Moving to Recovery By Design

The following is a guest post by Robert Bowman, MD, of the A.T. Still College of Osteopathic Medicine in Mesa, Arizona. He welcomes your comments and feedback.

Josh Freeman recently linked to the Charles Blow column in the NY Times, “These Children are our future” (June 14, 2013)  about the past, present, and likely future of the HS Graduating class of 2013 - and those missing from any high school graduation. We were both up into  the wee hours as I also reacted to this with the following:

A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: "Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it."

"Upstreamers", then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.

Upstream thinking is broken in our nation. Nations with effective social systems have people serving on the front line for health and other social services, who stabilize and support the people of the nation, anticipate their needs, and translate these to national leaders. The role of national leaders is to listen to the people and their translators while acting in the best interest of the nation to make the entire nation more efficient and more effective. When the stabilizing front-liners can no longer support the leadership of a nation, chaos reigns – as we should understand from numerous current examples.

Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing  makes it difficult to understand the daily lives of most Americans.

Falling Behind By Design

We are clearly falling behind as a nation. A greater proportion of or nation is falling behind in ways that make recovery more difficult. How we progress as a nation (or not) is about whether we can wake ourselves up to recognize the things that are required. Nations do not recover by economic development, defense, too much spending, or too little spending. Nations recover by investing in the earliest years of life. With progress made year to year or generation to generation, we can recover.

Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.

Our education focus is downstream and works for those who do well without any intervention. Designs for school funding and standardized testing and high school and college focus do not work for most children left behind -- almost a tautology. Investments focused downstream insure that school districts in communities with high property values have good outcomes, those with middle property value less, and that even the high performing children from lower property value school districts do less well than those in the bottom portions of the higher property value school districts. Advantages for the advantaged also may retard the needed development of the advantaged children, because they are never challenged by the majority of the population who, if offered the same advantages and opportunity, might spur real competition that pushes all of them further ahead. The result is the lack of social class mobility that worsens in our nation.

How Do Declining Opportunities for Most Americans Shape Lack of Health Access?

Resolution of health access has two multiplier factors – origin shared with the population in need of health access and family medicine choice. Frankly, as Rabinowitz[1] has demonstrated, the effect of origin to help distribute physicians is negated when rural origin candidates do not choose family medicine. This is because their practice location is dictated by their specialty rather than their origin. FM choice facilitates the influence of origin. Social determinants can greatly limit access to medical school, but FM choice is 2 to 5 times as potent a marker for rural choice than medical school training and origins. Only FM physicians, and family NP and Pas, have population-based distribution – the opposite of all other specialties which are more concentrated where health care workforce is concentrated already.

Access to health care is mostly limited by lack of front line health access family medicine. We have insufficient MD, DO, NP, and PA family practice positions supported, offered, and filled.  This is the failed health policy determinant. It fails even more when “flexible” potential sources of family providers can easily choose other specialties; this is seen in NP and PA training programs, which are adding both more specialties and more trainees in each specialty, as well as internal medicine training for physicians.

What I have learned in two decades about family physician origins confirms social determinants and social situations that shape the proportion of providers in family medicine. The same social determinants shape medical school admission and performance as a medical student. After all, those who take -- and in particular do well on -- the tests are more likely to be highest income, most urban, and children of professionals. The standard population for scoring for tests such as MCAT and board exams are the subjects that take the test. Those students whose language, culture, parents, or other origin factors are different will have different scores. Normal origins are associated with different scores because they are normal. Exclusive origin students have exclusive scores. Scores shape opportunity, type of medical school, and even subspecialty. A normal distribution of career choice types is different because it is normal. Normal origins, normal types of medical schools, normal distributions of health spending, and normal career choices such as FM are the recovery vehicles for health access. This is not what our national design dictates. Origins, training, health spending, and career choices favor the concentrated or exclusive.

