not only for income, but for wrap-around care. Support must be provided to these practices so that they can afford the capacity to care for the complex problems addressed in the survey.

A general practitioner from Denmark (not one of the 10 countries surveyed) told me about how his anesthesiologist son-in-law really liked his work. I chuckled about how much he must make. He told me no, actually in Denmark GPs make more. This is a good illustration of how our assumptions are context bound.

It is also the way we need to go in the US.

[1] Osborn R, Moulds D, Schneider EC, et al., “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, Health Affairs 34, no.12 (2015):2104-2112, doi: 10.1377/hlthaff.2015.1018

Saturday, January 9, 2016

Medicaid expansion: Is there something the matter with Kansas?

One of the key parts of the Affordable Care Act’s (ACA) effort to cover most Americans was the expansion of Medicaid to cover everyone under 138% of the federal poverty level (FPL). The Supreme Court decision in 2012 (National Federation of Independent Business v. Sebelius) found in favor of the “individual mandate”, allowing the law to go forward, but found against the ability of the federal government to withhold all Medicaid funding from states that did not expand Medicaid. This decision did not prevent the federal government from creating an incentive for states to expand Medicaid, which it did; for the first 4 years the federal share of cost of expansion would be 100%, dropping to 90% thereafter. This is quite a financial incentive, and as of December 15, 2015, 31 states have expanded Medicaid, 4 are considering it, and 16 are not, depicted on this map from the Kaiser Family Foundation (KFF).

Neither of the Kansas City area states, Kansas and Missouri, are in the expansion group, and thus a significant portion of their population remains uncovered. Like the other 14, control of their legislatures (and in Kansas, of the governor’s office) is in the hands of very conservative Republicans ideologically hostile to ACA. However, this is a problem not only for the poor people left without insurance and their advocates (like many of the healthcare foundations), but also the states’ hospitals, who continue to have to provide care for these people without reimbursement. To some degree it is also a problem for the state’s business community because more than half of the this group of people are employed, mainly in small businesses that cannot afford to buy private health insurance. It also decreases, in the opinion of many Chambers of Commerce, the state’s ability to attract new business and jobs.

On January 5, 2016, I attended a forum on expanding KanCare (Kansas’ privatized Medicaid program) sponsored by many of these business organizations (6 Chambers of Commerce), hospitals, physician provider organizations, and healthcare foundations (see list of sponsors on KC COC site). The event, held in Overland Park in the Kansas City area, followed a similar one held in Wichita in November, 2015.  It began with a presentation by Dave Kerr, a Republican former president of the Kansas State Senate, detailing how Medicaid expansion would bring in at least 10 times what the state would have to spend. After this were two panels, one consisting of 5 KS legislators (3 Republican, 2 Democratic; 3 senators, 2 representatives), and the other of 5 healthcare experts.

Prominently included in the second group was the president of the Indiana Hospital Association, Doug Leonard, who presented how his state had effectively expanded Medicaid. The presumption of the sponsors of the event was that this would resonate in Kansas, because Indiana is also a conservative state with a very conservative governor (Mike Pence) who had mandated the expansion based on certain principles of individual responsibility and fiscal neutrality. Indiana’s plan is one of 4 (those with asterisks on the map) that were developed with federal waivers. In its first year, it has enrolled 220,000 people into its Medicaid program, and, largely because it is paying providers at Medicare rates, increased by 1,000 those who accept Medicaid. It is paid for by a combination of increased cigarette taxes and levies on hospitals.

Unsurprisingly, this resonated well with most of the attendees and speakers, although support was not universal. Sen. Jim Denning (R., Overland Park), who is considered a health policy leader in the state senate (apparently he works for a group of private ophthalmologists), indicated that Indiana’s program would not pay for itself after the first year and would have to tap into the state general fund. The moderator asked Mr. Leonard, who drily indicated that perhaps Sen. Denning had information that Indiana did not have. When the moderator asked Sen. Denning the source of his information, he indicated “the Forbes article”. Mr. Leonard responded that, first of all, it was not an article but a blog post in Forbes, and second that the state had responded point-by-point to its incorrect assertions.  

Sen. Denning’s credibility as a source of facts was already questionable, as he had previously asserted that Medicaid expansion would affect only those between 100% and 138% of the FPL as those below 100% were already eligible for KanCare (not true; in Kansas, adults actually must be actual below about 33% of FPL, in addition to being a a special group like mothers of dependent children or disabled, to be eligible for KanCare) and that those between 100% and 138% of FPL could buy subsidized “silver” plan coverage on the exchanges for about $2.50 a month (not true; those below 138% of FPL are not eligible to buy coverage on the exchanges at all). I do not know if he misspoke or whether he believes those assertions to be true. If the latter, it is not clear whether whether those misconceptions in part inform his opposition to KanCare expansion (and thus could be changed by the facts) or if his ideological opposition informs his willingness to believe such incorrect information. However, he is a leader in the state senate, and so he is probably accurate when he asserts that the KS legislature will not expand KanCare. Other legislators on the panel, including the Republicans, indicated that such expansion would require leadership from KS Governor Sam Brownback, which the governor has not indicated will be forthcoming. One, Sen. Jeff King (R., Independence) is from the town whose hospital recently closed, at least in part because it could not count on KanCare expansion; he indicated that his father, who had had 2 heart attacks, was now 25 miles, not ¾ of a mile, from the closest hospital.

