Saturday, November 24, 2012

Health reform, ACA, and Primary Care: Is there still a conundrum?

Now that the election is over and the fact of the Affordable Care Act seems assured by the victory of the President and the increase in the Democratic majority in the Senate along with the Supreme Court’s upholding of most of the ACA’s provisions, the characteristics of change in the health care system (or, as I have often noted, non-system) can begin to be outlined. In my last post (November 17, 2012), I took note of the fact that even if the ACA is fully implemented there will be 30 million uninsured. If the states (mostly controlled by Republican governors and legislatures, including my own, Kansas) that have threatened to not participate in Medicaid expansion actually do not (and they can refuse; this is the part of ACA that the Supreme Court decision overturned), that number will be higher. But, clearly, there will be a large increase in the number of Americans with insurance coverage.

The big “systems” question is “How should health care delivery systems in the US re-engineer to deliver more efficient, more cost-effective care to more people for less money?” The key answer here is “more primary care”. Systems built around primary care have higher quality and lower cost than those which are built around specialty and sub-specialty practice. This has been recognized by the large health systems that do exist in the US (prototypically, Kaiser, but also others such as Geisinger in Pennsylvania, Cleveland Clinic, Inter-Mountain Health, and the model used in Grand Junction, CO) which are built around a large primary care base. They also have expanded services to support the practitioners (family physicians, most commonly, but also general internists, general pediatricians, and primary care nurse practitioners and physician’s assistants), which include many duties that do not have to be done by the physician (or NP or PA) being discharge by nurses, pharmacists, social workers and even community health workers.

Such organizations can do this because their systems are large enough, and because its expenditures in one area (say, higher salaries for primary care, or employing community health workers or more nurses, or more pharmacists) realize greater savings in other parts of its balance sheet. It works particularly well for Kaiser, because they are also the insurance company. This is what can happen with central planning and resource allocation, and provides some of the economic justification for a single-payer health system. In the current setup, especially in parts of the country less penetrated by large health systems, it can remain “everyone for themselves”. If the same organization does not control the primary care, specialty care, and hospital care, investments in one area will not necessarily result in savings in another.

The hope of ACA is that it will encourage even the most recalcitrant, specialist-dominated, fee-for-service communities to form such integrated models, called “Accountable Care Organizations”, or ACOs.    If these are to work, it will have to mean more primary care and fewer expensive (and profitable to the providers) procedures. The “primary care conundrum” is really two: there are not enough primary care providers (physicians, NPs, PAs) to meet the current demand, not to mention that which will arise in part from expansion of coverage but even more from expansion and aging of the population (see Petterson et al. “Projecting US Primary Care Physician Workforce Need [1]), and in most parts of the country the financial incentives are not in favor of students entering primary care, so this imbalance will increase.

Some communities, and even some academic health centers, are actively and aggressively moving toward the creation of ACOs; an excellent recent article in Health Affairs by Al Tallia and Jenna Howard [2] describes both the progress and the challenges of one AHC’s efforts to do so. The complexities and competing interests that exist in a situation such as that in New Jersey are a far cry from the integrated Kaiser model, but the obstacles appear as if they can be overcome, especially when, as under many of the provisions of ACA (most particularly not reimbursing hospitals for readmissions), the financial incentives are aligned.

The creation of additional primary care providers is going to be a longer haul. Payments for primary care are rising significantly in the same parts of the country where integrated health systems are dominant, as illustrated by quotes from a couple of family medicine chairs:
<           “…family physician salaries are going up quickly in Northeast Ohio. At Cleveland Clinic we have raised salaries of all family physicians by an average of 24% in the past 4 years.” (John Hickner)

\    •       n my neck of the woods (CA), there is huge unmet demand specifically for family physicians and enlightened organizations like Kaiser are paying handsome salaries (stunningly so) for FP grads fresh out of residency, and also offering loan repayment.”