FM docs arise at 1 per 100,000 people across various types of counties or types of populations. In the populations associated with lower income and other social determinants that have lesser opportunity, about 4 per 100,000 are admitted to medical school per class year (1970 county pop, AMA Masterfile with 90% birth origins). This is 25% family medicine result. In the populations of advantage, about 14 - 20 per 100,000 per class year are admitted. These are areas around DC or NYC or other major metro areas with the highest income, most urban locations with top concentrations of professionals.  When you map concentrations of physician origins it is the same as where physicists, engineers, research and development, colleges, and other concentrations of professionals are found. In these areas most associated with concentrations or combinations of concentrations of high-income professionals, about 14–20 per 100,000 become a physician – about 2 to 3 times higher than average. However, for these populations associated with such concentrations, there is still only 1 per 100,000 found in family medicine per class year. Only 1 in 14 to 1 in 20 enter family medicine (about 5 – 7%). Moreoer, this was data from 20 years ago, at the peak of FM choice. FM choice in all types of origins has declined since this time.

Access is more than FM docs. When I look at rural docs or docs for underserved locations and map them to their birth county, the same 1 per 100,000 applies. Higher proportions of FM doctors arise from locations associated with lower concentrations of people. When there are higher concentrations, the proportions of rural or underserved docs decline. Meanwhile the most subspecialized docs most dense areas (metropolitan) with higher and higher concentrations from origins associated with higher concentrations. A doctor with a sub-specialty such as gastroenterology is 6-8 times more likely to come from a county in the top tier of population concentration as compared to those with lowest quartile income or population density.

Only FM has equitable population based origins and the same 1 per 100,000 per class year distribution, or about 30 FM docs per 100,000, for the current past 30 years of FM graduates. FM will actually decline slightly with population growth as FM is locked at 90,000 due to just 3000 annual graduates dating since 1980.

 

Declining Middle Class and FM

Populations vary in higher education and medical school admission. In the lower income segments, few arise for admission at all. Carnevale[2]and the Century Foundation have demonstrated that only 3% from the bottom quartile were found in the top 146 colleges – the same ones that feed the same types of students to medical schools. About 74% arose from the top income quartile. In the US middle income populations are disappearing, groups that used to be able to access higher education and they also had reasonable FM probability and distribution probability. The highest income segments are lowest FM probability. For example, at the University of Nebraska Medical School, those whose hometown is Omaha and Lincoln and other metro areas have 2% family medicine while those from the rest of the state have 15 - 30% FM choice (4 years of data). Out of state and foreign born components have been increasing and are typically highest income, most urban, children of professionals.

Asian Indian choice of FM was 2% for the 1990s - the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 - 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.

It is not about artificial markers of race or ethnicity - it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr[3] demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.

Recovering Health Care Cost, Quality, and Access

The states doing best in health care quality consistently have the best child well being, the best markers of middle class, and the least divisions between rich and poor. Health care quality, access, and to some degree costs are related to child well being as expressed birth to admission in a student or as expressed birth until health care encounter in a patient. Downstream focus, and ever more dollars invested at the high school or college downstream level will not help. Research that attempts to claim better quality without changing Upstream tends to represent distractions from real improvements.

We have models such as Southcentral Foundation in Alaska and Grand Junction that illustrate what can be done - and these are just a start. These are models that recovered from poor designs to optimal designs. As a nation we can also recover from poor designs, by designing well from the earliest months and years of life. Who would deprive a 2 year old or a 3 year old of an opportunity to rise above?

We cannot do better as a nation with so many left behind from the earliest ages by design.

Health professionals such as family physicians can do Upstream work at the community level.

We need similar professionals working entire careers like we do to improve child development.

We need primary care and public health nurses that were trained specifically for primary care and public health - and who remain in such careers.

How we invest in our children and work locally in teams will determine our future.

---

[1] Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.

[2] Anthony P. Carnevale and Stephen J. Rose, “Socio-economic Status, Race/Ethnicity, and Selective College

Admissions,” in Richard D. Kahlenberg, ed.,America’s Untapped Resource: Low-Income Students in Higher

Education. (New York: Century Foundation Press, 2004),

[3] Barr DA, Gonzalez ME, Wanat SF, “The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students,” Acad Med. 2008 May;83(5):503-11. doi: 10.1097/ACM.0b013e31816bda16.

"Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

The main argument against not cutting (not to mention expanding) social services, including health care, for the most needy, is that we “cannot afford it”. This is the argument of the governors and legislatures in states that have refused to expand Medicaid, despite clear and convincing evidence that it will cost states much more to not do so (see Medicaid expansion will leave out many of the poorest: What is wrong with this picture?, May 26, 2013). This is portrayed in a very funny – except it’s really not -- “Daily Show” segment, cited by Dr. Allen Perkins in his blog, “Training Family Doctors”, Medicaid Expansion by the Numbers. Not being able to “afford” it is the mantra not only in the US, but also across Europe as those austerity hawks have been cutting off their people’s noses – and their election chances – in thrall to a false god.

