Wednesday, September 30, 2009
The recent release of the “Chairman’s Mark” of the Senate Finance Committee bill (Max Baucus, Chairman), the “America’s Healthy Futures Act” has brought to 3 the number of plans to be reconciled by Congress. The “Chairman’s Mark” is not legislative language, which is good; it is actually comprehensible – if you can get through the 273 pages. Or find a good summary. There are several. Not a summary, but useful, is the Congressional Budget Office (CBO)’s evaluation This joins the previously produced Senate Health, Education, Labor and Pensions (HELP) Committee (the Kennedy Committee) bill, and the 3 merged House bills, mostly modeled on the Energy and Commerce (Rep. Waxman) Committee’s bill, HR3200.
There is actually a lot of good stuff in these bills, things that will help address many of the issues that I have raised. Both the House and the Senate Finance bills shift GME slots to primary care, and address many vexing issues of graduate medical education funding, such as support for time spent outside the hospital, time spent in required didactic conferences, and allowing doctors in private practice to actually volunteer their time to be “preceptors” for residents., (The Senate HELP Committee bill doesn’t address this, as Medicare is not part of their charge; similarly there will be other areas where the Senate Finance committee is silent because they don’t have authority.) The House and Senate HELP bills provide excellent funding for “Title VII” Primary Care cluster for educational grants for primary care, fund the National Health Service Corps at good levels, and the House bill provides demonstration projects for funding GME directly to non-hospitals, especially Community Health Centers and Rural Health clinics. The various bills also creates committees or commission and provide funding for demonstration projects for actual workforce analysis and development. The Senate HELP bill provides funding for Primary Care extension services. The House bill and the Finance bill provide some funding for the Medical Home. All bills provide significant funding for Comparative Effectiveness Research.
That’s the good stuff, and there is more. The biggest problem in these bills, especially the Senate Finance bill, is that they do not cover everyone, and won’t. John Iglehart, writing in the New England Journal of Medicine, notes that “The Congressional Budget Office (CBO) has estimated the measure’s net cost at $774 billion over 10 years and projected that it would provide health insurance to 94% of Americans by 2019, leaving about 25 million people — one third of them illegal immigrants — without coverage.”
Excuse me? We now have 47 million uninsured in this country, and this is the greatest health threat. Ten years after implementation of this major overhaul of the health system, this bill promises us a reduction to – 25 million uninsured?? That 1/3 of them are undocumented is irrelevant; in addition to the fact that this leaves 2/3 (nearly 17 million people) who are legal residents uninsured, the fact that people are undocumented does not mean that they do not get sick, or cause a burden on our health system and taxpayers when they appear in emergency rooms with far advanced disease requiring expensive care because they were not eligible for prevention and early treatment. Nor does it change the fact that most of them are working, and when they get sick it has significant negative impacts on their employers, communities, and our economy. This is a fatal flaw. Health reform must cover everyone. (I feel like a broken record, but I will never stop saying it!).
The House, and Senate HELP bills, do provide potentially for covering everyone through a public option and/or requiring people to buy health insurance, but despite the intrinsic limitations to such systems (mainly cost) in comparison to a rational, sensible, cost-effective single payer system, the Obama administration, according to Iglehart (and others), “…considers Baucus’s bill the most promising vehicle for crafting a compromise, because it is less costly than the alternatives approved by four other congressional committees and is the most palatable to influential private stakeholders (large employers, health plans, and hospitals).”
This becomes even more concerning with the defeat of two proposals to re-introduce a public option into the Senate Finance bill on Sept 29, 2009 . Although the Democrats have a 13-10 majority on the committee, five Democrats opposed an amendment by Sen. Jay Rockefeller (D-WV), and 3 a second proposed by Sen. Charles Schumer (D-NY); Baucus voted against both as did his Democratic colleague from the “Group of Six”, Kent Conrad (D-ND). The water for the Republicans was carried by Sen. Charles Grassley (R-IA), who attacked the public option as a step toward “socialized medicine” and “government run health care” and sidestepped Sen. Schumer’s questions about why he didn’t oppose the government-run Medicare program.
So, by being the most likely to appease and please the huge private industries paying the lobbying bills, we will get no public option. Even though, as noted by Jacob Hacker in the NEJM , “According to a recent survey, a majority of U.S. physicians support health care reform that includes a new national public health insurance plan, which would compete with private plans” and that “Polls have shown that a substantial majority of Americans support the public option as well.” What care we for what the people think?
The Senate Finance bill, in lieu of a public option, proposes “co-ops”, where people would get together and buy health insurance as a group. Co-ops are a good idea, if vaguely socialistic (I mean that as a joke, but others certainly do not!). They have served farmers well. The original “HMOs” were (other than Kaiser) consumer cooperatives (before most were bought out by large insurance companies and perverted from their original goals – getting more care for the same money, or the same care for less money, for their member/owners – to the corporate ones of making more money by spending less on the actual provision of health care). However, co-ops will not address the lack of a public option, which is the main point of the Hacker article. Hacker quotes the Sept 16 CBO report: “The proposed co-ops had very little effect on the estimates of total enrollment in the exchanges or federal costs...they seem unlikely to establish a significant market presence in many areas of the country or to noticeably affect federal subsidy payments." Hacker concludes:“In short, neither the cooperative nor the trigger represents an acceptable substitute for the immediate creation of a national public plan. Rather than developing fig leaves to provide political cover, congressional leaders and the President should push for a national public plan that competes on a level playing field with private insurance to provide coverage to people who are uninsured and workers in the smallest firms. Such competition is the key to creating greater choice and accountability in increasingly consolidated insurance markets.”
This is starting to be nonsense. We need to cover everyone, and they need to be covered by a comprehensive, high-quality, affordable health plan. What we are getting is a lot of carrots (even, as I indicated, tasty ones for me!) to get buy in to a plan that contains the one core flaw. Folks will be left out. This is not OK, no matter what the lobbying efforts of insurance companies, pharma, hospitals, doctors, etc. All of us – including senior on Medicare – must avoid falling into these pits, so fearful we will endorse an immoral solution. “Give me everything, save money by not caring for you!” is not only immoral, it is untenable.
 see “Funding Graduate Medical Education”, May 25, 2009,
 Yes, indeed. CMS (Medicare) has been rigid in saying that community doctors have to be paid (or more likely, really are being paid but the sneaky residencies don’t tell us how much) to have residents in their offices from time to time. That is, that they don’t believe doctors would and do volunteer. They do, and it is honorable and good, and this legislation finally tells CMS that it is ok.
