Friday, January 13, 2017

"The Child is the father of the man: family physicians' screening for adverse childhood experiences

"The Child is the Father of the Man: Family Physicians’ Screening for Adverse Childhood Experiences", my editorial accompanying an excellent article on Adverse Childhood Experiences (ACEs) in the latest issue of "Family Medicine", at

Saturday, January 7, 2017

What do the American people want in a healthcare plan? Not what Trump, Price and the GOP will give them

Readers of this blog are probably aware that I am a member of Physicians for a National Health Program (PNHP) and, like that organization, support the creation of a single-payer health system in the US. Sometimes referred to as a Canadian-type health system, or as in Sen. Bernie Sanders’ presidential campaign, “Medicare for All”, it is pretty easy to understand, and is a system that has worked not only in Canada but, in modified forms, in most developed countries in the world. The key feature of such a system is that it is one program that covers everyone in the country, “Everybody In, Nobody Out” in the title of the book by the late Quentin Young, MD, a former President and executive director of PNHP and a “tiger for social justice” in the words of his Chicago Sun-Times obituary.

Such a system would replace the bewildering, dazzling, complex, confusing mess of the current US health care system, with its hundreds of different private insurance policies with widely varying benefits, premiums, and coverage, as well as the federal programs of Medicare, federal-state partnerships like Medicaid and the ACA’s health insurance exchanges, and of course that persistent, pesky mass of 30 million or so uninsured. And the underinsured, who are effectively uninsured, because they buy the only policy that they feel that they can afford only to find out when they need it that it, surprise, doesn’t cover what they need!

Much of the defense of the ACA has been based on the fact that an insurance pool must have healthy as well as sick people. This is a core tenet of insurance, which would otherwise be unaffordable. Life insurance cannot work if it only covers people on their deathbeds; car insurance cannot work if it only is purchased at the time of an accident, homeowner’s insurance cannot work if it is only bought by people in the midst of a fire. If this were how insurance worked, there would be no need for it, for the premiums would be basically the same as paying for the cost of the services. To have it otherwise, as insurance, requires a pool of money contributed by folks, whether directly or through their taxes, who are not immediately benefiting to cover those who need it. In fact, though, understandably but impossibly, people want coverage for when they are sick, but don’t want to pay when they are not. People may not want to pay a lot when they are healthy (or think that they are) but they want coverage for their sick parents, or newborn with health problems, or when they are diagnosed with cancer, or when their adolescents are in a car wreck. These are things that don’t happen to most of us most of the time but happen to enough of us over our lives that we know enough to fear or expect it. A national single-payer system gets rid of this problem, by having the largest possible risk pool.

But the people of the US did not elect Bernie Sanders, and he did not even get the Democratic nomination. We elected (OK, the Constitutional unfairness of the Electoral College elected) Donald Trump, whose positions may be erratic and change frequently, but whose appointments to Cabinet-level posts are remarkably consistent. Most are from the most right wing of the Republican Party, not unlike we would have expected from Ted Cruz. Despite a campaign that attacked Wall Street and the support Hillary Clinton received from the financial sector, he has appointed many Wall Streeters, including several former (and current) folks from Goldman Sachs -- most recently, their lawyer whose wife still works for them, to head the SEC. Foxes guarding the henhouse abound; climate change deniers will head the EPA and Department of Energy. And in the same vein, we have, for Health and Human Services nominee, Rep. Tom Price, the orthopedic surgeon from Georgia about whom I wrote recently (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters”, December 3, 2016).

Rep. Price certainly does not stand for a single-payer national health system. Nor does he stand for ensuring health care for the vulnerable, whether poor, elderly, rural, or sick, as demonstrated in an excellent piece in the New England Journal of Medicine by Sherry A. Glied and Richard Frank, Care for the vulnerable vs. cash for the powerful – Trump’s pick for HHS”. It notes that he “…favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant,” which would mean that not only Medicaid, and the coverage people have received under ACA, but even Medicare which has protected seniors for 50 years, would be under threat. The article contains information about his positions on other issues, including favoring greater access to armor-piercing bullets, opposing regulations on cigars and on tobacco as a drug, opposing the reauthorization of the Violence Against Women Act and laws prohibiting discrimination against LGBT people. In terms of ensuring health coverage he is as mean as they come:
His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.

But he is the President-elect’s health guy, and we might think that the folks who voted for Mr. Trump will get what they wanted. Except they probably won’t, other than that small slice of voters representing the wealthiest providers, insurers, drug manufacturers, corporate executives, and pundits (like the Wall St. Journal’s Kim Strassel). The health situation in the US is bad, particularly for lower income whites, whose mortality rate has, remarkably, as reported by the Commonwealth Fund, been static rather than decreasing or in some cases (low income women) increasing. These are many of the same folks who voted for Donald Trump, and are presumably looking for a solution. The Kaiser Foundation recently conducted focus groups among Trump voters in states have been hard hit by job losses and were key swing states in the election – Ohio, Michigan, and Pennsylvania. The participants either had Medicaid or were covered by ACA. The results are summarized by an op-ed in the New York Times by Kaiser’s CEO, Drew Altman, “The health care plan Trump voters really want”, January 5, 2017.
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

That’s what they want. That’s what I want. It is what I believe a single-payer system would deliver. But it sure isn’t what they are going to get from Tom Price, or from whatever “replacement” the Republicans come up with for ACA.

And that’s more than a shame.  It’s a scandal.

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