Payments for surgical complications: With a scalpel or a meat ax?

When you bring your car to a mechanic and there is a complication, when something goes wrong with the procedure they say they are going to do, you don’t expect to pay for it, at least if it is their fault, and if you know it. Say that in repairing one part of the engine, they cut a hose in another part; you wouldn’t expect to be financially responsible for fixing it. You’d think that they should absorb the cost, but of course it might unlikely that you would know whether the complication was their fault (sloppy work) or unpredictable, maybe a pre-existing problem that they hadn’t anticipated. On the other hand, if they fix your brakes or transmission and a few days later they fail, you do expect them to repair it for no cost to you.

The relationship between payment and surgical procedures done on your body in the hospital is more complex. First of all, just as with your car, complications happen. Sometime they are the result of “operator error”, whether mechanic or surgeon, but most of the time they occur with a predictable (but hopefully low) frequency. And, like with your car, some people have higher risk of complications because they are in worse shape. And one of (although certainly not the only) the predictors of being worse shape is, just as with cars, the age of the patient. Therefore, it is important to consider the risk (and potential seriousness) of complications and weigh it against the potential benefit from the surgery.

Secondly, payment for surgery (as for all hospital activities, and to some degree all medical activities) is bewildering and incomprehensible to health economists, not to mention doctors and regular people. With your car, you get a bill for “parts” and for “labor”; if you think you’re overcharged, you go somewhere else next time. In medicine, and particularly in hospitals, “charges” for procedures are a largely mythical but definitely inflated number that bears only a little relationship to the costs the hospital incurs, and is almost never the amount that is paid. Different insurers (private, Medicare, Medicaid, “self-pay”) pay different amounts; big insurance companies can bargain down the rates that they pay, government programs such as Medicare and Medicaid set their rates, and the uninsured are the only ones who get a bill for the whole set of charges (of course, they can rarely pay them, but are often bankrupted or have their credit ruined in the process). (See Bargaining down the medical bills, March 15, 2009, or the experience of health journalist Frank Lalli trying to find out what his medicine would cost, “A health insurance detective story”, NY Times December 2, 2012, and covered in my blog post “Medicare: Consumer choice or choosing your poison? How about coverage for everyone?”, December 15, 2012.)

So, do hospitals make or lose money when there are complications to surgery? The answer is “it depends on who’s paying”. In a recent JAMA, Relationship Between Occurrence of Surgical Complications and Hospital Finances[1], Sunil Eappen and colleagues from the Harvard School of Public Health (including, as last and corresponding author, Atul A. Gawande, the surgeon whose New Yorker essays I have discussed several times) examined this question in a large hospital system in the southeast US whose “inpatient surgical payer mix (Medicare, 45%; private, 40%; Medicaid, 4%; and self-pay, 6%) was comparable to that of an average US hospital in 2010 (Medicare, 40%; private, 41%; Medicaid, 9%; and self-pay, 5%)”. Their study found that “…The financial effects of surgical complications varied considerably by payer type. Complications were associated with more than $30,000 greater contribution margin per privately insured patient ($16,936 vs $55,953) compared with less than $2000 per Medicare patient ($1880 vs $3629). In contrast, for Medicaid and self-pay procedures, those with complications were associated with significantly lower contribution margins than those without complications. As a result, the payer mix will determine the overall economics of surgical complications for a given hospital."

Definitions  of Costs and Margins  (from Eappen, et al.)

Variable costs: Costs that vary with patient  volume (ie, supplies and nurse staffing).

Fixed costs: Costs that do not vary with patient volume (ie, costs for the hospital building, utilities, and maintenance).

Total margin: Revenue minus variable costs and fixed costs.

Contribution margin: Revenue minus variable costs. These are revenues available to offset fixed costs.

This absolutely does not mean that in these hospitals, or any hospital, surgical complications are seen as desirable. It does mean that, when the complications happen, the hospitals make money (their “contribution margin” toward fixed costs goes up – see the box which I have reproduced from the article for explanations of terms) if the patients are privately insured or covered by Medicare and lose money if the patients are covered by Medicaid or self-pay. It provides another example of why hospitals see some patients as “more desirable” based upon their insurance coverage, and illustrates how flawed this system is.

The study by Eappen was done on data from 2010, and there have been some changes since then. Medicare no longer pays for the treatment of complications (surgical or medical) that it has identified as preventable and that did not exist on admission (such as new bed sores or blood clots). It will soon go further and not pay for readmissions to the hospital within a certain period of time, whether or not the readmission is for the same problem. So, to carry on the car analogy, not only will they not pay again if your brakes fail after they’ve been “fixed”, they also won’t pay if you have to bring your car back because it needs transmission work. The latter may be as inappropriate for people as for cars; with time multiple things break down, not always related. With a car, we may sell or junk it; with a person we usually try to treat it. Our high-tech medical system can often get a person from the brink of death to “well enough” to go home or a skilled-care facility, but the same problem or another recurs and requires readmission. And, of course, since this is Medicare, all of our patients over 65 covered by this program now become “less desirable”; it means that, even more than before, hospitals will compete for patients with private insurance coverage.

This is no way to fix the problem. The first step has to be to put everyone in the same boat, to have a universal health insurance system, so that no patient is “more” or “less” desirable from a financial standpoint based upon their insurance coverage. Second, hospitals should not be paid on a “per case” basis or have a charge structure that no one understands. They should not have to seek out “well-insured” patients to cover their actual costs (fixed and variable) or put aside money for purchase of new capital equipment. In Canada, hospitals receive a global yearly payment for operating costs (and capital expenses are considered separately), and can thus make treatment decisions based on best meeting the needs of the patient, rather than “readmissions good” (we make money) or “readmissions bad” (we lose money. It is rather parallel to capitated payments for physicians, which I have discussed (recently, for example, Gaming the system: Integration of healthcare services can just raise costs, not quality, December 1, 2012), allowing physicians to treat patients in person, by phone or email, with long visits or short, depending upon what is most appropriate rather than which has the greatest reimbursement.

Of course, like capitated payments to physicians, hospital global budgets need to be adequate to cover costs and incent efficient but effective performance. A well-designed structure for payment that minimizes “gaming” the system no longer works when it is grossly underfunded. An open and transparent system of funding is most likely to permit cost savings where appropriate and not “across the board” (which is almost always wrong); it encourages the use of a scalpel rather than a meat ax.

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[1] Eappen S, Relationship Between Occurrence of Surgical Complications and Hospital Finances, JAMA 2013;309(15):1599-1606.