 Until now, most of medical workforce planning has been based upon the perceived short-term self-interest of a group of 25 year olds: that is, medical students decide what specialties to enter based on what they think will be best for them. There has been no national health workforce planning.
 See “The Primary Care Extension Service”, July 12, 2009,
 See “Clinical Guidelines and Technology Assessment”, May 12, 2009,
 Iglehart, J, Baucus’s Bill and the Long Road to Reform, NEJM 9/23/09
 Hacker, J, Poor Substitutes — Why Cooperatives and Triggers Can’t Achieve the Goals of a Public Option, NEJM 9/23/09,
 Keyhani S, Federman A. Doctors on coverage — physicians’ views on a new public insurance option and Medicare expansion. N Engl J Med 2009;361:e24-e24.
 The “trigger” is Sen Olympia Snowe’s (R-ME), the most likely Republican to support the plan. She opposes a public option “only in the event that private health plans failed to offer affordable coverage in a particular region, ‘triggering’ the creation of a public option.” (quote from Hacker). This is probably a more progressive position than Sen Baucus has taken!
Friday, September 25, 2009
Often it appears that Americans are obsessed by “rankings”. I am not talking about which is the best: car, TV, stereo, video game, and all the other consumer products we buy, and which are evaluated and often ranked by various organizations such as Consumers’ Union, based upon explicitly stated criteria. I am talking about the more subtle and subjective of rankings of various organizations and providers of services, particularly universities. More specifically, I will address the rankings of schools of medicine, and most specifically use as examples those in primary care and family medicine.
The US News and World Report rankings of colleges, and graduate schools in a wide variety of areas, including medicine, are the most well-known and “respected” (in the sense of “paid attention to”) of the national rankers. The question is, what do the rankings mean? How are they derived? What do they reflect about the “product” being evaluated? Are they using criteria that are accurately assessing what I am looking for in a school? Are these down-to-earth, utilitarian, “Consumers Report”-type evaluations or are they more James Bond-like brand-name dropping? Of course, if what I am looking for in a school is indeed cachet -- its status, fame and brand-name recognition -- then there is no difference. If, however, I am looking for outcomes – what is the success of that school in educating people in the area in which I wish to be educated, it is important to look at the criteria being used and the degree to which they accurately predict outcomes.
In general, most educators do not feel that US News rankings accurately reflect what they purport to be ranking – quality of the school in a particular area. These criticisms probably are more vocal from those who believe that they are ranked lower than they should be, but even those ranked highly will usually acknowledge, sotto voce, that they are not completely accurate – although they are pleased to be ranked highly. Recently, probably in response to ongoing criticism from the higher education community, US News has begun to publish the criteria that they use for ranking, the weight that they give to each criterion, and the method that they use to gather the information. This helps us to assess the validity of those criteria. (Validity is a concept that is used in research to evaluate the quality of a tool being used – how well does it actually measure what it is that I am using it to measure?).
Medical schools are comprehensively ranked by US News in Research and in Primary Care. For Research the criteria include “peer assessment” (by other Deans, Chairs and Residency Directors), selectivity (how high were the pre-admission grades and scores on the Medical College Admissions Test of its students, percent of applicants accepted – low is ‘good’), faculty:student ratio, # and $ amount of research grants. For Primary Care, peer assessment and selectivity are again considered but rather than measuring research grants, they look at the total number (#) and percentage (%) of graduates entering primary care residency training. In addition, US News reports top-ranked schools in a variety of program areas (AIDS, Family Medicine, Geriatrics, Internal Medicine, Pediatrics, Rural Health, Women’s Health); in these areas the rankings are done entirely by peer assessment.
The Peer Assessment counts for about 40% of the weight of the rankings for primary care (and 100% for the program areas listed above). Deans of medical schools, department chairs in the “primary care” specialties, and directors of residencies in those primary care specialties are asked to list the top schools, in their opinion. These are then cumulated and weighted. Selectivity accounts for about 15%, faculty:student ratio another 15%, and is the same as measured for Research. The final 30% consists of the schools self-report of the % of students graduating who enter the primary care specialties, defined by US News as family medicine, general internal medicine, and general pediatrics. Let us deconstruct those three sets of criteria.
Percent of students actually entering the primary care specialties might seem to be the most objective, outcome-based criterion, and thus the most important. However, there are some problems in the data. What is, for example, the definition of entering a “general internal medicine” residency? Virtually all schools count everyone entering an internal medicine residency because, after all, the first 3 years, the residency they matched in, is indeed general medicine. The problem, of course, is that after completing that residency a percentage of graduates will enter medicine sub-specialty training (to become cardiologist, gastroenterologists, endocrinologists, etc.) and not practice primary care. And, as detailed in previous entries (“A Quality Health System Needs More Primary Care Physicians” December 11, 2008, Ten Biggest Myths Regarding Primary Care in the Future” by Dr. Robert Bowman January 15, 2009, “More Primary Care Doctors or Just More Doctors? April 3, 2009, and others) in recent years the percent entering subspecialty fellowships on completing their residencies has been increasing so much that the number of students entering internal medicine residencies who actually become primary care/general internists is becoming vanishingly small.  So measuring those entering internal medicine residencies dramatically overstates the actual production of primary care doctors. But at least everyone does it.
Arguably, the most sensitive indicator is entry into family medicine; the reason is that virtually all family medicine residents become primary care doctors, so when the number of students entering family medicine is up, it means that interest in primary care is up, and it is likely that the percent of students entering internal medicine who will become general internists is also up. When, as now, the number entering family medicine is down, so is the number of internists entering general internal medicine.4,5
Peer assessment may be good, but it also has flaws. These include: people’s memories are dated (they may remember that a place was good and so assume it still is), they may assume that a place that is good in many things is good in everything (e.g., Harvard gets votes for great family medicine, even though there is no family medicine at Harvard!), and the ratings (especially from deans and chairs) may reflect the prominence of the faculty in primary care rather than the school’s success in producing primary care physicians. This is not to minimize the latter; “Best” primary care school does not equal “most students entering primary care”; it also includes the scholarship and prominence of the faculty on the national and international stage. Finally, because the chairs and residency directors surveyed are from all three specialties, the degree to which one or more is particularly strong or weak (or perceived as particularly strong or weak) can color the assessment.