Beyond Sen. Denning, there were other concerns about the forum. Every panel member was white, and other than one state senator, Laura Kelly (D., Topeka), every one was man. Women gave the opening and closing remarks, but there were no people of color who spoke. This was obvious, but not the only important way in which the speakers (at least) and probably audience differed from the average person. One reason was that there were a lot of business leaders, because they have clout. They do, however, have a limited – and not always accurate – view of the rest of the people in this country. They seem to think that support for expansion of KanCare (and other social programs) is important until people get good jobs and get these benefits from their work (they referred a lot, disparagingly, to the “able bodied unemployed”). But where are the jobs? Job creation is supposed to be a high priority of the governor and legislature, and is the stated reason for the dramatic tax cuts of 2012 (indeed, rich people are now renamed “job creators”) but not only has job growth been slow, but it is mostly in lousy jobs – poorly paid and without benefits (eg., health insurance!). There was a great deal of talk about “retraining”, but there simply are not enough “good” jobs to employ everyone no matter how retrained they are. Their myopia may be because many well-to-do people have contact with others who are like them; in their neighborhoods, work, and country clubs. They have little insight into the real issues confronting those in the bottom 80%, not to mention 50% or 10%. I doubt they even know what the numbers are, but this article from CNN Money, with its neat interactive graph, should help; the median household (not individual) income in the US is $52,000.

I see lots of both poor and “regular” people as a doctor in the clinic and in the hospital. I live in a neighborhood that is mostly, well, working class. I see my neighbors, adults and children, on the streets when I walk my dogs. They’re trying, but it is not easy for them. Jobs are scarce, and many of those  that  they can get involve the sort of physical labor that takes its toll on their bodies and leaves them prematurely disabled. Lack of health insurance exacerbates their problems. A major recent NY Times/Kaiser Family Foundation study, reported by the NY Times, finds “Even Insured can face crushing medical debt”. Those business leaders who may think that $200K a year (for a household, most with two earners) is “middle class” should know it puts that household in the top 5% (and, for goodness sakes, in many parts of the country households making $200K are still struggling!). It would be good for them to meet with some regular folks and find out about their lives. I applaud the work that the various healthcare foundations in Kansas, many of whom co-sponsored this event, are doing. But our leaders, political, business, and otherwise, need a little reality check to leaven the ideology.

There are a lot of things that impact on whether a person is healthy besides access to health care (the social determinants of health: housing, warmth, food, education, safety, etc.). But access to health care helps. 

Sunday, December 20, 2015

Integrated Health Systems and Cost: The Price is the thing!

When the Affordable Care Act (ACA) was being developed, much emphasis was put on the effectiveness of integrated health systems as a way to save money but still deliver quality health care. Many studies from various research centers had looked at cost to Medicare and found that places – usually smaller cities – with large integrated health systems spent less on Medicare without noticeable decrements to quality. These systems can have a single provider of both inpatient and outpatient care (such as the Mayo Clinic) or close collaborations, including shared electronic medical records (as in Grand Junction, CO). The presumption of policy makers creating ACA was that Medicare spending, which is much easier to track, would reflect overall spending. However, a recent article from the National Bureau of Economic Research by Zack Cooper, Stuart Craig, Martin Gaynor and John Van Reenen, The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured, demonstrates that this assumption was incorrect. Reviewing overall costs in the 306 Hospital Referral Regions (HRRs, developed by the Dartmouth Atlas of Health Care) in the US, they discovered wide discordance between Medicare costs and overall healthcare costs. Indeed, many of the places that were highly-touted for lower-Medicare-costs-but-still-high-quality, notably Grand Junction, CO (which was, for example, cited as a success story by Atul Gawande in his June, 2009 New Yorker article “The Cost Conundrum”) have far higher than average costs overall. (Dr. Gawande has just had a new piece in the New Yorker discussing the implications of this new article.)

The New York Times coverage of this study, by Kevin Quealy and Margot Sanger-Katz, The Experts Were Wrong About the Best Places for Better and Cheaper Health Care (December 15, 2015), includes a terrific feature that allows interactive access to the data collected by Cooper and his colleagues. You can put in a town (really, HRR) and find out where it ranks in terms of both Medicare and private costs. Grand Junction, for example, while ranking 3rd lowest of the 306 HRRs for per-capita Medicare spending, was the 42nd most expensive for private insurance spending. Rochester, MN, home of the Mayo Clinic, is another city lauded for its low Medicare costs (14th lowest), but its private spending is 10th highest! McAllen, TX, cited by Gawande in 2009 for being #1 in Medicare spending (and now still #4) is only 140th in private insurance spending. Tucson, AZ, on the other hand, while only in the lower middle (82nd from the bottom) in Medicare spending, is 7th lowest for overall costs. The Kansas City region, where I live, was atypically near the middle for both, 142nd lowest for Medicare and 82nd  lowest for private costs. New York City is high in both, but it is 2nd for Medicare and 34th (quite a bit lower) for private insurance. The map in the article depicts HRRs as low, middle or high for both Medicare and private insurance.