Premature babies and informed consent: we need to do it right

The New York Times reported April 10, 2013 that an investigation by the Department of Health and Human Services “has found that a number of prestigious universities failed to tell more than a thousand families in a government-financed study of oxygen levels for extremely premature babies that the risks could include increased chances of blindness or death.”  “Study of Babies Did Not Disclose Risks, U.S. Finds”, by Barbara Tavernise reports that the study of the use of oxygen in 1,300 infants born at 24-27 weeks of gestation during 2004-2009 and published in the  New England Journal of Medicine in 2010, “did have an effect on which infants died and which developed blindness, and that those risks were not properly communicated to the parents, depriving them of information needed to decide whether to participate,” and that these  “…conclusions were listed in great detail in a letter last month to the University of Alabama at Birmingham [UAB], the lead site in the study,” which included 23 academic institutions, including Stanford, Duke and Yale.

The science is complex. Very premature infants such as those studied are at high risk of death and other complications, including blindness. It has long been known that the use of very high concentrations of oxygen, near 100% (room air is 21% oxygen), causes them to have an increased risk of blindness. The Times notes that “Clinical treatment of premature infants has a troubled history. Attempts to treat them with higher oxygen levels that were thought to improve their odds of survival led to many cases of blindness. Premature babies need oxygen because their lungs are underdeveloped and they often need help breathing.” The study under investigation was using lower concentrations, 85-95%, in an effort to find a level that was most beneficial for survival without having an increased risk of serious outcomes, such as blindness. The response letter from the lead investigator at UAB argues that a similar (but not formal control group) of infants had a higher mortality rate than those in the study group; this is criticized by others who note that it is not valid science to retrospectively attempt to create a comparison group because they may be different in important ways. Usually, participants are randomly assigned to either receive the intervention or not, because this means that any differences that may exist, known or not, are likely to be equally present in both groups. In fact, one critic, Michael Carome of Public Citizen’s Group on Health, points to a study published in the journal Pediatrics in 2012 that noted the babies in the other group were sicker and thus more prone to die.

But what is of concern to the HHS investigators, and to me, is that the parents of the babies in the study were apparently not informed of the risk of blindness that is known to accompany high-level oxygen therapy, despite the study (and its consent form) having been approved by the Institutional Review Boards (IRBs) of all 23 participant institutions. This is shocking on the face of it, but is even more surprising given that consent forms have largely become, as the Times article quotes Arthur Caplan, head of the division of medical ethics at New York University Langone Medical Center, “...captured by worries about legal liability, so risks tend to come billowing forward like a huge fog… It’s a truth dump, so they are covered should something go wrong.” He is absolutely correct; consent forms commonly include a list of potential negative outcomes so long as to obfuscate what is important, e.g., “rash, fever, nausea, vomiting, headaches, bleeding, seizures and death”. (NOTE: This is MY rendition of what I think is typical; it is NOT the list contained on the premature infant oxygen study.) What is a patient or parent of a patient to think? How bad are these outcomes? How likely are they to occur? How can I make a decision? And, perhaps most important, how can I give a well-thought-out response, giving or withholding consent, when I am – or my baby is – terribly sick and at high risk. What usually happens, as Dr. Caplan notes, is that “…often in such emergency medical situations, parents often rely more on what doctors say in deciding whether to participate than on the fine print of a consent form.“

Much, if not most, research, even medical research, is done with people who are not at high or immediate risk; much early clinical research, as well as that in the social sciences, specifically looks at “normal volunteers” or at regular people in the community. All require informed consent by participants. There are (at least) 3 different sets of interests in any research. The researcher is interested in finding out the answer to a question, which in clinical research is usually about whether one type of treatment is better than another. The patient (or guardian), whose motivation, according to the urgency of the situation, may be to contribute to expanding medical knowledge, to earn some money (if there is an honorarium involved), to help others in the future who may confront the same problem, or, especially when the situation is very urgent and the patient very sick (as in this study) to hopefully get immediate benefit for themselves or their child. The institution in which the study is conducted (represented by their legal department) is interested in guarding, to the extent possible, against risk of lawsuits.

Interestingly, the allegation in this current study is the failure to mention the potential outcome of blindness, more a typical failing of the “bad old days” when patients were not informed at all of risks (e.g., the Tuskegee syphilis studies) than of the “bad new days” where the risk aversion of universities’ legal departments has created the type of laundry list of bad outcomes noted above. But both are bad. Consent cannot be “informed” if typical, regular, non-lawyer people cannot understand the consent form because the language is so abstruse, or if the list of potential outcomes is a jumble of serious and minor ones. This is particularly true when a patient  is critically ill, and they or their guardian is under incredible stress. This is when, as Dr. Caplan notes, they rely on what the doctors say; unfortunately this puts the doctor in the position of trying to dispassionately provide a recommendation as to whether or not to participate in a study that s/he usually feels passionately about. This is not a setting conducive to true informed consent.

The literature on informed consent is enormous, and it is a major focus of the field of medical ethics. But the key principle must be that participants be adequately informed of the risks that may exist, in language that they can easily understand. The risks must be presented with the most serious ones highlighted, along with the probability that they will occur. They must be presented openly and dispassionately, and study leaders must be available to honestly and completely answer questions. There is, unfortunately, an inverse relationship between the comprehensibility of a consent document and the degree to which it is written in legal language (as anyone who has ever tried to read anything written in legal language can believe).

Consents must be appropriate to the situation. Researchers who wish to, say, interview people outside a local supermarket to find out what they think are health problems in their community, should not have to have those people sign a 3-page consent to participate or no one would do it. Researchers who wish to study clinical interventions in high-risk patients in urgent circumstances need to provide adequate information about risks and benefits in a way that patients can understand, and not use their role as the “doctor” to “sell” a study because they believe the intervention will be beneficial even though the results are not yet in. IRBs need to take their responsibility to protect participants’ interests and be truly informed, while facilitating the conduct of research seriously. It’s not easy. Lawyers need to learn how to write in a way that folks can understand.

Clearly, leaving out a major potential complication like blindness from a consent form is wrong, but there is much more to getting true informed consent than a simple fix. But it has to happen if we are to continue to be able to conduct research in order to have new knowledge.

Research on disparities/inequities, in practices and communities needs much greater funding

This is my first attempt at a blog in several weeks; indeed only one in the last month. I took (and time will tell if I passed) the Family Medicine recertification exam, so I am now able to raise my head above water.

Research is the way we gain new knowledge. It is how we discover if the things that we are doing are the right things to do, or if they are of little or no value, or perhaps even of harm. In the decades after World War II, when the country was optimistic and growing and seeking new frontiers, science was a major area for investment by our government. Things were getting better, returned GIs found a plethora of well-paying jobs, were able to buy houses and cars and plan to send their children to college. American industry did extremely well, if not solely because of great planning and management here, because there was no competition from the rest of the world which had been devastated by the war.