Selectivity is an ironic criterion. The simple fact is that the more selective a school is the lower the primary care production. This is explained in many of the previous posts; in brief, students from medical families in upper class suburbs who had great schools and thus the likelihood of the highest grades are the least likely to enter primary care, while those from rural and inner-city backgrounds, as well as those from minority and lower income backgrounds are more likely to. High faculty:student ratio sounds good, but probably doesn’t matter to students unless they are teaching. In fact, schools with higher faculty:student ratios don’t usually have more teachers; the additional faculty are either doing research (good for the research criterion, less obviously so for primary care) or providing clinical care in a variety of settings that have little or nothing to do with educating students.
So what is the correlation between high US News primary care rankings and entry of students into primary care? I have only the data on family medicine, but given, as above, that this is the most sensitive indicator of primary care, it is probably worth using. Here it is:
Of the US News’ “Top 50” schools in Primary Care:
· -Only 10 were among the top 15 in either percent or total number of students entering family medicine.
· -Fully half (26) of these “Top 50” primary care schools were below the national average of 8.2% of students entering family medicine. Thirteen had 5 of fewer students entering family medicine, and 7 had 2, 1, or 0!
Conversely, only 6 of the top 15 schools in percent of students entering family medicine, and only 9 of the top 16 (4 way tie for 13) schools ranked by number of students entering FM, made US News’ “Top 50” for primary care.
What about US News’ “Top 10” for Family Medicine (remember, these are ranked only by “peer assessment”)?
Only 3 of these medical schools were in the top 15 for students entering FM by percent, and 3 by total number of students entering FM residencies. Two schools were both, so a total of 4 of US News’ “Top 10” medical schools for family medicine were in the top 15 in either category. And of these 4, the highest rank for percent of students was #11, and for total number, the highest rank was #4.
Among that group of “Top 10 Family Medicine” schools, 3 (30%) were below the national average for percent of students entering FM, and 3 of them were quite low: 7 students (4.1%); 6 students (4%); and 2 students (2.2%)!
Again, conversely, only 3 of the top 15 schools by number of students, and only 4 of the top 15 by percent of students, entering family medicine residencies made US News’ Family Medicine top 10.
So how valuable are these rankings? The answer is: it depends. If you want high status, they are “it”. If you want a school that is actually successful at producing graduates who enter primary care, don’t count on them.
 Also as in “you’re not respecting me – but you will now that I’m pointing this gun at you!”
 I presume there is some newer name-brand dropper, but Ian Fleming was the master at one time.
 Not always so obvious; I could ask people if they smoke, but the answers might have limited validity if people don’t tell the truth. A blood test for a nicotine breakdown product might, e.g., be a more valid test.
 Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
 Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64
Monday, September 21, 2009
I recently received an email from one of our Kansas Congressmen, Jerry Moran, Republican from the First District that covers essentially the western 2/3 of the state. (He is not my congressman, who is Blue Dog Democrat Dennis Moore, but we are a small state in terms of population with only 4 congressmen, and I get emails from many of them. Plus Rep. Moran is one of two Republican congressmen from Kansas running to succeed Sen. Sam Brownback who is resigning to become – the result is foreordained – our next Governor.) The email contained the text of an editorial that Rep. Moran posted on his website http://www.jerrymoran.house.gov/index.php?option=com_content&task=view&id=1524&Itemid=103 to explain why he did not think that expanding Medicare to cover everyone, as has been advocated by many, including myself, was a good plan for health reform. Unsurprisingly, the title was “A Medicare-Type Public Option Does Not Make Sense”.
Rep. Moran acknowledges that “This idea is supported by some in Washington and, at first glance, may appear appealing to many. Certainly, this idea seems easier to understand than other proposals that are being pushed in our nation’s capital and in the media.” He is a thoughtful man, not a reflex yahoo. He then goes on to give four reasons why it is a bad idea, and that he does “…not see how this plan will protect and enhance care for Kansans.” His four points are:
“Medicare is going bankrupt – The Medicare trust fund that pays for inpatient hospital stays is currently paying out more in benefits than it is collecting through payroll taxes. As a result, this fund is expected to go bankrupt in 2017, just eight years from now. Additionally, Medicare faces overall shortfalls of nearly $38 trillion, nearly three times current GDP levels…
Providers suffer major losses treating Medicare patients – Kansas health care providers and hospitals operate on razor-thin margins because they are drastically underpaid by Medicare. When Medicare underpays doctors and hospitals, the cost is shifted to private insurers. The average family in a private PPO health plan pays an additional $1,788 a year to compensate for Medicare underpayments. If these rates were expanded to those who currently have private insurance, many Kansas hospitals would be forced to close their doors and access to doctors and nurses in the state would be further limited.
Current Medicare fraud is staggering – According to the FBI, Medicare and Medicaid lose an estimated $60 billion or more annually to fraud. This amount equals 10% of all health spending in the U.S. Congress needs to address this problem in Medicare and Medicaid before creating a massive new program that would be susceptible to the same fraud.
Medicare regulations are a mess – The morass of regulations governing Medicare prevents progress and impedes doctors, nurses, and other providers from efficiently caring for patients...Bureaucrats in Washington set Medicare payment rates for providers and hospitals and these rates are so low that many doctors refuse to see Medicare patients. An expansion of this regulatory mess will lead to fewer providers and diminished health care access for Kansans.”
I had to write back and comment that these arguments, too, have pretty major flaws. They fall into three major categories:
First, misunderstanding (or misrepresenting) the source of the high cost of health care.
It is sick people who cost money. This is why, as I have pointed out, the key issues of health reform is so difficult to "sell" to most people, who are not (currently) really sick. The cost of what is perceived as “health problems” by the young, healthy journalists and Congressional aides -- colds, checkups, rotator cuffs, meniscuses, blood pressure checks – is essentially rounding error in the cost of health care. What costs money are the sick people -- the elderly who have multiple diseases and require mutliple hospitalizations, people with cancer, babies in neonatal intensive care, multiple trauma victims from car accidents. 5% of the people account for 55% of health costs; 10% for 70%. More than 50% of the people all together are about 3%. That is why insurance companies make money by underwriting -- insuring the healthy, disenrolling (or excluding, or sending to Medicare) the sick. Most of the people who cost the most are already in Medicare. The rest of us would cost much less per capita.