But this is certainly not uniform across the country, and even in these areas, despite such big increases, the earnings of a family doctor are much smaller than those of many other specialists. (Hey, a 24% increase is good, but when previously your income was 1/3 of some subspecialists, it still leaves a large gap.) Research by the Robert Graham Center [3] suggests that income no longer plays a role in specialty choice when the lower-paid specialty earns 70% or more of the higher paid. More significantly, even if there is great movement into primary care, it will take decades to begin to approach the 50% ratio in the overall workforce.

So, we are left with good news and bad news. The good news is that more people will be covered; the bad news is that there will still be many left out. The good news is that in some parts of the country integrated health systems are demonstrating cost-effective ways of delivering health care and rewarding the primary care workforce; the bad news is that it is not by any means consistently happening across the country. The good news is that this seems to work best not only when every patient involved is insured, but when the expenditures and savings are realized by the same organization; the bad news is that there are lots of people outside of such a system and lots of places where medical practice is still “everyone for himself”. The good news is that there is increasing recognition of the importance of primary care practice; the bad news is primary care incomes still lag seriously behind that of many other specialists while medical school debt is rising. The good news is that team-based care is the most effective model; the bad news is that there is still inter-professional and inter-disciplinary competition rather than collaboration.

We can work to turn the bad news into good. But we must keep our eyes on all the problems, not just a few. The cost-effective, high-quality health systems that are developed will not be truly good news until everyone benefits from them.


[1] Petterson S, et al., “Projecting US primary care physician workforce needs: 2010-2025”,Ann Fam Med 2012;10:503-509. doi:10.1370/afm.1431
[2] Tallia A, Howard J, “An Accountable Care Organization An Academic Health Center Sees Both Challenges And Enabling Forces As It Creates An Accountable Care Organization”, Health Affairs, 31, no.11 (2012):2388-2394
[3] Check out this very cool “Primary Care Mapper” from the Graham Center.

Saturday, November 17, 2012

ACA after the election: Is it is the "fiscal cliff" or the social cliff that matters to people?

I recently attended a talk by Paul Starr at the San Francisco meeting of the Association of American Medical Colleges (AAMC). Dr. Starr, a professor of sociology and public affairs at Princeton who is probably most famous for his 1984 book “The Social Transformation of American Medicine”, has recently written a new book, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform. His talk was on the same topic, and was pretty good. He spoke without notes or powerpoint (lauded by many as a display of great skill, but also meaning that his “slides” are not available to those who were not present). His main technique was to divide efforts to “do” health reform – essentially to cover everyone – into a “play” of 3 acts. The first act, with several “scenes”, was comprised of efforts during the Progressive Period around WW I, the New Deal, and after WW II, to develop a National Health Insurance program. He noted that, if the play had been written by a good playwright, the scenes wouldn’t have been so similar – but they were, scuttled, at least in part at all three times, by opposition from the American Medical Association. There were other issues: in the first, the anti-German sentiment during WW I was attached to the fact that Bismarck (in 1888) had developed the first national health insurance system in Germany; in the 1930s, the Roosevelt administration chose to focus on unemployment insurance and Social Security; in the late ‘40s, Truman’s efforts were again seen as “socialist” during the early Cold War.

The second “act” comprised the passage of Medicare and Medicaid in the 1960s, and the third act the efforts for comprehensive health reform begun under President Nixon, again attempted by President Clinton, and enacted in 2010 as the ACA under President Obama. Starr spoke the day before the November 6 election, and observed that if the Republicans won and, as planned, repealed ACA, 16 million additional people who would have been covered by expanded Medicaid would not be covered. Worse, he noted, if the Romney-Ryan plan to cut Medicaid expenditures by $1.7 Trillion over ten years was put into place, another 35 to 40 million people would lose coverage. Starr was a part of the core group who developed the Clinton Plan in the early 1990s, so it is, I guess, not surprising that he continued to exhibit a preference for that plan compared to ACA. He even argued that it was really pretty simple, not something anyone who can remember those days recalls. At the time, I remember a cartoon with two panels. The first, labeled “The Democratic Plan”, showed someone at a black board covered with complex formulas and “circles and arrows”. The second, “The Republican Plan”, showed a stern man (older white man, of course) in a suit saying “Don’t get sick.” Certainly, however, the expansion of health insurance coverage under ACA, with individual mandates, Medicaid expansion (limited by state choice given the Supreme Court decision), and support for private insurance companies, is pretty complex itself.
This, however, is not why I say the talk was only “pretty good”. The fatal flaw in Starr’s analysis is that he never mentioned the 30 million people who remain uninsured under ACA (or the probably comparable number that would have been under the Clinton plan). This is inexcusable; for a supporter of health “reform” not to even acknowledge this enormous population, even by saying “well, it was the best we could get through Republican opposition”, is hard to understand. Did he forget to mention it, or did he leave it out because it might somehow weaken some of his other arguments? I obviously don’t know, but it is not uncharacteristic of many political “insiders” who get so involved in their own issues that they forget things that are of great moment to tens of millions. Perhaps it is because the best, most effective, and most cost-effective answer is a single-payer health system, and that was something he and the other Clinton health planners rejected 20 years ago off the bat, so he didn’t want to bring it up even now.