So, what’s up? Were the experts trying to fool us? No, but the flaw  was the assumption that Medicare spending reflected overall spending. The data in this article demonstrates that it does not. It also reveals something about integrated health systems, especially those that dominate their smaller cities, given that some of the “top performers” for Medicare, like Grand Junction and Rochester, MN, were so high for private insurance. The integrated nature of these plans allows them to save money on patients by a variety of methods – they can be seen in ambulatory settings rather than in hospitals or ERs, and they share electronic medical record systems, and thus the information recorded therein, saving money by not having to repeat tests, x-rays, etc. This lower utilization is good for these health systems because Medicare is a relatively low payer, and because they can’t negotiate these rates – Medicare pays what it pays (it is a single-payer system, with minor regional variations). However, the same characteristic – being the dominant player in town – allows such integrated health systems to negotiate much higher rates with private insurers. Thus the mismatch; overall cost is a multiple of price for each service times the number of services delivered. These systems decrease the number of services for people insured by Medicare, for whom they cannot control the price (whether this does or does not decrease quality is a separate question) but they raise the price for services to people with private insurance. That places like Tucson and Kansas City have relatively lower prices for private insurance reflects the absence of a single large dominant system in those cities.

‘“Price has been ignored in public policy,” said Dr. Robert Berenson, a fellow at the Urban Institute, who was unconnected with the research’, in the Times article. Other health policy experts, such as Princeton’s Uwe Reinhardt, have been warning about this for decades. In the effort to pass the ACA, and please both providers and insurers, this point was in fact ignored, and it is the source of most of the common legitimate criticism of the ACA – that in many places decent health insurance policies bought through the health exchanges are unaffordable. With higher prices in these regions, insurers pass on the cost to their customers.  This is illustrated in the NPR story “Obamacare Deadline Extended As Demand For Health Insurance Rises” on December 18, 2015, which documents both the success of ACA measured by the large increase in the number of people signing up for coverage and their frustration at the frequently-high cost of this coverage. Of course, this is completely unrelated to the criticisms leveled at ACA by the Republican candidates for President and their allies in Congress, whose “solution” – abolish ACA – is Marie Antoinette-like. While the French queen is reputed to have said, in response to being told that the peasants had no bread, “then let them eat cake!”, Republicans, hearing that many people cannot afford health insurance on the exchanges even with subsidies, or get Medicaid in states (that they control) which have not expanded it, respond “let them pay out of their own pocket!”

The issues and solutions are clearly laid out by the reliably insightful Dr. Don McCanne is his “Quote of the Day” on this topic. A solution cannot come from a jerry-rigged program that allows either insurers or health systems or both to maximize their profit. It needs to come from a system that starts with price controls, most effectively by a single-payer system such as Medicare. There are, as he notes, still risks – mainly that health systems may under-utilize services when they cannot make profit, leading to lower quality of care. But we can guard against this both on the regulatory end, by measuring quality outcomes and holding providers responsible, and through the market because the incentive to not provide services to Medicare patients because they can be more profitably provided to the privately -insured (the “opportunity cost”) goes away.

The infatuation of both policy makers and providers for integrated health systems is not entirely misplaced. The potential savings from shared data and not repeating tests, and more importantly for caring for people in the most clinically appropriate setting (inpatient, ER, outpatient surgery center, primary care, long-term care) is a real positive feature of these systems. But to the extent that these providers are allowed to use their market muscle to raise prices to insurers which are passed on to beneficiaries, it becomes a real negative.

The key feature of a good health system is that it is not focused on balancing the financial interests of big insurers and big providers, but that it puts the benefits to patients, to the people’s health, first.

Saturday, December 12, 2015

Medical interventions we shouldn't be getting: issues of cost, health, and equity

Many of us are concerned about the cost of medical care, particularly in the US. We are also concerned about the care that we, ourselves or our families and friends receive. We want the diagnostic tests and treatments we get to be likely to benefit us and to not cause us harm. Or, if there is chance that we may be harmed, that the probability and degree of benefit exceeds the probability and degree of harm. Sometimes there can be a tension here: we want to spend less on health care globally (and certainly less on the portion that just goes into the pockets of big corporations, like pharmaceutical companies and device manufacturer, insurers and huge health provider networks), but don’t want to scrimp on things that may benefit us. Especially when we are well-insured and not paying for it directly out of our pocket.