If everyone was in Medicare, we'd have one system to pay our health bills, and Moran’s first issue could be addressed because all health care $ now spent by employers would go into the pool, while the sickest people are already in the pool, so the marginal cost of putting everyone else in would be must less than the income.
The second flaw is that his argument, in both his second and fourth point, is that providers are unhappy with how much (or little) Medicare pays and how complex their regulations are. On the other hand, his third point attacks providers (presumably the same group) because of the massive amount of “fraud” they are perpetrating on the Medicare system. You can’t have it both ways unless you can be sure that the “fraud-meisters” (presuming there really is extensive fraud) are not the same ones, doctors and hospitals, who are making the complaints you validate in points two and four. And there is no way to do that. The answer for these two points is the same as for #1 – with everyone in the same system we could increase our payments for certain services in Medicare. And, of course, not pay more, or even pay less, for certain other services. By having the one payer, we could make policy that says we are going to pay for what we value (e.g., primary care) and not for excessive technological interventions that are not needed.
The third issue, fraud, mentioned above, is arguable. Much of what the government calls fraud is unintentional incorrect billing. To the extent that there are providers -- the same providers the Congressman worries about underpaying in the second point – who are committing fraud, this needs to be addressed, and would be able to be more thoroughly address with a single source of payment. Does Rep. Moran think no one commits fraud against private insurers? Certainly those private insurers would not agree!
The third flaw is in Rep. Moran’s fourth point regarding complex Medicare regulations. Boy, are they ever! But so are – even more so – those of private insurers. And the problem is made many times worse because of the plethora of different insurers, all with their own rules and regulations, and indeed with the same insurer having different rules for different people in different plans or employed by different companies. Cleaning up the Medicare regulatory complexity is important, but could be done by the government. If we had everyone in Medicare, it would be all cleaned up. If we continue to have multiple private insurers, it will stay a mess anyway. And blaming “bureaucrats” for low Medicare payments is at best disingenuous; Medicare pays what Congress will support. If Congress wants to pay more, they can appropriate more, at least for Part B and D. And this argument runs absolutely counter to the first, which is that Medicare is going broke. It sure isn’t from lack of parsimonious administration.
Rep. Moran concludes by saying “Medicare guarantees health care for seniors. But, what good does it do to have an insurance card if there is no doctor, nurse, or hospital to provide care? Instead of expanding Medicare, Congress should address Medicare’s current challenges and consider common-sense reforms to make quality coverage more affordable and more accessible for Americans. Medicare cannot pay all of its bills now and the problems will be exponentially magnified if it is expanded to include an additional 114 million Americans.”
Congress should address Medicare’s current challenges, and the most effective way to do so would be to put the other (?114 million) Americans into it. This would dilute the number of sick people already in the program with the younger and healthier, support the program financially with the current employer contributions now going to private insurers, and, most importantly, put all of us in the same plan together, all of us concerned about how well it works and how it spends its money.
Because, Congressman, we really are all in it together.
Wednesday, September 16, 2009
I am not a huge believer in protocol and quietly and respectfully listening to what you consider to be evil lies. I kind of enjoy the spectacle of the British Parliament where opposition members get to boo at the Prime Minister. So maybe, to that degree, I should be less upset about Rep. Joe Wilson’s “You lie!” outburst during the President’s speech on health care. Washington Post columnist Kathleen Parker http://www.kansascity.com/273/story/1442853.html condemns such impropriety while also minimizing and lumping it with hecklers from the galleries (“Although heckling by individuals usually emanates from the public gallery, group histrionics are a time-honored tradition in American political theater.”) it is different because it has never been done before when a President has addressed a Joint Session of Congress. The real question is “Why did this representative do it at this time with this President?” That is the question that Maureen Dowd supplies with some information to consider: her point, in her op-ed piece “Boy, oh Boy!”, is that it was racism, an extremely racist act performed by an extremely racist man because he cannot accept that a black man is the President of the United States and needs to be accorded the respect due that office. (http://www.nytimes.com/2009/09/13/opinion/13dowd.html) There is a better than even chance that she is right.
Now, I don’t know that Joe Wilson is a racist, in the sense that I cannot look into his heart, or his brain, to know what he really feels or believes. But he absolutely has long manifested racist behaviors and provided racist leadership. He, Ms. Dowd informs us “…belonged to the Sons of Confederate Veterans, led a 2000 campaign to keep the Confederate flag waving above South Carolina’s state Capitol and denounced as a ‘smear’ the true claim of a black woman that she was the daughter of Strom Thurmond, the ’48 segregationist candidate for president.” That is all racist, and remains so no matter how many sons of the South want to tell us that the Confederacy was about everything but slavery. Even to the extent that it might have been, the only reason to remember it and keep it up is to be racist, if in a thinly-veiled way. Mr. Thurmond, Mr. Wilson’s mentor, and all the racist, segregationist colleagues of his era, deserve to be remembered – as wrong. As perpetuators of an inhumanly evil system that derives from slavery. Not, in any way, shape or form, to be emulated. Let us instead award accolades to the Southern Senator and President Lyndon Johnson, who may or may not have been racist inside, but outside, where it mattered, pushed through the landmark Civil Rights and Voting Rights Act. There can be no quarter given, ever, in any sense, to racism in public policy.
I do not know if Mr. Wilson and his Republican colleagues are cynically using racist references to push their anti-people policies, perpetuating the ultimate reason for people in power to push such issues, divide and conquer, or if he really thinks this way; if, as Ms. Dowd says, he “…clearly did not like being lectured and even rebuked by the brainy black president presiding over the majestic chamber.” In any case, he must be soundly and unequivocally castigated and repudiated, not for interrupting, but for thinking he, as a white guy, could do it because this President was not a white guy.