But the Obama victory on November 6, as much of a relief as it was, as much of a deep breath that we can take to know that a majority of the people were not taken in by lies, racism, and meanness of the campaign, does not end the struggle, either for the ACA or those left out of it. Yes, the election shows that America is no longer completely controlled by white men (whose votes Romney overwhelmingly won; see Maureen Dowd, Romney Is President, New York Times, November 11, 2012), but nearly half the country voted for the Republicans. This included many who were not white men, as well as most of the white men who voted for Romney despite his support for policies that would be counter to their economic self-interest. And a huge swath of states, mainly through the South, Plains, and Mountain regions, were bright red and have governors and legislatures still staunchly opposed to “Obamacare” and in opposed to Medicaid expansion in their states. And the people returned a significant Republican majority to the House, who can be expected to do everything that they can to limit the full implementation of ACA.

The Republicans opposed ACA, and opposed the individual mandate that was the necessary condition required by the health insurance companies to agree to key components of ACA such as guaranteed issue of health insurance and no exclusion of people for having pre-existing conditions. Having lost both the Supreme Court decision and the election (which means that the Court is unlikely to have its more “liberal” justices replaced by conservatives) it remains to be seen whether they will move toward support for the mandate because it benefits one of their natural constituencies (read: “contributors”), the large health insurance companies, or continue to oppose it because of their principled (read: “mean spirited and selfish”) opposition to everyone having health insurance coverage.

I fear that it will be the latter. It will not appear (at least not often; there will be gaffes) as “we don’t think everyone deserves coverage” but will be dressed in the guise of “fiscal responsibility”.  “Deficit hawks” will tell us that we can’t afford it, that we will fall off the “fiscal cliff”. In his November 12, 2012 New York Times piece, Hawks and Hypocrites, Paul Krugman addresses this issue, and calls those who argue this position “deficit scolds” because their warnings and suggested policies (mostly cut taxes especially on the rich) don’t make sense. Rather, it is clear, their agenda is to decimate and eliminate Medicaid, and Medicare if they could (or at least privatize it, which will make it unable to cover seniors’ health expenses), and preferably Social Security (if they could get away with it) and any other programs that support the most, rather than the least, needy.

This is wrong (I was going to say “obviously”, but it is clearly not obvious to many). It is not only wrong on the moral count, as was succinctly presented by FDR, who said “"The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough to those who have too little"; it is wrong economically. For our nation and economy to grow, everyone needs to contribute, and to be able to do that they need to be healthy and have good access to health care. I have written about the “social determinants of health” (“Social determinants, personal responsibility and health system outcomes”, September 12, 2010), but it is really a vicious cycle, in which health and other social factors affect each other. Those social determinants, including especially poverty, that lead to poor health also lead to difficulty in getting a good education and getting a good job, thus repeating the cycle for future generations. (A good example is that of “cold winter housing”, discussed by the British Medical Association in "SocialDeterminants of Health: What Doctors Can Do” (link to pdf is on the right side of that page), and by me in “Michael Marmot, the British Medical Association, and the Social Determinants of Health”, November 1, 2011).