Things were not all good, especially on the political front; there was the cold war, and the associated fanatic fear of Communists epitomized by Senator McCarthy, and there was a legitimate fear of nuclear. But, on the economic front, things were going well for the US. The growth benefited many more people, and the gap between the income of the average worker was large but not unconscionable. Not like today, where as demonstrated by much research, and the title of this HuffPost article, “CEO Pay Grew 127 Times Faster Than Worker Pay Over Last 30 Years”, (“It’s good to be a CEO!”), or in this graphic from Prof. GW Domhoff of UC-SC.

The most dramatic expenditures on science were on space travel; after the Soviet Union launched Sputnik, the first artificial satellite, in 1957 and the space race was on. With the election of John Kennedy in 1960, space exploration moved front and center. All of us who were schoolchildren, in addition to hiding under our desks to protect us from nuclear weapons, were much more productively engaging in a new-found, broad-based physical fitness program encouraged by the President. While Harry Truman was unsuccessful in passing a national health insurance plan, thanks to both the reactionary opposition of the AMA, and the fact that labor unions chose to demonstrate their effectiveness by negotiating health coverage rather than seeking political change as the Labour Party successfully did in Britain, in other areas of science, health moved to the forefront.

The National Institute of Health (NIH) became the major government institution funding medical research and saw enormous growth in the ensuing decades, including a doubling of the budget from about $15B to about $30B in the decade surrounding the last millennium. This fueled the development of an enormous expansion of medical research in laboratories, primarily in universities and medical schools. In addition, corporate support, mainly from pharmaceutical research companies, further enhanced the growth of these laboratories. There were many successes, of which the most famous is the sequencing of the human genome, but our understanding of human biology and how it might contribute to human health and diseases has been remarkably enhanced. Some of this research has led to true medical breakthroughs, with the creation of new drugs and treatment modalities that have sometimes been of great help to large numbers of people with common diseases, and sometimes of enormous help to a few with uncommon ones.

However (and you knew that there was going to be a “however”), the focus on laboratory research and new discoveries at the molecular, protein and genetic levels left unfunded areas of research at least as critical, but not seen as “hard science”, and thus not generally funded by NIH and drug companies. This is a problem. Yes, there are “clinical” research studies, but these are mostly trials of drugs and interventions in populations. The number of studies based in communities, looking at health disparities, and trying to discover how most effectively to have a positive influence on the health of people, populations, rather than occasional individuals, remains small.

 

Certainly, it has grown. As demonstrated in the graph, after the NIH budget doubled, it leveled off, “stagnated” given inflation, until the one-time infusions of American Recovery and Reinvestment Act (ARRA) funds in 2009. Funding for health disparities research has increased, both from NIH and from other federal agencies such as the Centers for Disease Control (CDC) and the Agency for Healthcare Quality and Research (AHRQ), which has but a tiny fraction of the funding that NIH does. NIH created Clinical Translational Science Awards (CTSAs) which funded centers at many medical schools to look at moving research into the community, but much more from the basic science laboratory to first-in-humans trials (or even from one basic science laboratory to another). A major new initiative of the Affordable Care Act (ACA) is the creation of the Patient-Centered Outcomes Research Institute (PCORI), designed to evaluate not just new treatments but how they affect people. However, even the community-based research has focused largely on the recruitment of research subjects to studies designed by academic researchers, rather than on directly studying issues that would improve the health of the people in those communities.

Part of the problem is that it is difficult to get community members to think about what would be in the best interests of their health and that of their communities. They are, after all, not trained in such assessment. In addition, particularly in the communities that are the most vulnerable, that have to greatest health inequities, people are just focused on getting by, paying the rent, buying food, working multiple low-wage jobs. However, another part of the problem is that research at this level is seen as less important and significant, particularly by those who have always focused on new discoveries in the lab and who control most of the agencies such as NIH.

But it is not true. No matter how wonderful the discoveries in the lab, no matter how much they might lead to new understanding, new drugs, new treatments, these are only of value if people benefit from them. So this requires clinical research in the real world, with actual people. But beyond this, if they are to benefit not just a chosen few, the interventions have to be studied among diverse populations, including people facing economic, social, psychological and environmental challenges. In addition, the delivery of these treatments is sporadic. It is clearly demonstrated that administration of aspirin is of benefit to people who have had heart attacks. So it should be used. Why, then, are half the Americans who should be on aspirin not? I don’t know. It probably isn’t cost. It requires research to find out why and to change it. Saying (as is often done) that “new medical knowledge takes 10-20 years to penetrate into practice” is not adequate. Finding out how to get this effective treatment to the people who need it is as important as discovering the treatment. This is known as “fidelity” research.

Finally, effective research on improving people’s health needs to involve medical practices, where the people are being seen. There are many Practice-Based research networks (PBRNs) around the nation, but they are all challenged by how busy the providers are seeing patients; this is at least as true in practices such as Federally-Qualified Health Centers (FQHCs) that care for poorer populations. And yet, without involving them in research, how can we know what is effective in delivering the “best quality” care, and how can practices at the point of care be changed?

This is not to say that we should not fund basic biomedical research or early clinical trials. Nor is it to say that the current programs from NIH and PCORI and others to fund work in health disparities and inequities, and in population and community health are not good. But they are too little. People working in basic laboratory research, early clinical research, practice-based research, and community health should not be competing with each other. There should be more money for all of it, but especially a lot more for fidelity research, community-based participatory research, and practice based research.

Where will the money come from? From policies that are used in every other successful country, and every time the US has been successful, progressive tax policies that take some of our wealth out of the control of private corporations, who use it only to sock away more money, and into the public sector where it can be used to benefit us all.

Can you be "too strong" for family medicine?

Last week medical students and residency training programs received their “match” results, the end product of a complex computerized process. Now (except for the 1100 students at US allopathic schools who did not match and programs that did not fill), students know where they will be training and residency programs know who will be joining them. The number of “un-matched” US students is greater than last year; so is the number of positions. This is the result of recent expansions in both the number of medical schools and the number of students in existing medical schools.


The Association of American Medical Colleges (AAMC) has been lobbying hard for the expansion of residency positions, arguing that expanding medical school class size is not going to translate into more doctors if there are not more residency positions. AAMC is not, however, calling for those increases to be tied to a certain percentage of primary care. Since primary care residents are not big money-makers for the hospitals that are the main sponsors of residency training, and not in great demand by medical students (see more below), it is quite likely that, absent specific stipulations, the opposite will occur – most of the expanded number of residency slots will be in non-primary care specialties. This will, of course, further exacerbate the already unbalanced subspecialty/primary care ratio that currently exists.