And let us remember that the other nonsense being propagated by either honest or opportunistic racists are wrong, are lies. Having a black President is great, but it does not reverse the tide of history or put racism behind us. Saying that “white men are discriminated against” by affirmative action is only true to the extent that “when you’ve had the wind at your back for your whole life, a calm day seems unfair.” (I wish I could get the attribution for that great quote!) On the same day that Ms. Dowd’s column appeared, Barbara Ehrenreich and Dedrick Muhammed had a guest op-ed in the NY Times , “The Recession’s Racial Divide”, http://www.nytimes.com/2009/09/13/opinion/13ehrenreich.html?_r=1&ref=opinion, in which they carefully and systematically demonstrate how much worse this recession has been for black people than white – because, despite lies widely propagated by the right wing, they started so much farther behind. “In fact,” they write, “you could say that for African-Americans the recession is over. It occurred from 2000 to 2007, as black employment decreased by 2.4 percent and incomes declined by 2.9 percent. During those seven years, one-third of black children lived in poverty, and black unemployment — even among college graduates — consistently ran at about twice the level of white unemployment.
That was the black recession. What’s happening now is more like a depression.”
They assert that “Thanks to a legacy of discrimination in both hiring and lending, they’re less likely than whites to be cushioned against the blows by wealthy relatives or well-stocked savings accounts.”
For those continuing doubters, here are some more facts that support their assertion:
--“In 2008, on the cusp of the recession, the typical African-American family had only a dime for every dollar of wealth possessed by the typical white family.
--Only 18 percent of blacks and Latinos had retirement accounts, compared with 43.4 percent of whites.
--…even high-income blacks were almost twice as likely to end up with subprime home-purchase loans as low-income whites — even when they qualified for prime mortgages, even when they offered down payments.”
Ehrenreich and Muhammad do attribute some blame to the individuals caught in this situation, and to those who encourage it. Specifically, they cite a “cultural factor” that is “…widely shared with whites — a penchant for ‘positive thinking’ and unwarranted optimism.” They note that this has taken on a “…theological form of the ‘prosperity gospel.’ Since ‘God wants to prosper you’ all you have to do to get something is ‘name it and claim it,’” and name both the black evangelist Creflo Dollar and white megachurch pastor Joel Osteen as propagators of this “gospel”. They do not, interestingly, mention Oprah Winfrey in this article, although Ehrenreich has cited her before as one of the leading figures purveying the “positive thinking” mantra to both blacks and whites (“The Power of Negative Thinking”, NY Times Sept 24, 2008, http://www.nytimes.com/2008/09/24/opinion/24ehrenreich.html?_r=1&scp=5&sq=ehrenreich&st=cse). Although not talking about racism, David Brooks (NY Times Sept 15, 2009, http://www.nytimes.com/2009/09/15/opinion/15brooks.html?_r=1&ref=opinion, does address this issue of “me”-ness, comparing the humility of Americans – soldiers, politicians, celebrities, and the rest of us, at the end of World War II. “When you look from today back to 1945, you are looking into a different cultural epoch, across a sort of narcissism line. Humility, the sense that nobody is that different from anybody else, was a large part of the culture then….Everything that starts out as a cultural revolution ends up as capitalist routine....Today, immodesty is as ubiquitous as advertising, and for the same reasons.”
“’I did not take a racial connotation from Mr. Wilson’s remarks,’ said Representative Steny H. Hoyer of Maryland, the majority leader, who introduced the resolution” to “rebuke” Mr. Wilson (House Rebukes Wilson for Shouting ‘You Lie, NY Times Sept 15, 2009, ’http://www.nytimes.com/2009/09/16/us/politics/16wilson.html?ref=us, but he added “I do believe that there are expressions throughout the country being made that are unusually harsh. I think the attacks being made on Mr. Obama are unusually vitriolic.” Yeah, racist.
Ehrenreich and Muhammad conclude: “So despite the right-wing perception of black power grabs, this recession is on track to leave blacks even more economically disadvantaged than they were. Does a black president who is inclined toward bipartisanship dare address this destruction of the black middle class? Probably not. But if Americans of all races don’t get some economic relief soon, the pain will only increase and with it, perversely, the unfounded sense of white racial grievance.”
Of course, this would require us, as a society, to actually deal with truth, to actually look at what is happening to actual people. When we have “jobless recoveries”, in which Wall Street has “recovered” while we celebrate the loss of more jobs because it is fewer than last month (and we are 9.4 million jobs down from before the “recession”), it is not surprising that reactionary populists will take this as an opportunity to try to garner support for their agendas by spreading racist lies. But we have to take responsibility for calling them what they are, not letting them happen, fighting back against deceit and shameful pandering.
Saturday, September 12, 2009
Three articles in the September issue of Academic Medicine, the journal of the Association of American Medical Colleges (AAMC) address the issue of development – or more concerning, the erosion -- of empathy among medical students and doctors. All three used the Jefferson Scale of Physician Empathy (JSPE), developed at the Jefferson Medical College in Philadelphia, and all included Jefferson faculty who developed the JSPE as authors. Two were done in collaboration with authors from other countries, one examining doctors in Italy and the other medical students in Japan. However, the most important one for us looked at US medical students, at Jefferson Medical College. The authors administered the JSPE to students entering medical school in 2002 and 2004, and then administered it again to each of them 4 more times, at the end of each of their years of medical school. The results, while unfortunately not surprising to those of us who teach in medical schools, should be very concerning for everyone else in the country. The empathy scores were pretty much unchanged from entry to the end of the second year, but dropped significantly by the end of the third year for both classes. They stayed down, picking up slightly, by graduation at the end of the fourth year.
For those of you who don’t know, the third year of medical school in the US is when the main “clinical” portion of the education of students begins. In most schools, the first two years are largely dedicated to learning “basic science”, although increasing amounts of clinical material have been added in more recent years. But in the third year, students do their “core” clinical rotations (usually internal medicine, surgery, pediatrics, psychiatry, family medicine, obstetrics/gynecology, sometimes neurology and geriatrics). They spend this time largely working in the hospital, on hospital services with faculty members and residents, who are medical school graduates training in the particular specialty. This is the main time of “clinician formation”, when the student, who has been spending the bulk of his/her time in a classroom, works, under close supervision, in the actual care of actual people. One would hope (at least this one would hope) that working with actual people (called “patients” in the medical jargon) would provide students an opportunity to become more empathic, seeing the pain and suffering and hopes and expectations and fears and prayers of the people with whom they work. That it has the opposite effect is scary.