The right thing to do is also the economically prudent thing to do. There is a “cliff” that we should be worrying about. It is not the “fiscal cliff”, but the cliff face that so many people live too close to and are in danger of falling off.*

  *(See Camara Phyllis Jones’ “cliff analogy”, “Social Determinants of Health and Equity, the Impacts of Racism on Health”.)

Saturday, November 10, 2012

"The Public Health and Social Justice Reader"

I'd like to call attention to the publication of the PUBLIC HEALTH AND SOCIAL JUSTICE READER, edited by Martin Donohoe, MD, and just published by Jossey-Bass.

Those who are not familiar with Dr. Donohoe's remarkable website, Public Health and Social Justice ( or will be amazed at the depth and breadth of the contents, addressing most important aspects of the subject, from Human rights to war, from issues addressing special populations and women to environmental health and justice, from the impact of the "modern epidemics" of obesity, tobacco and suicide by firearms to the modern epidemic of corporate control of our lives and health.

Those who are familiar with and the breadth of powerpoints on that site will not be surprised to find that Dr. Donohoe himself has written a large number of chapters himself, although there is a very impressive list of other chapter authors.

The PUBLIC HEALTH AND SOCIAL JUSTICE READER is an indispensable resource for students and teachers of health and medicine as well as for policy makers and activists, and is a wonderful accompaniment to the resources available on

The table of contents is below; more information is available at

Public Health and Social Justice Reader
PART I Human Rights, Social Justice, Economics, Poverty, and Health Care; 1. Universal Declaration of Human Rights; 2. Public Health as Social Justice, Dan E. Beauchamp; 3. What We Mean by Social Determinants of Health, Vicente Navarro; 4. The Magic Mountain: Trickle-Down Economics in a Philippine Garbage Dump, Matthew Power; 5. Family Medicine Should Encourage the Development of Luxury Practices: Negative Position,Martin Donohoe
PART TWO Special Populations; 6. Homelessness in the United States: History, Epidemiology, Health Issues, Women, and Public Policy, Martin Donohoe; 7. Historical and Contemporary Factors Contributing to the Plight of Migrant Farmworkers in the United States, Safina Koreishi, Martin Donohoe; 8. The Persistence of American Indian Health Disparities, David S. Jones; 9. Prejudice and the Medical Profession: A Five-Year Update,Peter A. Clark; 10. Sexual and Gender Minority Health: What We Know and What Needs to Be Done, Kenneth H. Mayer, Judith B. Bradford, Harvey J. Makadon, Ron Stall, Hilary Goldhammer, Stewart Landers; 11. Mental Disorders, Health Inequalities, and Ethics: A Global Perspective, Emmanuel M. Ngui, Lincoln Khasakhala, David Nndetei, Laura Weiss Roberts; 12. Incarceration Nation: Health and Welfare in the Prison System in the United States, Martin Donohoe
PART THREE Women’s Health; 13. Individual and Societal Forms of Violence Against Women in the United States and the Developing World: An Overview, Martin Donohoe; 14. Obstacles to Abortion in the United States, Martin Donohoe; 15. The Way It Was, Eleanor Cooney
PART FOUR Obesity, Tobacco, and Suicide by Firearms: The Modern Epidemics; 16. Weighty Matters: Public Health Aspects of the Obesity Epidemic, Martin Donohoe; 17. Cigarettes: The Other Weapons of Mass Destruction, Martin Donohoe; 18. Guns and Suicide in the United States, Matthew Miller, David Hemenway;
PART FIVE Food: Safety, Security, and Disease; 19. Factory Farms as Primary Polluter, Martin Donohoe; 20. Genetically Modified Foods: Health and Environmental Risks and the Corporate Agribusiness Agenda, Martin Donohoe; 21. Opposition to the Use of Hormone Growth Promoters in Beef and Dairy Cattle Production (American Public Health Association Policy Statement, Adopted 2009), Elanor Starmer, David Wallinga, Rick North, Martin Donohoe;
PART SIX Environmental Health; 22. Roles and Responsibilities of Health Care Professionals in Combating Environmental Degradation and Social Injustice: Education and Activism, Martin Donohoe; 23. Global Warming: A Public Health Crisis Demanding Immediate Action, Martin Donohoe; 24. Flowers, Diamonds, and Gold: The Destructive Public Health, Human Rights, and Environmental Consequences of Symbols of Love, Martin Donohoe; 25. Is a Modest Health Care System Possible? Andrew Jameton
PART SEVEN War and Violence; 26. The Health Consequences of the Diversion of Resources to War and Preparation for War, Victor W. Sidel, Barry S. Levy; 27. A Brief Summary of the Medical Impacts of Hiroshima, Robert Vergun, Martin Donohoe, Catherine Thomasson, Pamela Vergun; 28. Medical Science Under Dictatorship, Leo Alexander; 29. War, Rape, and Genocide: Never Again? Martin Donohoe
PART EIGHT Corporations and Public Health; 30. Combating Corporate Control: Protecting Education, Media, Legislation, and Health Care, Martin Donohoe; 31. The Pharmaceutical Industry: Friend or Foe? Jennifer R. Niebyl; 32. Unnecessary Testing in Obstetrics, Gynecology, and General Medicine: Causes and Consequences of the Unwarranted Use of Costly and Unscientific (yet Profitable) Screening Modalities, Martin Donohoe; 33. Urine Trouble: Practical, Legal, and Ethical Issues Surrounding Mandated Drug Testing of Physicians, Martin Donohoe
PART NINE Achieving Social Justice in Health Care Through Education and Activism; 34. Promoting Public Understanding of Population Health, Stephen Bezruchka; 35. Some Ideas for a Common Agenda, Peter Montague, Carolyn Raffensperger; 36. Taking On Corporate Power—and Winning, Robert Weissman; 37. US Health Care: Single-Payer or Market Reform, David U. Himmelstein, Steffie Woolhandler; 38. US Health Professionals Oppose War, Walter J. Lear; 39. The Residency Program in Social Medicine of Montefiore Medical Center: 37 Years of Mission-Driven, Interdisciplinary Training in Primary Care, Population Health, and Social Medicine, A. H. Strelnick, Debbie Swiderski, Alice Fornari, Victoria Gorski, Eliana Korin, Philip Ozuah, Janet M. Townsend, Peter A. Selwyn; 40. Stories and Society: Using Literature to Teach Medical Students About Public Health and Social Justice, Martin Donohoe