Fortunately, there are many times when these two different interests come together, when tests or treatments that are costly are also of no benefit to us, and may cause us harm. The problem is that sometimes our doctors recommend them to us anyway, or, frankly, we ask for them (because we’ve read about it on the Internet or seen an ad on TV or because a doctor recommended it for our Cousin Shirley who had the same thing, or at least something that sounded a little the same). How can we, as patients, know when our doctors are recommending a test or treatment that is not indicated for us, will not benefit us, may even cause us harm? How do we know when we are appropriately advocating for ourselves as opposed to asking for something inappropriate? It is not easy, but we can try.

One answer is NOT to reject all medical recommendations for diagnosis or treatment, to assume that something “natural” is always right. Medicine can do a lot; it can treat a lot of illnesses that can cause you to suffer or die prematurely. There are many tests that are proven useful or valuable for making diagnoses. Another is to not reject things simply because they cost money (difficult when you don’t have much and they cost a lot), but also not to ask to have them because you have money (or insurance). To a great extent it is asking your doctor questions, asking about the degree of benefit, hoping that they are up to date, trying to question what the likely benefit is from another test or treatment, especially if costly. It also, sadly, means understanding if the doctor themselves, or a company they work for, stands to make profit on the test or treatment, since this creates a conflict of interest (but certainly does not mean that it always or usually isn’t appropriate).

There is an entire medical literature on medical overuse, and your doctor should be familiar with it, or at least the most egregious overuses that are in her/his field. A recent article in JAMA Internal Medicine , “Update on Medical Practices That Should Be Questioned in 2015”, by Morgan et al., reviews some of these.[1] The authors reviewed the literature on articles published in 2014, and came up with 104 that at least one of the 3 thought was very important, and 33 that all agreed were very important. The article reports on the “Top 10”, because this is a nice, round number and because it seems to be a manageable number of things for doctors to remember. Just these 10 represent a lot of excess tests and excess expense.

I will summarize some of these 10 (the ones I feel are most relevant; you can find them all in the article), both to remind doctors and other health care providers who might not have seen it, and because other readers may have had these tests recommended. Before doing so, it is important to review the difference between a screening test, done on the general population (or a subset of it) who don’t have any symptoms, and a diagnostic test, which may be the same test done on someone with symptoms related to what that test tests for. Frequently a test is useful for diagnosis for someone with symptoms but in someone without may not only be of little use, but find “false positives” that end up leading to more testing with more cost and greater risk.

  • There Is No Benefit to Screening for Asymptomatic Carotid StenosisNone, for screening. Ultrasound or other tests may be of value for people with TIAs or other symptoms.
  • Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. Again, none, for screening. You can’t screen for ovarian cancer. I have been trying to convince my residents of this for years, despite their being often taught otherwise by OB-Gyns. This is the part where the provider puts his/her hands inside. It is NOT the same as a Pap smear, which is recommended for screening.
  • Head Computed Tomography Is Often Ordered but Is Rarely Helpful. Often finds clinically insignificant abnormalities. Also, often repeated with no added benefit. (“A retrospective cohort analysis reviewed 130 patients admitted for any cause at least 7 times during a 1-year period to a tertiary care center. Patients received a mean of almost 7 CT scans, including 3 head CT scans. More than one-third (36%) of head CT scans were ordered to evaluate for altered mental status. Only 4% (7/127) of head CTs had clinically significant findings that resulted in a change in management.”)
  • Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms.  Study is from S. Korea, where they screen for it.
  • There Is No Benefit to Paracetamol (Acetaminophen) for Acute Low Back Pain. “The median times to recovery were 17 days in both of the paracetamol groups and 16 days in the placebo group.” This does not mean we should be using opioids, though. In fact, when we give opioids for good reasons, like postoperative pain…
  • Postoperative Opioid Use Continues Past the Postoperative Period.

Some overuse comes because practices once felt to be appropriate, but now shown not to be, are being taught to trainees, who either don’t know or are loathe to disagree with their instructors. Some comes, consciously or not, from the potential for providers to make money. Another recent JAMA Internal Medicine[2] study looked at family medicine and internal medicine residents who saw “secret shoppers”, standardized patients who were requesting inappropriate imaging. About 25% of the time the tests were ordered, which could be seen as either bad or good (75% of the time they weren’t). The study also showed no difference between those residents who got significant feedback and those who didn’t, and similar (and generally good) techniques of communicating to the patients why these were not indicated. An interesting wrinkle is that some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the  American Academy of Orthopaedic Surgeons in their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients. (By the way, among the recommendations of the AAFP is not doing screening pelvic examinations!)

What is the social justice issue here? After all, tests and treatments that are not indicated should not be done on anyone, regardless of financial or insurance status, racial or ethnic characteristics. Indeed, one could argue that those with more money or better insurance would be the most likely recipients of extra tests. But poorer, or less well-insured, people often don’t get the tests and treatments that they actually need (which has often been discussed in this blog; see for example Dead Man Walking: People still die from lack of health insurance, November 17, 2013), while tests and treatments are overused for others. This creates the (accurate) perception of a two-class health care system, and the (sometimes, perhaps, less accurate) perception that the disadvantaged are, in addition to not getting care they need, are not getting discretionary care that benefits the wealthy. Also, the more money spent globally on unnecessary medical care, the less available for necessary non-medical initiatives (housing, food, education) that would actually create better health.