Students were given the opportunity to identify themselves so that data could be analyzed over time for individuals or groups of individuals as well as the whole group. Unfortunately, only 25% did so, so looking at trends among sub-groups, which could only be done on this smaller group, provides less robust data. However, within this “matched” group, women started with higher empathy scores than did men and dropped less, although still significantly. In addition, students who planned to enter “technology-oriented” specialties (anesthesiology pathology, radiology, surgery, orthopedics, etc.) not only had greater drops in their empathy scores than those entering “people oriented” specialties (family medicine, internal medicine, pediatrics, emergency medicine, psychiatry, obstetrics and gynecology), but had lower scores to begin with. This means that (at least among the 25% who allowed themselves to be tracked, among these two classes at Jefferson) there is a difference in empathy levels even at baseline, at entry, between those entering the different types of specialties (when taken as a group). It may also be worth noting that Japanese students did not demonstrate this decline; the reasons are presumably cultural.
Why? All medical educators have their theories, but this research only can contribute information gleaned from the elective, open-ended comments students were invited to make. Themes that arose included exhaustion (working so hard and so many hours makes it difficult to care so much about others), victim blaming (it is hard to feel for someone whose behaviors brought their illness on themselves), and negative role models (the residents and teaching physicians were not empathic):
“Reflecting on the nature of the training environment, one student stated ‘I was constantly reminded of the hierarchy of medicine and how it was not the student’s job to speak up even in defense of the patient’s best interest. The bureaucratic side of medicine overshadowed the human, empathic side.’ When students perceive from their training experiences that the ‘’humanistic side of medicine is too soft and a waste of time…I worry that over time I will be “molded by the system” into this idea””, they are correct. The study shows that they are.
The authors spend a fair amount of time distinguishing between empathy, which they are trying to measure, which they feel more of is always good for the practice of medicine, and sympathy, a less cognitive (thinking) and more affective (feeling) characteristic which they feels helps at some level but at too high a level can impede the practice of high-quality medicine. Empathy is less innate, more subject to learning and thinking, requires more effort, and is more likely to be accurate. The behavioral motivation is altruistic, while sympathy is egoistic; that is “I feel your pain” (sympathy) is instinctive but also is about the “feeler” (the student or doctor) rather than the patient. It is different from “I understand your suffering”. This latter not only is more likely to lead to helping, but is more likely to be “energy conserving” and lead to growth; the former to burnout.
This suggests a few things to me. The first is, obviously, that we need to change our medical education system, and the way patient care is role modeled. This may seem easy, but it is not; societies (and medicine is a micro-society) do not change easily, because new apprentices are taught by those in power. However, they do change, and the difference between medical education today and twenty or forty or sixty years ago is enormous. There is, for starters, teaching about these issues. Small group discussions, reflection papers, support networks exist where they never existed in the past. And students come from much more varied backgrounds – there are more women, and people from different class and geographic backgrounds and even pre-medical majors (music and English as well as biology and chemistry). And student are increasingly often older, second career – with prior life experiences in other professions, in business, in the workplace, and have had more experiences with healthcare as consumers either first-hand or in their families. But old traditions die hard; when biochemistry is valued more than ethics (and of course it is, because this is what you are tested on and your grades are based on both in school and your National Board exams); when being knowledgeable about the lab tests and x-rays is valued more than knowing the patient (and it often is by clinical teachers); when getting the work done is more important than understanding what work the patient wants done (and it very frequently is), it is hard to change.
What about experiences in medical school? The NY Times, September 9, 2009, “Summer of work exposes medical students to system’s ills” (http://www.nytimes.com/2009/09/09/health/policy/09medschool.html?ref=health) describes the experiences of medical students at the University of Washington working with rural, therefore mostly primary care, doctors in the 5 states the school serves (Alaska, Idaho, Montana, Washington, Wyoming). Many schools do similar programs, either required like Washington’s (e.g., New Mexico) or elective, like at the University of Kansas. The feedback seems to be similar – many students really like it and learn a lot and find it incredibly valuable pointing them to a future of service, and others find it frustrating to see inefficient systems, poor reimbursement to primary care, overwork of physicians, and thus plan (or are reinforced in their original plan) to be urban-based subspecialists. Like the Jefferson work on empathy, exposure to actual people and actual practice can reinforce either positive or negative attitudes; the sad part is when it introduces negatives to those who came in thinking more positively.
Thus, as I have written before, input variables matter. If we want more empathic physicians, the best strategy is to recruit more empathic students to medical school, and to provide them with role models who demonstrate empathy and learning settings in which having greater empathy is more valued and is considered a core quality. Medical educators are working hard on this; the public needs to demand it.
 Hojat M, Vergare MJ, Maxwell K, et al, “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”, Academic Medicine, Sept 2009;84(2):1182-91.
 Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS, “Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education,” Academic Medicine Sept09;84(9):1192-7.
Tuesday, September 8, 2009
Like many progressives in the United States, I’m wondering what it was all about. “It”, in this case, being the election of a President who cared about people, who was committed to health reform, who believed that single payer was the best idea for health reform, and that government existed not only, as Rousseau and Thomas Jefferson said, by the consent of the governed, but for the interests of the governed. And, to help him out, we threw out bunches of no-nothing Bush supporters and gave him almost (now, with Specter and Franken, actually) 60 votes in the Senate and an overwhelming majority in the House. So, what has happened? Not much. The painful story is detailed by Matt Taibbi in Rolling Stone, "Sick and Wrong", September 3, 2009, http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/. Sit down and keep your fist away from glass tables when you read it, but read it.
The President and the congressional Democrats we elected seem to have wasted the goodwill, enthusiasm, and hope for the future that we gave them, and mired it in a sea of legislative inertia, with the President not leading but watching, without apparent pain, as the rest of us face great pain. Taibbi writes: “The more the Republicans and Blue Dogs fidgeted and f****d around, the easier it would be for them to kill the public option. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.” He is of course, correct. The President and most of the “progressives” in Congress have moved away from the “left” and such “leftist” ideas as, first, single payer, and now probably the public option, and soon, it seems from even employer mandates or minimum requirements for what insurance companies have to offer us in the way of coverage. They have done this, ostensibly, to become more acceptable to Republicans, but without an ounce of chance of success. Every “compromise”, every give-back of a promise to actually provide the all the American people with the health care that they need at a price that they can afford and with a system that has at least some possibility of controlling costs has been given away with absolutely zero acceptance, gratitude or compromise from the MINORITY, the right-wing cabal currently called the Republican party. They and their supporters have had nothing at all positive to say. They continue to call the President a socialist or a communist, they object to his talking to students in school, and they get away with it.