Sunday, November 4, 2012

Health is not a commodity: Let us get the language right

Sometimes the starkest realities are hidden by the language that we choose to speak about them. This week I attended two important conferences, the annual American Public Health Association (APHA) meeting of about 8000 or more public health workers from across the country, and, on the day preceding it, the annual Physicians for a National Health Program (PNHP) meeting, with about 400 doctors and medical students.

While the PNHP program was more targeted, examining the impact of lack of access to health care in the US on the health of our people, it also included international participants. One, Dr. Alex Benos of Greece, talked articulately about the impact of European Union and IMF imposed “austerity” measures on the health of the Greek people -- so bad that the child poverty rate there has risen to 16%. The impact of the penalties for “bad” (albeit sanctioned and even encouraged by governments) behavior by bankers is being borne by the people, and especially the poorest, in Greece, in Spain, in Portugal – and in the US, where the child poverty rate, 23% still significantly exceeds that of Greece. While they have been dramatically underplayed by the US media, there have been massive, massive, and regular demonstrations against these attacks on the people, and in Greece (as elsewhere) physicians such as Dr Benos are there on the lines with their patients, providing medical care and demanding the core basic social services that their patients need.

“Health and health care,” Dr. Benos says, “are not commodities that exist to drive the economy. They are among the social goals which we have an economy to achieve.”

Think about that. We have been so inundated with news articles, pundits, politicians, and others talking about The Market, about the need for austerity, that we have forgotten to ask the key question of “why is there an economy? What is the goal of production?” It is the national and international version of the phrase we hear so often in businesses, including hospitals: “No margin, no mission.” Perhaps, but much more important is to have a mission; otherwise it is “No mission, no mission”. When a hospital makes money on its profitable “product lines”, what is the mission? To help provide for the basic healthcare needs of the poor and uninsured? Or to invest in expanding those already-profitable product lines? If our national and international economies generate wealth, is the goal to provide the basic health needs of those whose labor created that wealth? It is clear what we have, de facto, chosen in the US: since 1992 the top 400 taxpayers have had a 500% increase in income, and the rest of the top 5% a 150% increase. 50% of the total increase in income over that period has gone to the top 400 people, and 93% to the top 5%!