A single payer system would not in itself achieve this goal, but it would create far more equity in the allocation of healthcare dollars, and at least eliminate the profit motive that might impact the recommendations of some providers and healthcare institutions.

[1] Morgan DJ, Dhruva SS, Wright SM, Korenstein D, Update on Medical Practices That Should Be Questioned in 2015, JAMA Intern Med. 2015 Dec 1;175(12):1960-4. doi: 10.1001/jamainternmed.2015.5614.

[2] Fenton JJ, Kravitz RL, Jerant A, et al., Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial, JAMA Intern Med. Published online December 07, 2015. doi:10.1001/jamainternmed.2015.6840

Saturday, November 21, 2015

Medicare Advantage plans, CMS, and providing high-quality care to -- and care for -- all people

Medicare Advantage plans, also known as Medicare HMOs, or officially as Medicare Part C, are an alternative to traditional Medicare. By enrolling in such a plan, at additional out-of-pocket cost, the Medicare recipient gets additional benefits that are characteristic of HMOs. This may include smaller (or no) copayments or deductibles, coverage for things not covered by traditional Medicare like dental care, eyeglasses, and hearing aids, and other “advantages”. There are disadvantages, also, of course, just as in other HMOs. Beyond cost, the main one is that there is a limited panel of providers – doctors and hospitals – that the person can use. This is particularly an issue for retired people who travel a lot, or may spend the winter in a warmer climate, since these HMOs’ panels are usually in a limited geographic area.

Older “closed panel” HMOs usually had only doctors and other providers employed by the HMO itself. There are fewer of these than there once were; some of them, like Kaiser, are well-known. Other HMOs are “open panel”, where any doctor can be “approved” to be part of their provider group, but many doctors may choose not to be for reasons such as lower reimbursement or onerous regulation. Thus, it is at least theoretically possible that a Medicare Advantage enrollee could receive lower quality care from the doctors and hospitals that were part of the HMO’s network than from another doctor or hospital that might not be, but would be available to traditional Medicare patients. In addition, some Medicare Advantage plans are open to “dual-eligibles”, people with both Medicare and Medicaid, with Medicaid paying the additional premium. That such programs might provide worse care than others isnot an unreasonable concern based upon other services targeted Medicaid patients (e.g., nursing homes) and other programs targeted specifically to low income people.

Thus, Medicare has developed a rating system for Medicare Advantage plans, which assigns from 1 to 5 stars based, presumably, on carefully considered and assessed quality measures. If you want a good plan, it would behoove you to choose one with a “5 star” rating. Provided, of course, one is available in your area, and provided you can afford the out-of-pocket costs, or, if you have Medicaid, it is one that Medicaid will pay for. Unsurprisingly, many plans that have enrolled Medicaid or other lower-income patients have had lower ratings, based on the outcomes of those patients. The plans argue that this is because these low-income patients are higher-risk, have more co-existing medical, mental health, and social conditions outside of the plan’s control. Others, including the Center for Medicare and Medicaid Services (CMS), which administers Medicare, have argued that considering these characteristics might “give a pass” to plans that provide lower-quality care to poor people. A similar rating system exists for hospitals, and similar arguments have been made. As I discussed in a blog from November 10, 2013, “Does quality of care vary by insurance status? Even Medicare? Is that OK?”, there are legitimate arguments to be made on both sides.

Now, however, according to a report in “Modern Healthcare” on October 21, 2015, CMS interim administrator Andy Slavitt and his deputy administrator who runs the Center for Medicare, Sean Cavanaugh, are considering adjusting its quality ratings for Medicare Advantage plans based upon the pre-existing risk of the patients enrolled. This is important to the plans, since Medicare can drop them if they have several years of lower-than-3-star ratings. And they don’t want to be dropped, because these plans are moneymakers, in no small part because CMS treats them, financially, better than traditional Medicare plans (a result of purposeful federal policy to try experiments to “privatize” Medicare). While new criteria have not been officially announced, and would not take effect until 2017, “The comments from Slavitt and Cavanaugh were somewhat surprising because the CMS has previously downplayed the effects of socio-economic status on the ratings. The agency described the effect as ‘small in most cases and not consistently negative’ in a summary of findings from an analysis the CMS commissioned by the RAND Corp.”

It is not only surprising, but when one considers why the (possible) change of heart is happening, it is difficult to not consider the financial and political clout of the insurance industry that sponsors these programs, and the political support that such “private” Medicare-replacement programs have.  It is worth noting that CMS has not indicated that it will consider revising the ratings for hospitals, despite the fact that hospitals that care a higher proportion of poor and socially disadvantaged people face the same issues. The financial penalty for hospitals is very direct, as Medicare is not paying for readmissions which occur within 30 days. If this seems, on its face, reasonable, consider that sometimes even when the care provided in the hospital is of high quality, people go back to their homes (or long-term care facilities) where it may not be. This is sometimes a result of lack of money, lack of social support, and other stressors, but the result is that they are more likely to be readmitted. Again, CMS has argued that it would not want to encourage hospitals providing lower-quality care for poor people (which certainly would be a bad thing). But if CMS penalizes hospitals for readmissions that are outside their control, it simply encourages hospitals to not care for low-income people, or, if they are sole providers in their community, possibly even close their doors, and that would be a very bad thing. Studies that have been done indeed show that readmissions are higher when hospitals care for lower income and Medicaid patients, and that this is not the result of poorer quality care provided when those people are inpatients. (See “Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program” from the Kaiser Family Foundation and “Socioeconomic status and readmissions: evidence from an urban teaching hospital” in Health Affairs.)