Unlike AAMC, many family medicine organizations are calling for expansion of residency slots to be tied to primary care, and I am in agreement with that. However, the concept of “forcing” students to choose primary care residency slots who may not want to makes many people uncomfortable. They would prefer to “make family medicine” more desirable to our students. I would argue that this is going to be an uphill battle given the priorities of many current medical students.

As a family medicine educator, I try to stay on top of the trends in medical education, student preference, and workforce. I also interact with a lot of medical students, so have, I think, some idea of what their priorities are. Sometimes, however, I am surprised by the lack of knowledge about family medicine among students who, I thought, should “know better”. For example, a student recently contacted me about a friend who had applied to family medicine residencies as a “backup” for their preferred, more “selective” specialty, and did not match; the perception was that this student was rejected because they were seen as “too strong” for family medicine. I was surprised. I wrote the following in response:

"I don't think it is possible to have someone be "too strong" for family medicine regardless of how you define strength (grades, board scores, compassion, ability to learn and apply learning, multi-tasking, or how much you can bench press). Family Medicine is truly the most complex and difficult specialty. The breadth is enormous, as I am reminded as I -- for the sixth time in my career -- study for my recertification boards, and study maternity care, sports medicine, caring for people with heart disease, well-child care, ICU care, lung disease, diabetes, fractures, arthritis, acutely-ill children, preventive care, epidemiology, nutrition, diabetes, gynecologic problems, management of psychiatric problems, adolescent issues, and on and on. There is nothing like it. It is also true that the skills, preferences, and experiences that make someone strong for one specialty may not make them "stronger" for another.

"As far as the practice is concerned, family physicians have to see undifferentiated patients and try to come to a conclusion about what they have and how to manage them. This is a lot more conceptually challenging than seeing someone with a ready diagnosis or a narrow scope of diagnoses and applying your in-depth knowledge to figuring out a best method of treatment for it, or doing a procedure on it. Family Physicians (and other primary care/generalist physicians) do not care for one disease or organ system of a person, they care for the person. They manage multiple co-existing chronic diseases -- our adult patients typically have a large number of them such as hypertension, diabetes, heart disease, arthritis, depression, and social stressors in their lives, for example -- and balance the treatments for each so that they do not make the others worse and are best designed for that individual person. And to, while doing so, learn and care for the person. This is harder than doing the same limited set of procedures or treating the same limited set of diagnoses day after day. While a typical subspecialist may have 5 diagnoses that account for 80% of her patient visits, for family medicine the top 20 diagnoses do not cover more than 30%!

"I do not mean in any way to insult or seem to be critical of other specialists; they do important things and we need them to refer to for the procedures that we don't do or the uncommon cases of diseases that are rarer or unresponsive to usual treatment (although I do think that the current balance between subspecialists and primary care doctors is way off). I also do not mean to seem ignorant of the fact that many other specialties, including orthopedics, are much more competitive than family medicine to match in. This is because demand (from students) exceeds supply (of positions) and allows those specialties to set higher (by whatever they mean by this, usually grades and scores) standards. But this should not be confused with the complexity of the specialty. Demand is driven by many things including (but I am sure not limited to), the particular interest of a student in the diseases cared for by a specialty, their interest in performing psychomotor skills (such as procedures), anticipated income, anticipated lifestyle issues, and many others. It is also true that many other specialties require strong medical students. But do not confuse supply/demand issues with the intelligence, hard work, difficulty, decision making ability needed, breadth, and conceptual complexity of a specialty. For these, nothing exceeds family medicine."

I also sent a link to this (I think) wonderful post called "Desperately Seeking Herb Weinman" by Steve Lewis in Pulse, an online journal of narratives about health and medical issues, that gets to other characteristics of primary care doctors that are important to people. The author has a very scary health episode that takes him to the emergency room, and acutely feels the depersonalization of not having a doctor who knew him (like his old, now retired, doctor, Herb Weinman, did): “I know that the overworked ER staff who treated me were good and competent healthcare providers. But I also know that there was not a soul in the ER that day who would have cried if I had died. As Herb Weinman would. And I want that. I want that.”

A colleague, who also has concerns about the motivations of some medical students, reposted a post from a student on “studentdoctor.net”, the largest discussion group for medical students about whether Allergy should replace Anesthesiology on “the ROAD” [Radiology, Ophthalmology, Anesthesiology, Dermatology, which are widely considered by medical students to be the specialties with the highest income-to-work ratio] because it seemed like “…such a cush job.” Then followed a listing of the incomes of different specialists, which I will not replicate, but will note that the low end of all was much higher than the high end of primary care incomes; however, primary care doctors earn a lot more than the average person!

My colleague commented: ”We need a different pool of applicants...We need a different yardstick...We need payment reform. There are plenty of smart people who want to serve. There are a lot of folks who would be thrilled to be the smartest, best paid person in their town.”

I agree. I want many more medical students to want to go into primary care. If it is about money, we are not going to be competitive. It is going to have to be about wanting to care. And that means, to me, using different criteria to accept people to medical school.

More people like Herb Weinman, I guess.

Squeezing the needy: a truly flawed financing system for healthcare

In his always-valuable “Quote of the Day” for February 26, 2013, Don McCanne, MD, cites an article by Robert Pear in the New York Times from February 25, “States Can Cut Back on Medicaid Payments, Administration Says”. He quotes from the article that “In a brief filed with the United States Court of Appeals for the Ninth Circuit, in San Francisco, federal officials defended a decision by California to cut Medicaid payments to many providers by 10 percent…. [it] urged judges to uphold those cuts, which are being challenged by patients, doctors, dentists, hospitals, pharmacists and other health care providers in California…[who] said California’s payment rates were inadequate even before the cuts. They pointed to a federal study that said,’ “California stands out because of its very low Medicaid payment levels.’”

 A similar article that he cites from the Los Angeles Times by Anna Gorman, February 25, 2013, “Healthcare overhaul may threaten California's safety net” states that “An estimated 3 million to 4 million Californians — about 10% of the state's population — could remain uninsured even after the healthcare overhaul law takes full effect,” while at the same time the public hospitals and clinics that would provide care to those additional millions are having their funding streams from the state cut.

And this is in a state with a long history of providing care for its medically indigent by having such hospitals and clinics (unlike, oh, say, Kansas) and with a reasonably progressive Democratic governor, Jerry Brown. But it also has a huge budget deficit. At the most narrow level, the state has no choice but to spend less on the programs over which it has control, and these programs are the ones that benefit those whose low-wage jobs (or no jobs at all) make them dependent on public programs to ensure the health of their families.