Solidarity,” Dr. Benos adds, “means no one should be left alone in this crisis.”

His work and that of other Greek physicians is to be sure that this definition of solidarity is the one they live by. For us, in the US, a stronger sense of social solidarity would be important; indeed, any sense of social solidarity would be an improvement. The evil myth propagated by many in the US is that when we support the core needs of the most vulnerable, we weaken the economy; in fact, the reverse is true. Providing a core set of social service, including health care, education, housing, food, and opportunity, increases our ability to be a strong society. It is the opposite, the concentration of all wealth in a few, that jeopardizes our future. Trickle down, it should be clear now, doesn’t happen.

“The ideology,” said Andrew Coates, another speaker and PNHP president-elect, “is that whatever is private is good and whatever is public is bad. It is not true, and it is certainly not cheaper.” Let us compare the US to our closest neighbor, Canada, where most health care services are privately delivered, but are paid for by a single payer, the government. The US spends $8230 per capita on health care, of which $5290 are public $ (counting not only direct expenditures for Medicare, Medicaid, VA, military, and federal , state and local employees and retirees, but also the foregone tax revenue resulting from employer contributions to health insurance being tax exempt). In Canada, total expenditures are $4440 per capita. Thus our public fund expenditures per capita exceed Canada’s total expenditure. Hospital billing administrative costs in the US are $570 per capita and total administrative costs are $2685; in Canada, the numbers are $182 and $809 respectively. The gap in life expectancy between the highest and lowest quintiles of income was 1.5 years in 1972. In 2011 it was nearly 6 years. Life expectancy is lower in the US, as are life years adjusted for disability, infant mortality, and virtually every other health indicator. Our money is not buying value; it is accruing wealth to a few.

That language is important was emphasized by presenters at several of the APHA sessions I attended (there are literally hundreds of them over the course of the conference). Sonja Bettez, from the University of New Mexico, observed that talking about health “disparities” tends to minimize the structural violence done to the populations of people who suffer those disparities, and that in Latin America this term is never used; rather the discussion is of inequities, or inequalities. Broad-based differences in health status between populations based on class, race, and other characteristics are not just disparities, they result from deeply seated societal and social problems. Using the language of disparities serves a political purpose, she notes, as it tends to pre-empt social change by emphasizing individual behavior change. She also notes the absence of the term “social justice” from any of the decennial iterations of Healthy People, not to mention the absence of “racism”. How we label things has a great deal to do with how we think about what is necessary to correct them.

In another vein, Donald Light spoke about pharmaceutical companies and marketing, noting the language of “the risk-benefit” ratio (which I have used in this blog) does not make sense because it doesn't identify risk of what? Accurately, it is a risk-risk ratio, the risk of harm vs the risk of benefit, or “harm-benefit” ratio. This is more stark, and more correct. Dr. Light also discussed what he calls the “inverse benefit law”: that the more widely marketed and used a drug is, the less benefit and more harm results. This makes sense; the lowest harm-benefit ratio accrues from the limited use of a drug for those specific conditions, and in those specific people, in whom it has been shown to have the most benefit; as the use of the drug expands to conditions for which it has been less clearly shown to be beneficial, the risk of harm does not decrease and the harm-benefit ratio increases.

It was a very instructive week, and one in which a lot of information was shared. Sadly, it was not all good, and the future, from the economic crisis in Greece to the health care system in the US, is pretty cloudy. But using language carefully and accurately to correctly label problems helps us to identify potential solutions. I think a good touchstone is for us to reject the idea that our health, and that of our families and friends and the entire society, should be a vehicle for profit. Dr. Benos has it right when he says the health is a social good for which we must strive, not a commodity.

Now our task is to make that a reality in the US.

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