The Sharp End of Ideology

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This powerful piece was written by Robert Ferrer, MD, MPH, who has previously written guest blogs. It is too bad that the pundits and policy wonks will not see it.

On any given day there are five to ten of them on our hospital service. In the room that our clinical team uses to discuss patients we reserve one of our two white boards just for them. As a group they are defined by three characteristics: they have suffered from diabetes for many years, they have lacked steady health insurance and medical care, and they are in various stages of dismemberment. Uncontrolled diabetes has damaged their blood vessels, and the ensuing gangrene or bone infections brings them to our hospital, where we care for their medical problems while the surgeons amputate toes, feet, or lower legs. The patients often lose these parts in sequential episodes as their circulation worsens and the complications progress.

Most are men, and many of them are younger than you would expect, in their late thirties or early forties. Almost all have been recently working, though the operation they now require will usually end their employability in the blue collar jobs they occupy. When we ask when they last received regular care for their diabetes, the only mystery is where they*ll fall in the range from "a year ago" to "never". And therein lies what makes these complications especially sad, because with patient education and periodic low-tech evaluations, most of the amputations could have been prevented.

The fact that they are so often not prevented emerges from an unhappy synergy between two epidemics: diabetes and uninsurance. Among large American cities, San Antonio ranks near the top for both; a quarter of its residents lack health insurance and about 1 in 10 have diabetes, though in the less affluent parts of town the diabetes statistic is closer to 1 in 4. Being poor puts one at risk for both diabetes and being uninsured, but being poor in particular locales is especially risky. What those locales share is stingy public insurance programs, (for example, the earnings ceiling above which adults with children no longer qualify for Texas Medicaid just 26% of the federal poverty level -- about $5200 for a family of four -- and, as in most states, childless adults without disabilities don*t qualify at all), and many jobs that don*t come with health insurance. In many cities, as in ours, a large number of undocumented immigrants also add to the number of uninsured.

So there are three of the big conundrums of national heath care reform: the scope of public insurance, expanding coverage under private sector insurance, and what should be done about non-citizens. (A fourth, costs, will come up later). Framed in this way, as bloodless policy questions far removed from the daily realities of the ward, the urgency is drained out of them. Raised yet another level of abstraction higher -- Socialism! -- the debate becomes an absurd joke, the cruelty of which will be felt by those who will needlessly lose limbs in the coming years if reform fails yet again.

For the patients who occupy the beds on our wards -- high-risk people in low-benefits occupations living in a low-services state -- the list of responsive policy options seems very narrow. The realistic options are heavily regulated public or private plans based on large risk pools and with adequate subsidies to ensure that cost is not a barrier to regular care. Less important than the exact mechanism, however, is that there be a path to coverage short of losing a leg, becoming disabled, and qualifying for coverage through disability benefits. As for the non-citizens, our county decided in 1997 to respond to the compelling local needs by creating a publicly funded plan that allows the working poor to access full-spectrum health care on a sliding repayment scale. Hard-liners may balk at reform that even considers these types of arrangements, but what is the alternative? Deporting people with gangrenous limbs or failing kidneys? Continuing to provide only expensive, last-minute rescue care?

Although we have much yet to learn about controlling health care costs, one clear message is that preventing complications among high-risk patients with chronic disease will yield important savings. A typical hospital bill for a diabetic patient having an amputation runs to $10,000 or $20,000 or more, not because of the surgeon*s fee, but because the patients* other diagnoses, often including antibiotic-resistant infections and failing kidneys, complicate their treatment. Investing in access and regular care before a crisis occurs saves money - as well as limbs, kidneys, and hearts.

Meaningful reform cannot be postponed any longer. George Orwell wrote that in political discourse, *words fall upon the facts like soft snow blurring the outline and covering up all the detail.* Through the seasons of debate, the the urgent needs of those suffering for lack of care have been buried beneath the snow of words. But those needs are still there, regardless of the political calculations. To pretend that there is not a way forward to a workable conclusion coldly discards the opportunity to ease the suffering for millions of our people. If that happens, many will feel the metaphorical phantom pain of another lost opportunity for reform. And a smaller subset of the vulnerable among us will experience the real thing.
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Some good, but a lot still wrong, in health reform bills

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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.[1],[2] (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.[3] The Senate HELP bill provides funding for Primary Care extension services.[4] The House bill and the Finance bill provide some funding for the Medical Home. All bills provide significant funding for Comparative Effectiveness Research.[5]

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[6], 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 [7], “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[8]” 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[9] 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.
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[1] see “Funding Graduate Medical Education”, May 25, 2009,
[2] 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.
[3] 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.
[4] See “The Primary Care Extension Service”, July 12, 2009,
[5] See “Clinical Guidelines and Technology Assessment”, May 12, 2009,
[6] Iglehart, J, Baucus’s Bill and the Long Road to Reform, NEJM 9/23/09
[7] Hacker, J, Poor Substitutes — Why Cooperatives and Triggers Can’t Achieve the Goals of a Public Option, NEJM 9/23/09,
[8] 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.

[9] 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!
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