It is important for CMS to ensure that the care provided to all Medicare recipients (indeed all people) by a hospital is not discriminatory or inequitable and that all patients have access to the care they need at the highest possible quality level. But unadjusted readmission rates are a very crude measure of quality, and it is unreasonable for CMS to expect that hospitals will be able to compensate for the impacts of poverty and lack of access to preventive care and early diagnosis and treatment. It is not unreasonable, however, for us, the American people, to expect that our government develop and help pay for programs that ensure that people’s basic needs for shelter, food, clothing, warmth and other social determinants of health, as well as post-hospital care (access to primary care, home health, and high-quality long-term care).

A single-payer health system is insufficient to address all of these needs. But it is a good start for some of them.

Saturday, November 14, 2015

Rising white midlife mortality: what are the real causes and solutions?

 A widely covered and important health research study was recently published by Princeton economists Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences,Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”. The main message is contained in the title – mortality rates for white middle-aged Americans are going up – but there are three other important findings that emphasize its significance.

The first is that mortality rates are going down for every other age and ethnic group, as well as for whites of the same age in other developed countries (see graphic). This means something special is happening to this population group in the US. The second is that this increasing mortality rate is not evenly distributed across class, but is concentrated in the lower-income, high-school-educated or less, group of people. This begins to suggest what is special about this group: that they are being hit hard by societal changes that particularly affect them. The third is that the mortality rates for African-Americans, while decreasing, still significantly exceed those of this group of midlife whites. All of these bear further examination.

That these death rates are rising was apparently surprising to the study’s authors, according to the New York Times article “Death Rates Rising for Middle-Aged White Americans, Study Finds” by Gina Kolata on November 2, 2015, which begins with the sentence “Something startling is happening to middle-aged white Americans.” It surprises not only Case and Deaton, but also numerous commentators quoted in the article and in subsequent coverage. An example cited by Kolata is Dr. Samuel Preston, professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, whose comment was “Wow.”  I guess this is an appropriate comment about an increase in mortality rates of 134 more deaths per 100,000 people from 1999 to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.

But the findings are not too surprising to me. After all, Deaton and Case are economists, not physicians or health researchers, and they came upon this data almost serendipitously while studying other issues (such as whether areas where people are happy have lower suicide rates). But others, those who are physicians and health researchers, should know better. Maybe the doctors expressing surprise are those who don’t take care of lower-income people. And the health researchers are those who have not been reading. In a blog piece  from January 14, 2014 (“More guns and less education is a prescription for poor health”) I cite  Education: It Matters More to Health than Ever Before, published on the Robert Wood Johnson Foundation website by researchers from the Virginia Commonwealth University Center for Society and Health, which notes that “since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.” This was reported over a year and a half ago, and discusses a trend in place for two decades!

Or maybe I am not surprised because I am a doctor, and see these patients both in the clinic and in the hospital. We do take care of lots of lower income people – those not in the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population by income do exist, and many of them are white, and they are not doing well. The study by Case and Deaton indicates that the causes of death that are increasing the mortality rates in this group of people are not increases in the “traditional” chronic diseases such as diabetes, heart disease, and cancer, but are rather due to substance abuse (illegal drugs, prescription narcotics, and alcohol) and suicide. This is not to say that we don’t see much illness and many deaths from those other chronic diseases in this population; we do, and they account for the high baseline mortality among this group, but these other causes are the reasons for the rising mortality rate.

We have seen the explosion of prescription opiate use in people who (like Dr. Case, as it happens) have chronic musculoskeletal pain (despite increasing evidence that opiates are not very effective for such pain). This often results from their work as manual laborers, either from a specific accident or from the toll wreaked by chronic lifting, bending, twisting, and straining. We also see increased use of alcohol, that traditional intoxicant. While sometimes it seems that we hear more about studies touting the benefits of a couple of glasses of wine a day, the reality is that millions of lives are destroyed directly and indirectly by alcohol use: those of the drinkers, those of their families, those of the people they hit when driving drunk. And in both urban and rural areas (people in rural areas were particularly affected by the mortality increase in Case and Deaton’s study) the use of methamphetamine. And as the drop in standard of living for people who used to make their living with their bodies doing jobs that have disappeared or they can no longer physically do becomes clearly irreversible and leads to serious depression, often compounded by chronic pain and substance use, increasing rates of suicide.