The key point here is that the huge transfer of funds from the public sector to private control, as a result of tax cuts on corporations and wealthy individuals, has led to the inability for even states such as California, which arguably want to, to provide the basic health and social safety net for its most needy citizens. This is precisely the result that advocates of these programs want, to “choke” government, and precisely the impact on the poor that would be predicted. Meanwhile, at the local, state and federal level, tax “relief”, in terms of both cuts and direct giveaways to major industries, continue to support the least needy.

At the same time (February 20, 2013), Time magazine has published an amazing exposé by Steven Brill of the ridiculous over-pricing and capricious billing done by US hospitals, “Bitter Pill: Why Medical Bills are Killing Us”. It is a long and through article, citing case after case and example after example, of how the current system of billing and reimbursement in health care, and particularly in hospitals costs a fortune, is sapping the economy overall. And, of course, the burden falls hardest on those who are either uninsured or poorly insured, and are billed “list” prices, which are much higher than those paid by either public (Medicare or Medicaid) or private (eg., Blue Cross, Aetna) insurers. MUCH higher. Often dozens of times higher. A few examples that he cites:

• A troponin (blood test for a heart attack) test billed to an uninsured patient at $199. Medicare pays $14; a CBC (blood count) billed $157 when Medicare pays $11.
• A nuclear heart scan for which Medicare pays $554 billed at $8,000.
• A Medtronic spinal stimulator that lists for $19,000 from the manufacturer (if the hospital paid full list) billed to the patient for $49,000.

The article is good investigative journalism, and goes beyond such simple examples to look at the entire structure of the health system’s payment mechanism, including the incentives to do more and more (even when unnecessary or possible even harmful) expensive – and high profit – tests and procedures. It looks at enormous hospital profit margins and salaries of “C-suite” executives: “…in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million.” (Of course, salaries in the measly low one-digit millions pale before the incomes of those in the pharmaceutical industry!) It helps us to understand both why costs are so high and why programs that limit payment, like Medicare and Medicaid, are so hated/fear/despised by hospital administrators.

The hospitals may well be taking a loss on Medicaid/Medicare reimbursement, because “Medicare takes seriously the notion that nonprofit hospitals should be paid for all their costs but actually be nonprofit after their calculation.”  But while “Hospital finance people argue vehemently that Medicare doesn’t pay enough and that they lose as much as 10% on an average Medicare patient...even if the Medicare price should be, say, 10% higher, it’s a long way from $11.02 plus 10% to $157.61.”  The thing is that they “need” to make more because, although “non-profit” they make big profits – they just don’t share them with stockholders. “…thousands of nonprofit institutions have morphed into high-profit, high-profile businesses that have the best of both worlds. They have become entities akin to low-risk, must-have public utilities that nonetheless pay their operators as if they were high-risk entrepreneurs.”

What was interesting to me is that most of the patients who received those outrageous bills above were neither unemployed nor uninsured (although the one who was uninsured had the misfortune of being 64 rather than 65, so paid the $199 for her troponin instead of Medicare paying the $14). Rather, they were employed in low wage jobs and had lousy insurance, with very low per-visit, per-year, or lifetime caps and were treated by the hospitals as if they were uninsured (“’We don’t take that kind of discount insurance’ said the woman at MD Anderson [Cancer Center]” when Stephanie Recchi called to make an appointment for Sean; they needed to come up with $48,900 cash up front – and that was just the down payment!). So all estimates about the burden on the uninsured need to be augmented by the impact on the under-insured.
Dr. McCanne’s incisive comment on the two articles notes that while “We have said over and over again that Medicaid, as a welfare program, will never have the political support to fund it adequately. The burden of the additional load of Medicaid patients will surely find the health care resources strained beyond the capacity of willing providers, especially when you consider that California already is not meeting the costs of providing care to this vulnerable population…

"Here's an amazing fact: Low income patients do not have the money to pay for health care. (What an intuitive stroke of genius!) What they need is an affordable system that removes financial barriers to care while ensuring adequate financing of our entire health care delivery system, thereby removing health system disincentives to providing essential care for this vulnerable population. Make that for all of us.”

All of the nonsensical billing and collecting issues that are so horrifyingly reported on by Brill do not need to occur. The simple answer is that there should be a single, posted, price for each item or service and everyone is billed at and pays (or their insurance pays) the same amount. This is the situation in Canada, where fees for physicians are negotiated annually with the provinces and hospitals operate within a global budget. Probably fewer millionaire hospital administrators, but of course creating them should not be the goal of the money we spend on health care.

No poorly-insured, well-insured, uninsured, Medicaid-insured or Medicare insured. Just everyone covered. Simple, clean, elegant, and effective.

Corruption and Scandal in the NHS: What happens when you introduce private incentives to public services

The United Kingdom has a National Health Service which covers everyone (although it allows those with private insurance to access care elsewhere). While not perfect – nothing is – and historically underfunded, it is one very reasonable model for how we could ensure access to health care for everyone. It goes back to the post-WW II period, when the British Labor Party made the decision to expand the existing National Health Insurance program to create the NHS through the political process, while in the US the emphasis among unions was to use collective bargaining to get health insurance as a member benefit.

But the NHS, while profoundly supported by the vast majority of British people, has been a target of attacks by Conservative governments since the Thatcher years. One of the big changes was the creation of several regional “trusts”, quasi-public entities that were invested with NHS funds and made responsible for the provision of care in their regions. This was consistent with the Tory assertion (held even more strongly in the US) that the private sector, or as close as they could get politically to the private sector, would be more efficient and effective than a public “bureaucracy”. Success at meeting "targets" (often high production with inadequate resources) could lead a trust to "foundation" status, where they would have even more control.

Many in Britain had their doubts, certainly among those to the left of the Conservatives. There was concern that the trusts might not be responsive to the health care needs of the people and might be more concerned with enhancing their own salaries, perks, and power. Conservatives (small 'c') tend to believe that government bureaucracies are more inefficient; those on the left see more evidence that privatization is much more likely to serve the self-interest of those in control than the interests of those who are supposed to be served.

I recently read the 1996 mystery novel “Quite Ugly One Morning” by the Scottish writer Christopher Brookmyre. One of the major plot lines involves corruption in the Edinburgh-based regional NHS trust. I don’t want to spoil the plot, and I do recommend the book, but the portrayal of self-serving, stealing, and lack of attention to the actual care of the patients of the NHS was scary. Of course, it was a novel; there were not actual patients being harmed by corruption in the actual regional NHS trusts in the actual United Kingdom. After all, I thought, the British don’t do such things. We do, but that is because so much of our system is private and for-profit. Surely the British value the NHS too much for such things to really happen.