The leadership of this movement, which seems to be mainly Rush Limbaugh and Bill O’Reilly and Glenn Beck (sorry, Sarah) is truly Neanderthal, truly anti-people. Many people have written about the why of this, of how all these White Men fear that they are becoming less than completely powerful, that the history that always gave preference to them and any old thing that they believe may have to be compromised with – well, everyone else – and that is the reason for their venom. The New York Times article on the proposed creation of a “day of special significance” on Harvey Milk’s birthday, http://www.nytimes.com/2009/09/05/us/05milk.html?_r=2&ref=us, quotes opponent Randy Thomassen of SaveCalifornia.com as saying “The bill is so broad it could encompass all kinds of things. Remembering the life of Harvey Milk could allow for gay pride parades on campus or mock gay weddings or cross-dressing. There is no prohibition of what the bill calls ‘suitable commemorative exercises.’ The sky’s the limit.”
Let’s look at that. Thomassen is worried that what? That other people might do things that he doesn’t like? Things that won’t (except I suppose psychically) hurt him. Those people won’t make him do any of those things, but he doesn’t want anyone else to be able to do them either. He could just say he is opposed to the bill, which of course doesn’t call for any of these things, without sounding like a finger-wagging scold. Does Thomassen, and do his friends, really think it is ok to make people do, or not do, things just because he doesn’t like it or it offends him? If so, maybe they could come here to Kansas and tell the other folks on the lake here to stop using their speedboats and jet-skis so I can have more quiet and be able to use my kayak without all that wake threatening to topple me. Hey, I am much more affected, limited in my choice of activities, by those power boats than he is by a Harvey Milk day or any of the bugbears he calls out. Why do people think they can – or should – tell other folks what they can do, as long as it doesn’t hurt them? How can we honestly condemn the fanatics in the Mideast who want to do the same thing?
But it is not funny. Thomassen may or may not be only a finger wagging scold, but these same ideas, these same limits, are often imposed on others, sometimes violently. And certainly this is not new, the reason Thomassen and his friends are worried. It is the same reason that it was in the 1920s and 30s. In his mystery novel “The Redbreast”, Norwegian writer Jo Nesbø has a character talk about the old men from Norway who volunteered to fight with the Nazis on the Eastern Front: “Oh yes, they’re still angry. At Third World aid, cuts in the defence budget, women priests, marriages for homosexuals, our new countrymen, all the things you would guess would upset these old boys. In their hearts, they’re still fascists.”  At least in the book the old men who believed these things had once been acknowledged fascists and Nazis. If you were to accuse the folks – the O’Reillys and Limbaughs and Becks and Thomassens who say these same things now, of being fascists, you would be attacked. But you’d be a whole lot closer to the truth than those who accuse Obama of communism are. George Bush is no longer President, and Dick Cheney is no longer – whatever he was – but the venom of the “we’re going to tell you – make you – do what we want” crowd is, probably as a result, more overt.
Meanwhile, regular people have a lot bigger issues; the Times (Sept 4, 2009) reports on the “Jobless recovery”, whatever that is. What I see is that people are still losing their jobs, just at a slower rate, but not getting jobs. So who is recovering? The bankers and Wall Street folks? If you can’t pay your mortgage and feed your family, if you don’t have a job, it is not a recovery. And let’s get this straight: Unless we’re going to go for big-time socialism and pay everybody a living wage even there is no work for them to do, the only purpose of the economy is to create jobs. This is actual people we’re talking about. They need work, and they need health coverage, and they need to know that they won’t lose their health coverage if they, again, lose their job.
The folks who are so worried about losing their coverage now are those who are, like the vast majority of Americans, not sick – yet. As Dr. Ferrer wrote as a guest in this blog on May 8, 2009 :
“The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year. None of those is engaging in discretionary spending or likely to 'value shop' for health care or to direct their own spending.”
Should they become seriously ill, it will be a sad time to find out what is NOT covered in their policies.
It may be too late for the President to do something. The Times doesn’t think so. Their very strong and atypically long editorial from September 4, 2009, “President Obama’s Health Choices” (http://www.nytimes.com/2009/09/06/opinion/06sun1.html?_r=1) gives very clear advice on what they think President Obama should say in his Wednesday talk to a Joint Session of Congress.
“Given the raucous, often ill-informed attacks on Democratic proposals over the past month, and the clear aim of most Republicans to oppose any bill, no matter how much he compromises, Mr. Obama now needs to spell out in some detail what he wants and how it would benefit both the uninsured and most other Americans as well.”
The Times takes on the Republicans and the “Blue Dog” Democrats, who are supposed to be deficit hawks but have distinguished themselves in this debate mostly by opposing any reform that will pour less government money into the pockets of insurance companies:
“The Bush administration and a Republican-controlled Congress enacted a Medicare prescription drug benefit that will cost the government almost $1 trillion over the next decade without raising or saving a penny to pay for it. They also passed tax cuts for wealthy Americans that will cost more than $1.7 trillion over 10 years, again without making provisions to offset the costs. Now they are complaining that $1 trillion for health care reform — fully paid for over the next 10 years — is too much to spend on a problem that has been festering for decades.”
And the Times has a suggestion for the President: “Rather than yield to Republican intransigence, the Democrats ought to resort to a parliamentary maneuver known as 'budget reconciliation,' which would allow them to push through most reforms by majority vote.” I don’t know about parliamentary process. Maybe President Obama can still say, “OK, this is the way it is going to go. We are going to have health care for the people,” and make it pass the Democratic majorities in Congress. I don’t know if he still can; worse, I don’t know whether, even if he can, he will. If he is going to really lead on making sure we get real, comprehensive, health reform, this is the time to do it. I hope he does, and hope it is not too late.
 Nesbø, Jo. The Redbreast. US paperback edition. Harper. New York. 2009. P. 257.