What is only alluded to in some of the coverage of this study is the most important point: this is about our society failing its people. It is about the “social determinants of health” writ large. Yes, the direct causes of the increased death rate in this population are alcohol and drug use and depression leading to suicide, and we do need better treatment for these conditions. But to leave it there would be like looking at deaths from lung cancer and chronic lung disease and concluding only that we need better drugs to treat these conditions without considering tobacco. Our society has, for at least four decades, been somewhere between uncaring and hostile to a huge proportion of its people. Where once we were a land of rising expectations, where people who worked hard could expect to have a reasonably good life, this changed beginning in the 1970s. Jobs for those with high school educations started to become rarer, and in the Reagan 1980s, “Great Society” programs that supported the most needy were decimated. (For the record, the “War on Poverty” actually worked; poverty rates went down!)

In the 1990s, economic growth hid the concomitant growth in income disparities. With the crashes of the tech and housing bubbles leading to severe recession in the mid-2000s, the impact of these disparities became apparent. While there were protests in response (e.g., the “Occupy” movement), the banks were bailed out, the wealthy continued to grow wealthier, and working people have seen their jobs, incomes, standards of living, health, and ultimately lives disappear. Only the blind or willfully ignorant could have not seen this coming.

To a large extent, then, this is an issue of class, however much “important people” decry the use of that word. It is also an issue of race, since, as noted, mortality rates for African-Americans (although not for Latino/Hispanics) continue to exceed those of whites; even as they begin to converge, there is still great disparity. Camara Jones, MD, the new president of the American Public Health Association (APHA) uses the term “social determinants of equity” to describe why African-Americans are so over-represented in the lower class.  The current data showing that lower-income whites are moving toward the long-term disadvantaged should not obscure this fact, but rather remind us that white people have had a privilege that is now, for the lowest income, being eroded.

The irony is that many of the people in the groups reported on, and their friends and relatives and neighbors, voted for those in Congress and their states who pursue policies that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153 families have contributed 50% of all campaign donations this year!) like these policies is understandable provided that they are not only rich but selfish, but they alone don’t have many votes. That their money controls votes, both by buying advertising and directly buying politicians, is undeniable. Maybe poor people cannot contribute as much as rich people, but they can vote (most of the time) and there are so many more of them. If we must reject “trickle down”, we must also reject appeals for votes that are implicitly or explicitly racist; lower income white people are not benefiting by voting for the racists.  The lives and health of Americans will be improved by improving the conditions in which they live, by an economy whose growth is marked by more well-paying jobs, not money socked away by the wealthiest corporations and individuals. People, of all races and ethnicities and genders and geographical regions need dignity and opportunity and hope that is based in reality, not false promises.

We need to treat the diseases that affect people and cause rising mortality, but we need to treat the conditions that lead to them even more urgently.

Sunday, November 1, 2015

Who is left out of ACA, and how does this affect Health for All?

The Affordable Care Act (ACA, Obamacare) has been very successful, despite the pronouncements of doomsayers (mostly Republicans). More than 10 million people who were previously uninsured have received coverage, and this has dramatically increased their access to health care. However, many people remain without health insurance, and many more are barely able to afford their premiums or can afford only the most basic plans. These people fall largely into three groups: those who the law was never planned to make eligible (mainly those people who are living in this country without documents), those people who make less than 133% of the poverty level but were not previously eligible for Medicaid and live in states that have not opted for Medicaid expansion, and lower-income people above 133% of poverty who have either not bought insurance on the exchanges or bought it and have since dropped it.

The first group, those without papers, comprise over 11 million real human beings in this country, people who work and go to school and get sick and visit our emergency rooms. That they are not even considered in ACA or any other proposal considered politically viable is a head-in-the-sand approach that ignores both human suffering and the cost of providing care to them. This cost is often shifted to hospitals, doctors, and volunteer organizations, such as the student-run Jaydoc Free Clinic in Kansas City, KS. The work that volunteers do is admirable, like that of the people celebrated by the first President Bush as “1000 points of light”, but it is not the way a wealthy country should have to provide care to people.

The second group is composed of those that the ACA intended to be covered by Medicaid expansion, but who live in states that have opted not to expand Medicaid. Given that the federal government would have picked up 100% of the bill for the first 4 years and then 90% thereafter, it is financially a good deal for the states. The reason that states like Kansas have not done so is entirely political; these are all states with Republican governors and/or Republican-controlled legislatures (although it does not include all of those!) whose core political position is opposition to anything coming from President Obama. Their proposed health plan is -- well, nothing, but they are against Obamacare, and against expanding Medicaid, and if this seems not only mean but economically stupid, so be it. People who in other states can access care when they need it are going without care or showing up in extremis in ERs. Hospitals end up footing the costs for people who could have been insured..