Wrong. It appears, however, that this in fact has been happening. In “English hospital report cites ‘appalling’ suffering”, NY Times February 6, 2013, Sarah Lyall describes conditions cited in a government report on Stafford Hospital, operated by the Mid-Staffordshire Trust: “Shockingly bad care and inhumane treatment at a hospital in the Midlands led to hundreds of unnecessary deaths and stripped countless patients of their dignity and self-respect, according to a scathing report published on Wednesday…. The report, which examined conditions at Stafford Hospital in Staffordshire over a 50-month period between 2005 and 2009, cites example after example of horrific treatment: patients left unbathed and lying in their own urine and excrement; patients left so thirsty that they drank water from vases; patients denied medication, pain relief and food by callous and overworked staff members; patients who contracted infections due to filthy conditions; and patients sent home to die after being given the wrong diagnoses.”

HUNDREDS of people. Maybe as many as 1200 people died unnecessarily. And, in the followup of this scandal, there are investigations into at least 14 other trusts, reported across the British press such as this article in the Telegraph, “Head of NHS ignored warning that patients were in danger, alleges whistleblower”. One of these trusts is United Lincolnshire, whose former chief executive has turned whistleblower, accusing the head of the entire NHS, Sir David Nicholson, of ignoring warnings that substandard care was being provided there. The whistleblower, Gary Walker, was fired from his job and paid off to the tune of about a half-million pounds, to keep quiet.

This would be a great example of “life imitating art” if it weren’t for all the people who died or suffered serious morbidity as a result of “…its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care,” (NY Times).  As further documented in the report, this was essentially “speed up”, a condition familiar to assembly-line workers.

“Speaking in the House of Commons,” the NY Times article goes on, “Prime Minister David Cameron apologized for the way the system had allowed ‘horrific abuse to go unchecked and unchallenged’ for so long. So deeply rooted was the trouble, he said, that ‘we cannot say with confidence that failings of care are limited to one hospital.’” Apparently not, given the accusations at Lincolnshire. However, despite these accusations, and perhaps more damningly, the fact that he was the Chief Executive of the Mid-Staffordshire trust during much of the time that the scandalous activities were occurring there, Nicholson is staying put, and so far the government is backing him. (more coverage in the Mail (Feb 13 and 17).

Well, he is staying put so far, but people in Britain far and wide are calling for his resignation, as well they might. Demonstrations in support of the NHS as a system designed to serve the people, not its administrators, have broken out across Britain; an example is this wonderful “Youtube” video of a “flash mob choir” (!) at King’s Cross railroad station in London singing in support of National Health (h/t Alex Scott-Samuel).

It would be possible to pin these atrocities on the National Health Service, as an example of the failing of socialized medicine, but that would be wrong. It would even be wrong to point out that the problem is chronic under-funding of the NHS. The problem, in fact, is a public good being run for private benefit, for the temptation of even great “autonomy” (read: potential for exploitation) by becoming a “foundation” led to deaths far in excess of the scale fictionally portrayed by Brookmyre in the mid-90s. The NHS does not suffer because it is tasked with providing health care to all of the British people; it suffers when a lack of adequate regulation and supervision allow such abuses to go unchecked.

The British people deserve much better. So, for that matter, do Americans. Let’s listen to the “flash mob choir” again!

Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

The shortage of primary care physicians in the US, which I have often discussed (most recently in “When is the doctor not needed? And who should take their place?”, January 5, 2013), has become a national theme. The Robert Graham Center of the American Academy of Family Physicians (AAFP) has done much of the work in documenting this shortage, such as in the article “Projecting US Primary Care Physician Workforce Need” by Petteson, et al., discussed in my post “Health reform, ACA, and Primary Care: Is there still a conundrum?”, December 24, 2012. Essentially the problem is we have too few primary care doctors for the current population, the demand for them will continue to grow, and the rate of production (medical students entering primary care specialties) is below that even needed to replace those who retire. The growth in demand is a result of (in order of impact): population growth, aging of the population, and a more-or-less-one-time blip from increasing coverage under ACA (although for the latter, the people with a need for care were already there; it is just that with having insurance they will be able to seek it more easily).

 In a recent issue of Health Affairs, Green and colleagues argue that “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication “.^[1] This is not a new concept; it is a central component of what is known as the “Patient Centered Medical Home”. The article suggests that many functions now carried out by physicians can be done by others, ranging from nurse practitioners and physician’s assistants, to nurses, to others on the health care “team”. It also suggests that many problems that now require face-to-face communication (trips to the doctor’s office) could be done by phone or “virtually”, such as by structured email or web-based visits. Thomas Bodenheimer and his colleagues in San Francisco have done much of the work in this area, most recently published in Annals of Family Medicine “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation”.[2]

Green, et al., use computer simulation models to estimate the “panel size” (number of patients that can be cared for per doctor) by the employment of such techniques; they add calculations for “pooling” of physicians, that is, sharing of patients among a group of doctors. This allows greater efficiency by “smoothing out the bumps” that may occur when one physicians has more or fewer patients coming in for same-day care or not showing up for their appointments by allocating them among the group. Using these statistical models they estimate that the ability of patients to access care (get in to be seen) would be dramatically increased by the implementation of such policies.

The work done by both the Green and Bodenheimer groups is convincing, and provides a model for more efficient primary care practice that would help to address the problems our country faces from having too few primary care doctors. Indeed, these approaches utilize the “crisis” as a way to actually improve both access to and quality of patient care. There are, however, challenges to implementation of this model. One is payment; while health systems in many parts of the nation have demonstrated that it is possible to restructure their practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer (notably Kaiser). In those parts of the country where this model of care is less prevalent, where most payment to medical providers is “fee for service” for face-to-face visits to doctors, there is not only no incentive to change, there is a large negative financial incentive since any non-face-to-face care is, essentially given out free.

A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale; as with most such analyses, it leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but Geisinger is atypical; there are not many like it. In addition, it is a financially integrated system (like Kaiser) – that is, it is also the payer -- and it works in a relatively-densely populated rural area of northeastern Pennsylvania, not like the vast empty frontier counties of the West.

It is interesting to me that so much of this emphasis on efficiencies, and particularly the use of professionals other than physicians to provide care, has been on primary care. This, I am sure, is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. It is also because there is not a shortage of many non-primary-care specialists for the needs of the population (although there are for some, such as general surgery, especially in non-urban areas). The reason usually given for this non-shortage is largely that these specialists make so much more money than primary care doctors, so medical students are attracted to them. To the extent that some specialties also have more regular work hours and a limited scope of work, it may also increase their attractiveness.