So it was very interesting for me to watch the first episode of the British (BBC One) television series (now in its second season) “Call the Midwife”. Set in a poverty-stricken area of East London in 1957, midwives pedal their bicycles around the crowds of people and rubble that still covers the streets more than a decade after the end of World War II to attend to

pregnant women in their homes, delivering prenatal care and babies and even caring for the babies afterward. It is a not a beautiful scenario; the young midwife, Jenny Lee (based on the real life midwife Jennifer Worth, whose memoirs form the basis for the series and who died in 2011) has never seen such poverty, such crowding, such filth, so many children. It is the height of the “baby boom”, attributed initially to returning GIs who had to wait to start their families, but continuing with no end in sight; the women portrayed are having their fourth or fifth baby in their early 20s and many far more. In fact, of course, the end of this “boom” was not the aging out of the reproductive population but the introduction of effective and widely available contraception (especially birth control pills) in the 1960s.

The midwives, all nurses and many Anglican nuns, set up clinics in a gym in the interval between the pensioners’ breakfast and the evening dance classes, as well as attending women at home. They practice an obstetrics that is quaintly anachronistic, both in its tools (the wooden “fetoscope” to amplify the fetus’ heart sounds, and the glass rectal tube), and in practice (shaving the pubic area and administering enemas – “high, hot, and a helluva lot!”) but they provide much safer pregnancies and deliveries than had ever been available to this population in the past. At one point, a woman in her 23^rd (!!) pregnancy (already with 24 children, because of two sets of twins) goes into premature labor and the midwife is there to deliver what seems to be a stillbirth and begin care for the hemorrhaging mother while awaiting the arrival of the “obstetrics flying squad” with its ambulance, obstetrician, and pediatrician to continue to care, including blood transfusion in the home. When, miraculously, the baby comes to life, the mother refuses to send it to the hospital, feeding it milk with a dropper. The senior midwife tells Jenny that “we don’t ever care for these babies anymore; in the old days they died; now they go to the hospital.” When asked what they will do, she tells her they will visit three times a day until the baby is stable, and then at least once a day thereafter. In the home.

It is a dramatic and engaging story, but what fascinates me is that these services were available to these poor women. Home visits for prenatal care and delivery. Visits from nurses three times a day. An obstetrics “flying squad” to come to the homes of women who would otherwise die in childbirth. Where did the money for these services come from? Who paid these midwives, and these flying squad doctors? Well, the National Health Service (NHS). The NHS, established after the war, in 1948, to provide health care to all people in the UK. Not established at a time of prosperity, when we could “afford” it, but right after World War II, with both the nation’s economy and its literal infrastructure in shambles, with the piles of rubble still on the streets of London in 1957, 15 years after the Blitz. The National Health Service was not founded as a gesture of magnanimity from the wealthy, but as but as an explicit and well-thought out policy to provide one of the most basic of needs, health care, to all of the British people even though there was not much money; it was seen as a priority. In the second episode of "Call the Midwife", a woman who has lost 4 babies because of a pelvis contracted from rickets (vitamin D deficiency in childhood) is delivered of a healthy baby by Caesarean section. Rickets itself, the senior midwife says, is a disease of poverty and malnutrition eliminated by the NHS.

From the time I went to college and met upper-middle-class people, through my career as a doctor when I know lots of them, I have heard “horror stories” about the NHS, about the waits for things “we” never have to wait for, like elective surgeries. “My cousin says”, or “the people we had visiting from England told us”. But it was always apparent to me that this was a skewed group; the folks visiting from Britain on holiday were not the poor, were not the Welsh coalminers who had never had health care before. It is hard, I guess, when you have always been at the front of the queue, when the queue has always been so short for you that you didn’t even know there was one, to have to take your place in it; to wait in line with the hoi polloi. But ask those who never had had care, ask the poor, ask the women having babies in the Docklands.