In Kansas, the first hospital closure that might have been forestalled with Medicaid expansion has occurred. Closing of Kansas hospital adds to Medicaid expansion debate (Kansas City Star, October 18, 2015) describes the closure of Mercy Hospital in Independence, KS. Doctors from relatively nearby towns that still have a hospital report increases in ER visits from people from Independence.There are many reasons that contributed to this closing, including the fact that residents of rural areas such as Independence are older and sicker than the national or state average, but a large proportion of them would have been eligible for expanded Medicaid had the state implemented it. The article makes clear that “While Medicaid expansion may not have saved Mercy Hospital, there are some in Montgomery County who say it could save many individuals.”

The Kansas Hospital Association (KHA) has been lobbying hard for Medicaid expansion because their members are losing money caring for uninsured people who are covered in the states that have expanded Medicaid. These hospitals are absorbing the impact of cuts to MediCARE which were supposed to be offset by the decrease in the uninsured resulting from the expansion of MediCAID, which is of course not happening in states such as Kansas, and it sees Mercy as the first domino to fall. KHA has a lot of influence in the state capital, Topeka, and rarely loses battles that it engages as strongly as it has this one, but so far there has been no movement from the Governor or legislature. While some legislators are beginning to rethink the issue: “ ‘My sense is a lot of legislators are saying we need to have that discussion (about Medicaid expansion). We need to take a hard look at that issue,’ said Rep. Linda Gallagher, a Lenexa Republican. ‘I do support that myself’”, others are adamantly opposed: “’I know that’s on the table. I don’t think any decision has been made on that,’ said Rep. Tony Barton, a Leavenworth Republican. ‘I think it would be moving in the wrong direction. I’ll leave it at that.’” And well he might leave it at that, as there is really nothing he can say that makes economic or social sense. It is a quintessential statement of opposition, being against something because, well, he is against it.

The Star article makes clear that Independence, KS has had, like many small towns, difficulty in recruiting and retaining physicians, but even those towns with doctors have hospitals with major financial challenges that could be helped by Medicaid expansion. Dr. Doug Gruenbacher, board chair of the Kansas Academy of Family Physicians (KAFP), an organization representing the family doctors who are the mainstay of rural health care, practices in Quinter, KS. While Quinter has fewer than 1000 residents (compared to Independence’s 9300), its group of family doctors cares for people from perhaps a dozen surrounding counties. Dr. Gruenbacher wrote a letter to the Salina Journal (October 10, 2015) calling for Medicaid expansion. He says “I know that my hospital [Gove County Medical Center] and more importantly, my patients, would benefit from the expansion.”

This leaves the third group of people who have had little or no benefit from the ACA: those who have  either not been able to afford to purchase insurance on exchanges, despite subsidies, or have dropped it as a result of rate increases by insurance companies. In “Insurance Dropouts Present a Challenge for Health Law” (NY Times, October 11, 2015), Abby Goodnough focuses on people in Mississippi, another states that has not expanded Medicaid. She observes that many of those who are working and making more than 133% of poverty are eligible for subsidies on the exchanges – indeed, 95% of Mississippians receiving coverage this way have subsidies, the highest percentage in the nation – but increasingly are finding the premiums more than they can afford on their tight budgets. Sometimes people were dropped from their insurance companies simply because they did not provide some information that the law requires to prevent undocumented people from signing up. Sometimes they just couldn’t afford it.

The ACA prohibits insurers from denying coverage for those with pre-existing conditions, but does not prohibit them from charging more for that coverage. And they do. “Walter Whitlow, 56, a remodeling contractor in Volente, Tex., said he had never seen the emails the federal marketplace sent him asking for additional proof of income after he signed up for a Humana plan in January. Doctors diagnosed throat cancer in February, and in June he learned from his oncologist’s office that his monthly premium had gone to $439 from $103 and his deductible to $4,600 from $900.” Whoops. Glitch.

Or not. The ACA was an attempt to accommodate many political interests, and thus is a conglomeration of different programs. Its commitment to insurance companies, whose support seemed to be necessary to pass the bill, was to have the “individual mandate”, so that the insurers, now required to cover everyone, would have everyone, not just the sickest, in their risk pool. However, beyond this, the ability of insurers to increase premiums for the sick was projected to be a problem, but the advantages of passing the program outweighed it. ACA is not intended to ensure health for all, but coverage for most (except those noted above). In the aggregate, it has been of great benefit. But for individuals, like Mr. Whitlow, the impact has been disastrous.

It is important to remember that this impact is not because we passed a bill that tried to cover as many people as possible, as opponents of ACA maintain without any data. It is because that bill did not go far enough, did not cover everyone, did not provide sufficient protection for people from the predatory practices of insurance companies. These are not the reasons that most ACA opponents want to fix, although they should be fixed. Dismantling ACA will not help the people who are described above, suffering despite this program; it would only vastly increase their number.

But change is necessary. We do, in fact, need a comprehensive national health program that simply, like those of most countries, covers everyone. Like Medicare for all. This will not solve all problems. It will not necessarily bring doctors to rural Kansas. It will not insure quality. It will not, in itself, completely control costs. But it is a necessary, if not sufficient, step.

Our mission as family physicians is to provide care to all Kansans, not just the insured,” Dr. Gruenbacher writes. The next step is to make sure that there are no Kansans, or Americans, left out. 

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