The limited scope of work (although not, necessarily, less difficult work, especially when considering surgical interventions) also makes them, in many ways, more appropriate fields to use non-physician professionals than primary care. This is the reverse of the usual assumptions that sub-specialists are seeing difficult problems, while primary care providers see mostly colds and blood pressure checks. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, seeing a much more limited set of diagnoses with a more limited set of interventions; for the typical subspecialist, less than a half dozen diagnoses may account for 80% of visits, while for a family doctor the top 20 are probably 30%. Thus, the breadth of knowledge and skills in making complex decisions and appropriately prioritizing problems, require a level of sophistication and training not taught or developed in most other health professionals (family nurse practitioners are one other provider group where there is at least an effort to have this breadth of training). It is, then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.

This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician’s assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists, they manage chemotherapy recipients for oncologists, they use algorithms to care for people in intensive care units, they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar; following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.

The targeted but limited expertise of such nurse specialists have explains why they function so well clinically in subspecialties. What explains why it works financially is that the doctors (or hospitals, or health systems) that employ them are reimbursed at subspecialist physician rates (already very high) for work that is done by others; thus they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.

Unfortunately, the problem with such practice is challenging because the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the “top of their license”, is important, so is payment. As long as primary care is reimbursed at lower rates it will continue to face challenges in recruitment of physicians, nurses, and other team members. 

We need to develop and implement great strategies for team-based care. We also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.

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[1] Green LV, Savin S, Lu Y, “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication”, Health Affairs, 32, no.1 (2013):11-19

doi: 10.1377/hlthaff.2012.1086

[2] Altschuler J, Margolius D, Bodenheimer T, Grumbach K, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation” , September/October 2012 vol. 10 no. 5396-400 doi:10.1370/afm.1400

Creating more family doctors: should we shorten medical school? How?

At the recently-completed Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education, held in San Antonio, one of the big areas of discussion was the shortening of the medical school experience to 3 years for students planning to enter family medicine. Steven Berk, Dean of the Texas Tech University School of Medicine, and Betsy Goebel Jones from the Department of Family Medicine, described the Lubbock medical school’s recently-instituted program in a plenary presentation, and a later seminar featured presenters from several other schools which have instituted or are planning such tracks, including the Savannah campus of Mercer University School of Medicine, Medical College of Wisconsin, as well as Texas Tech. The goal of such tracks is to increase the number of students choosing to enter family medicine by eliminating one year of school, and thus tuition; these schools believe that this financial incentive at least helps a little to offset the lower income that accrues to family physicians compared to other specialists. To the extent that these students then enter family medicine residencies at those same schools, it also decreases uncertainty for both the student and the program.

The most direct forebears of these programs were in the 1990s, at some of the same schools. They offered an “accelerated track” for family medicine, in which students began their first year of FM residency while completing their final year of medical school, getting the MD degree after that year. While initially approved by the American Board of Family Medicine as a pilot, these programs were closed when the decision was made by the body that accredits residencies that one could not get credit for residency training until after receiving the MD degree. This latest effort gets around this by granting the MD degree after 3 years, mainly by compressing the final year of medical school; in most schools the fourth year is already largely used for electives.

Not all accelerated MD programs are about increasing the number of primary care, or certainly family medicine, physicians. A program at the NYU School of Medicine, which remains one of the few US medical schools to not even have a Family Medicine department, was featured in the New York Times "N.Y.U. and Other Medical Schools Offer Shorter Course in Training, for Less Tuition" by Anemona Harticollis, December 24, 2012. While the Texas Tech and Mercer-Savannah programs are also mentioned, NYU’s program is clearly not about producing more of the primary care physicians that the US needs, as this is not something NYU seems to care about at all. As of now all of these programs are “tracks”, rather than for all students; they recruit “high-performing” students who can finish the traditional curriculum in a shorter time.

Interestingly, these current programs do not focus on shortening the amount of time or changing the content of the first two years of medical school, the “basic science” years. This struck me as odd, because when I went to medical school (Loyola-Stritch) in the mid-1970s, it was precisely this component that was shortened (to 12 months, with 2 full years of clinical training). Loyola was far from the only school to do so during that period; my current school, the University of Kansas and many others did so; according to an article by Walling and Merando in Academic Medicine[1] “…By 1973, 27% of U.S. schools offered compressed three year curricula.”  For most, this was not a “track” but was the curriculum for all students. The primary method of shortening the curriculum was abbreviating the time spent in basic science, although the amount varied (at KU it was 15 months). It is thus, to me, surprising that in the current efforts to decrease the length of training very little attention has been paid to shortening the basic sciences. Walling and Merando note that “Although educational outcomes were very similar for three-year and four-year curricula, most schools subsequently reinstated the fourth year to provide students with a broader clinical experience.” I don’t completely buy that; at least at Loyola, the clinical experience was not shortened during its 3-year curriculum. It surprised me in talking to people at the conference that so few even knew about these “experiments” from the 1970s.

My guess is that the current efforts focus on reducing the 4^th year rather than the first two years because of politics. No one “owns” the 4^th year, but the first two years are “owned” by the basic sciences in most medical schools, and by a strong advocacy constituency in the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners (NBME) which offers the US Medical Licensing Examinations (USMLE) and other groups. They have strongly resisted efforts to decrease the time spent on basic science teaching in medical schools individually, as well as nationally. An effort by the NBME to combine the 3 “steps” of the USMLE into two was seen as “elimination of Step 1” and generated huge opposition from the basic science community; the change has been put on hold for several years.

While the need for students to pass “Step 1” is often used as the ultimate reason to not cut back biologic science curricular time, the fact is that students can pass this test with significantly pared-down content. Hopefully, however, there is a better reason to teach basic sciences. That would be that learning the concepts that are important for everyone training to be a doctor to know rather than forcing the memorization of details that are irrelevant, can be looked up, or are likely to change regularly. It means both subjecting the content of curriculum to the this test of relevance, and increasing the breadth of disciplines included as “basic” to include social sciences such as psychology, anthropology, sociology, epidemiology. The teaching -- and testing -- of all this material should focus on understanding concepts, solving problems, and knowing where to look up detailed facts, rather than memorization.

We do need more primary care doctors, and more family physicians to meet the health needs of the American people. We need to do everything possible to make this happen, and addressing financial incentives is a big part of it. Another plenary presentation at the meeting from STFM President Jerry Kruse addressed the successful efforts in Canada to increase the number of primary care doctors (in that country, all family physicians); the key element is decreasing the ratio between primary care and specialist income, and the effective ratio is between 80-85%. There are also good arguments for decreasing the cost of medical education, and perhaps shortening medical school is one method of doing so, especially if it can be done without sacrificing important training; it certainly needs to be relevant training.

But these efforts – to increase the primary care workforce and to consider the appropriate length of medical education – are different. They may complement each other, or may not. The strategies that we employ should be based on their effectiveness at achieving our goals, and for that to happen we need to be clear on what those goals are.  Piecemeal approaches may ultimately work, but they are not the most efficient ways of approaching the problem.