Thursday, September 3, 2009
I have written a great deal about the shortage of primary care physicians in the US, both at present and probably worsening in the future. One of the main reasons is that they make less (much less!) money than many other specialists. This has led to a true shortage of physicians in many Migrant Health Centers, Indian Health Service Clinics, public (e.g., county owned) clinics and other safety net providers, and can even affect Community Health Centers (especially those serving rural areas), although they are in a special category. Another reason that these clinics have difficulty in recruitment of primary care doctors is that their salaries, and these days most primary care doctors are salaried, are lower than those of “private” for-profit (a typical medical practice) or non-profit (when a medical practice is owned by a non-profit hospital, for example) groups. Thus, there are fewer doctors to serve the underserved.
There are also fewer nurse practitioners and nurses. The salaries offered at most of these public settings are much lower than can be earned in private practices or hospital based practices caring for the patients in a particular sub-specialty. County health clinics, which often provide prenatal care, children’s care, family planning, and treatment for sexually-transmitted infections (STIs), as well as other highly infectious diseases which can put the entire community at risk (e.g., tuberculosis) are grossly underfunded, pay low salaries, and thus usually have open positions or people operating above their level of training. Because these nurses and others are not independent practitioners, they often operate under very rigid protocols that can limit care when referrals are not available.
In addition, such clinics (county, public health, etc.) have inadequate non-staff resources, so that their patients get second-class treatment. For example, a county family planning clinic may be able to offer intrauterine devices (a very effective and appropriate method of contraception for many women) only if the company making one of the two brands available in the US approves them for a free IUD. And if the clinic has not exceeded its “allotment”. Very different from a patient in a private office whose insurance will pay for the IUD. And this is just one of many, many examples of patients in public clinics getting inferior care.
Well, you may say, what did you expect? These are after all, public clinics, funded by tax revenue. They can’t expect to have high salaries competitive with the private sector, to have all the equipment and drugs that they need. Governments, both state and local, have always underfunded these operations, and it is obvious that it will get worse in economically hard times. After all, the people who come to these clinics are poor people, without insurance, without money. What do you expect? This is the free market at work: doctors, practices, and hospitals that can be private and take only insured patients will make more money; those at the mercy of our public generosity have to take what they can get. Maybe some of us think it would be nice to do better, but, hey, these are hard times. Taxing the middle-class to be able to provide all these nice services for poor people simply won’t fly. This is the way of the market and the way of the world.
Except, simply, this is a lie. Pretty much we all pay for everyone’s health care. We just choose to do it in different ways, to segregate the market, so that more middle and upper class people have access to more services and better paid doctors and nurses (and thus, obviously, more doctors and nurses!) and poor people have to make do (or not) with what we have left over and choose to devote to this cause.
First of all, there are a lot of health care dollars spent directly by government, federal state and local. This was discussed in the last posting (“Senator Kennedy…, August 30, 2009). Medicare, Medicaid, VA, military, Indian Health service. Then there are the public dollars filtered through private insurance companies – the Federal Employees Health Benefits Plan and the various state and local governments that pay the premiums for their employees. Then there are the tax subsidies for employer contributions to health insurance – the money that the government would get if your employer paid you higher wages, but doesn’t get because, instead of higher wages, you get health insurance, which is tax-deductible to the employer. Of course, even with the availability of this tax break, you may not get health insurance; it depends upon your employer. Not, mainly, whether they are nice or caring, but whether they are big enough to negotiate a good rate with an insurer, and also pay enough in tax to get the break. So your neighbor, the machinist working for Ford, may have a good health plan while you, the just-as-skilled machinist working for a small company may not. But your income taxes are subsidizing his (or her) health insurance. And if you are the insured worker and are healthy, your premiums subsidize the costs of those who are not. That is the way of both insurance and, more important, a society that functions together.
Of course, the reimbursement received by providers for particular episodes of care is higher from some payers, mainly those large companies that insure employees, than it is from other payers, such as Medicare and particularly Medicaid. This is because those costs are paid directly with tax dollars and thus subject to more scrutiny than those filtered (laundered?) through insurance companies. Therefore providers, doctors and hospitals, prefer to care for privately insured patients because they get more money. But, as noted above, a significant part of that cost is paid by government funds. And, of course, the costs are higher because the insurance companies do not provide their laundry service for free; the taxpayer is paying more, the recipient patient is often getting less, and the middleman, the insurance companies, are making the profit.
Thus, the financial justification for provided more limited services to patients (there is no moral justification!) who have to access public or other safety net clinics for their care, is very weak when the entire picture is considered. Obviously, those individual clinics, public hospitals and other safety net providers face limited resources to provide care. But that is because so many dollars, that could be used to provide such care, are being siphoned off for subsidies to “privately insured”, insurance company profit, and administrative waste. The system, as all systems, is “perfectly designed to get the results it gets.” Huge administrative waste, huge insurance company profits, 47 million uninsured, and enormous numbers of underinsured who find out when they get sick what their insurance doesn’t, or won’t, cover.
And a system, noted at the beginning of this piece, that perversely incents the production of high-intervention subspecialists rather than the prevention-and-chronic-disease-management primary care doctors that we need more of. There are also not enough nurse practitioners, physician’s assistants, and nurses working in these areas, because they too can make much more money in high-tech, high-intervention areas. Not as a result of the market, but simply federal government policy decisions. The relative reimbursement for any medical activity (office visit, procedure, hospitalization) is basically set by federal policy. The actual amount will vary depending upon the insurer, but they are virtually all tied to Medicare reimbursement. That is, Blue Cross, or Aetna, or CIGNA will pay 120% of Medicare or 150% of Medicare, or whatever rate the provider (usually based on their power as market share) can negotiate, but always tied to Medicare rates. So, if intervention is paid higher than prevention, if subspecialists are paid higher than generalists, if certain drugs are paid with big markups (like chemotherapy), this is not the market at work, it is simply government policy – it is set by Medicare. This is succinctly and well explained in a recent Slate.com article by Darshak Sanghavi, “The Fix Is In: The hidden public-private cartel that sets health care prices.” http://www.slate.com/id/2227082/pagenum/all/#p2.
And, again, the system is perfectly designed to get the results it gets.
We get it. But it is not what we want or need.
 Community Health Centers, CHCs, get significantly higher reimbursement from Medicare and Medicaid – often 3 times higher than do non CHC providers. Therefore they have an incentive to see Medicare and Medicaid recipients, but not uninsured people.