My point here is not to romanticize poverty, or to suggest that things have always been perfect with the British NHS. It is, rather, to say that the provision of basic health care to all people is not and never has been a question of economics, it has always been a question of will. We can afford do it; indeed we cannot afford not to. Not only is it a “good investment”, it is essential humanity. Paul Krugman calls the group of health care expansion opponents “The Spite Club”, (June 7, 2013), arguing convincingly that their opposition is ideological, not fiscal. It is doubly sad to see this ideology acting in Europe, cutting the social safety net that has been in place there for decades.

When you think about what we can “afford” in health care, think about midwives making home visits to premature infants three times a day in the poorest areas of London in 1957. The expansion of Medicaid under the Affordable Care Act (Obamacare) may not be the best vehicle to bring care to the poorest (I still argue for a single-payer, Medicare-for-all, system), but opposing it is not fiscally responsible; it is both fiscally and morally reprehensible.

Helping primary care help the health of all of us

I recently described how primary care can improve the health of our population – proven by dozens of studies – as well as save significant money.  Recently, the distinguished family physician George Rust, MD, co-director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, made many of the same points in his testimony in front of the Senate HELP Committee’s Subcommittee on Primary Health and Aging (Dr. Rust is pictured here with Subcommittee Chair Sen. Bernie Sanders, I-VT). Rust specifically asked for significantly increased funding for Title VII and Title VIII, the sections of the Public Health Service law that provide grant funding for, respectively, primary care medicine and nursing programs, saying that they would represent "solid investments in the primary care workforce."

Rust also called for separating the funding for residency training provided by Medicare for primary care from hospital training of subspecialists, arguing that the current system has resulted in  "absurd proportions of subspecialists and hospitalists." I have often argued this (for example in GME funding must be targeted to Primary Care, December 10, 2011), noting that hospitals have an interest in training specialists and subspecialists who do things (usually procedures, given our current reimbursement system) that make money for hospitals, and much less for training the primary care doctors that are needed in the community. The problem is that, because academic medical centers provide a great deal of tertiary (and quarternary) care, the mix of primary care and subspecialist and super-subspecialists may be appropriate there, but not for the overall community. However, since these are the places where new physicians are minted and trained, providing the right mix for the community, for the rest of the state and country, means having a very different mix of specialists in training from those working there. This is hard; it is a very common reaction to want to replicate yourself, to want the “best” students to enter training in your specialty, so for an academic medical center which looks like the upside-down pyramid to train doctors in proportion to the right-side-up pyramid is a major challenge! Rust then suggests moving primary care training “back to its community roots”, and says "Instead, let's create direct, sustainable funding for community-based outpatient residency programs that train doctors to keep people out of the hospital”.

As strong as Dr. Rust’s arguments are, primary care will still have problems. One of the comments on the posting at the “AAFP News Brief” that covered this testimony  said “I must be missing something. Can anyone explain how creating more residency slots will increase med student interest in family medicine?” I believe that this is an excellent point – if we cannot fill the slots that exist today for family medicine, particularly with excellent medical students, how will increasing the number of slots improve things? One of the answers, certainly involves reimbursement, dramatically decreasing the difference between what primary care doctors earn and what more highly-paid subspecialists earn; work by the Altarum Institute cited by Jerry Kruse, MD MSPH in his article “Income Ratio and Medical Student Specialty Choice: The Primary Importance of the Ratio of Mean Primary Care Physician Income to Mean Consulting Specialist Income”, suggest that the ratio should be about 80%.

However, there are other factors at work. Sometimes they are referred to as “lifestyle” (perhaps defined as hours of work needed to generate a certain income, or what I have called the income/work hours ratio) but they are more profound than that. In the May/June issue of the Annals of Family Medicine, Christine Sinsky and her colleagues refer to it as “the joy of practice”. “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices” [1] identifies the “deep dissatisfaction” experienced by primary care physicians who care for adults (general internists and family physicians) demonstrated by the many reports of high “burnout” rates. The authors relate this to the extraordinary amount of time that physicians spend doing paperwork and administrative functions, and the pressure by employers to generate high numbers of visits; doctors experience this as alienating and not the reason that they became physicians.

“We propose joy in practice as a deliberately provocative concept to describe what we believe is missing in the physician experience of primary care. The concept of physician satisfaction suggests innovations that are limited to tweaking compensation or panel size. If, however, as the literature suggests, physicians seek out the arduous field of medicine, and primary care in particular, as a calling because of their desire to create healing relationships with patients, then interventions must go far deeper. Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. Joy in practice includes a high level of physician work life satisfaction, a low level of burnout, and a feeling that medical practice is fulfilling.”