Of course, in terms of health insurance reform, piecemeal is the way we have chosen to go rather than a comprehensive national health program such as Medicare for All; why would we expect a more rational approach to improving medical education?

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[1] Walling A, Merando A, “The Fourth Year of Medical Education: A Literature Review”, Acad Med  November 2010  85(11): 1698-1704.

Kansas, Medicaid expansion, and human rights

In his well-covered “state of the state” speech, the Governor of Kansas, Sam Brownback (full text from the Lawrence Journal World, reported by the Kansas City Star or as you prefer either the Huffington Post’s reporting of it or the Kansas City Business Journal’s), addressed the thorny issue of Medicaid, the program that ostensibly provides medical coverage for the poor, but in reality only covers a portion of them. Most states do not cover childless adults, no matter how poor, unless they are demonstrably disabled, and what qualifies varies from state to state. The financial standard for eligibility is also very variable from state to state; in many places, including Kansas, it is well below the poverty line. Most Medicaid recipients are children in dire poverty and their mothers, and most Medicaid dollars are spent on nursing home care for the medically indigent (and, given the cost of nursing home care, it is really easy to become indigent if you are in one for very long). One of the mainstays of increased coverage for the uninsured in the Affordable Care Act (ACA) is the expansion of Medicaid to all people under about 140% of the federal poverty level.

Brownback said that “Many states have made the choice to either kick people off Medicaid or pay doctors less. Neither of those choices provides better outcomes. Kansas has a better solution,” but, while whether it is better or not may depend upon one’s interpretation of that word, it is not likely to cover more Kansans. He has indicated that no state money would be spent on expanding Medicaid. This does not, however, mean that there will be no Medicaid expansion in Kansas, as for the first several years the costs of such expansion under the ACA will be 100% borne by the federal government. If the state opts for taking the money (and the governor, unlike many other very conservative governors in the US, has been coy about this) it will be able to do so without state dollars. Brownback is committed to eliminating the state income tax, to compete with states like Texas (“Look out Texas, here comes Kansas!”) and is confident, along with his funders like “Americans for Prosperity”, that business growth resulting from his already-implemented tax cut, which has cut almost 1/3 of the state budget income, will more than make up for it (critics note that other states without income taxes have other big sources of revenue, such as oil in Texas and tourism in Florida, that Kansas does not have). This job growth is also part of his plan for getting people off Medicaid “With jobs providing an off ramp from Medicaid, we will be able help those in need of services and reduce our waiting list.” (Did I mention there was a waiting list?) But, of course, this assumes that those jobs will come with health insurance. Definitely not a certainty, as most will be low-wage jobs, the kind most likely to not have health insurance coverage, and a state requirement for such coverage is definitely not something supported by the Governor or his political allies.

Whether Brownback will actually refuse the federal funds is uncertain; not all conservative governors have stuck to this principled, if cruel, position. Governor Jan Brewer of Arizona, a darling of the right with her aggressive enforcement of Arizona’s anti-immigrant laws (in an interesting coincidence, largely written by Kansas Secretary of State Kris Kobach), has reluctantly agreed to accept this money (“Medicaid expansion is delicate maneuver for Arizona’s Republican governor”, New York Times, January 20, 2013), as have Republican governors Susana Martinez of New Mexico and Brian Sandoval of Nevada. Of course, all three have a large and growing Latino population which supports and will benefit from Medicaid expansion, and whose votes are becoming increasingly important. Latinos are also the fastest growing population in Kansas, accounting for 70% of the state’s population growth from 2000-2010; they are not only in the bigger cities such as Wichita and Kansas City – the state’s first majority-minority counties are in its southwest -- but they are still not a significant enough voting block for Brownback to have any concern that they might swing an election to a Democrat. Indeed, in the 2012 election, extremely conservative Republicans supported by the Governor and lots of money from Wichita’s Koch brothers unseated most of the states just very conservative Republicans in primaries, giving him control of the state senate as well as house. Indeed, one of those defeated was the Senate majority leader, a rancher from the far southwestern corner of the state where the Latino vote did not prevent him from being beaten by a Koch-funded political newcomer.

Of course, there are reasons to doubt the core economics of Governor Brownback’s policies, based on the state’s economy picking up as a result of his tax cuts; even if one believes that will happen, it will be a long time and those whose benefits have been cut (who, given that the vast majority of the state budget is spent on education, followed by Medicaid and other core social services for the aged and disabled, will be the most vulnerable and our future) will suffer. As for the benefit of no state income tax, I lived in Texas, and the result is that every other tax is burdensome, and those taxes are much more unfair than a graduated income tax: real estate taxes that hurt the elderly and sales taxes that hurt those for whom the costs of the necessities of life are most of their income.

Expanding Medicaid, as called for by ACA, will not solve the problems of uninsurance. There remain not only the undocumented, but those who are employed by businesses that do not provide health insurance, including many that are too small to be required to do so even under the new law (and these are the jobs that Brownback’s policies, if they are successful, are most likely to create). But it will certainly help many families. And that should be the role of government, to help its people survive, and become educated, and be able to maintain their health. Economic growth will likely follow, at least much more likely than by cutting the taxes on the most wealthy.

And of course, at the most basic level, economic growth is not the goal; it is at best a strategy for improving the lives of our people. An article in Kansas City Star on January 20, 2013 ( “As the number of minority students grows in area schools, a learning gap remains” addresses the growth of minority, African-American and Latino, students in suburban as well as inner-city school districts. The article notes that the way school taxes are tied to real estate, “The rich get richer.” But it also quotes an educational leader who notes that “The moral imperative is now an economic imperative….The purchasing power of the new generation will depend heavily on the achievement of students of color. Social Security will need their economic success.

‘Everyone needs to understand…Someone else’s child is directly linked to your economic security.’” That is all true, but, at bottom, the core reason to provide education and health care is not so people will be able buy more stuff.

Recently, I saw the movie Les Misérables. I may be one of the few who did not see the stage play, but I am familiar with the story and loved the Jean-Paul Belmondo version set in WW II. Yes, it was long and not every actor was a great singer, but it told the story, and the story is of the oppression of the poor by those with power, and the occasional brave resistance of people who speak truth to power. And, in the last scene, after Jean Valjean dies, he is transported to a heaven not of clouds and harps and angels with wings, but one in which he and all of those who fought with him are standing on a barricade, continuing the fight.

Yes, the rich and powerful will buy and will influence politicians, and they will often win. But as health workers, and as citizens, it is our job to keep on advocating for the core needs of people, especially education and health care, to be met, not as a byproduct of economic development but as a human right.