The authors go on to list a number of common problems, and solutions that have been found by one or more of the 23 practices that they visited and analyzed in detail. They included:

·       Reducing work through pre-visit planning and pre-appointment laboratory tests;

·        Adding capacity by sharing the care among the team;

·         Eliminating time-consuming documentation through in-visit scribing and assistant order entry;

·         Saving time by re-engineering prescription renewal work out of the practice;

·         Reducing unnecessary physician work through in-box management;

·         Improving team communication through co-location, huddles and team meetings;

·         Improving team functioning through systems planning and workflow mapping.

These are all good ideas, and the solutions are sometimes creative, sometimes painfully obvious, and sometimes obstructed by our bizarre health system. One of my favorites, the second, is an example of the latter:

“We observed that team development must often overcome an anti–team culture. Institutional policies (only the doctor can perform order entry), regulatory constraints (only the physician can sign paperwork for hearing aid batteries, meals delivery, or durable medical equipment), technology limitations (electronic health record work flows are designed around physician data entry), and payment policies that only reimburse physician activity constrain teams in their efforts to share the care. An extended care team of a social worker, nutritionist, and pharmacist may be affordable only in practices with external funding or global budgeting.”

Thus is illustrated the tie-in between innovations that can make practice again joyful and the payment reform and re-working of our entire non-system which we desperately need! There is a long way to go; as the authors point out, no single practice has solved every problem. But the linkage is clear – a medical care system designed to reward expensive interventions for a relatively small number of people has created an inappropriate mixture of physicians as well as an incentive for hospitals to focus mainly on such procedures, as it has increased the burden on, and in many cases taken the joy out of, being a primary care physician. It is important to remember that it is not just about the doctors (I try to remind my students and residents, precious as each of them are to themselves and their families and often to me, that ultimately it is not about them). The authors put it this way:

“The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.”

Both the macro-structural changes in the structure of the system as identified by Dr. Rust and the more micro-level changes in the practices of primary care clinicians identified by Dr. Sinsky and colleagues need to occur to make us have a sustainable, healthful, system of health care. And they need to happen soon.

---

[1] Sinsky, C, et al.,, “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices”, Ann Fam Med May/June 2013 vol. 11 no. 3 272-278, doi: 10.1370/afm.1531  

Primary Care Contributes More than Money....

I have often written about why the US needs a comprehensive national health system to cover all of its people, and my preference for a single-payer system similar to that in place in Canada. I believe that this is necessary for our country to address its poor health statistics. You can’t have lots of people without financial access to health care and have a healthy country.  When financial obstacles exist, we have artificial and unnecessary suffering, pain, and death.

But having financial access to care is, although necessary, not sufficient. We need other changes in our health care system. For starters, we more primary care doctors and other providers, for another we need systems that encourage and reward quality of care, and we need to have everyone receive care that is need, no one receive care that is not needed, and have health, not profit, drive the system.

Unfortunately, this is not what we have. While a sensible health care system, such as that in most countries with better health outcomes than our own, is built on a broad base of primary care, with a much smaller number of subspecialists, and even less hospital (and even less tertiary care). Our system, or non-system as I have called it, is skewed toward high-technology, high intervention care, aimed at the top of the pyramid. Most of the resources are allocated there, and balanced on a relatively small number of primary care providers. As should be obvious, inverted pyramids are inherently unstable.

One reason for this inversion is the demand of people in the US, particularly those with good health insurance or lots of money, for more and more expensive, high-tech care. This follows from the general assumption that “if some is good, more is better”, and “if it costs more it must be better, and if it is better it is what I want” that pervades much of our culture. Unfortunately, those old saws are not true when it comes to health care. Frequently, less is better, and more is worse. This has increasingly been demonstrated with a number of ostensibly-preventive interventions that have been showed to both increase morbidity (because of false-positive tests that lead to dangerous but unnecessary intervention) and cost. These include PSA testing for prostate cancer (even the American Urological Association has come on board by not recommending this test for most men – AUA guidance cited in AAFP Smart Brief May 15, 2013; it should actually be for no men), mammography for breast cancer screening, and the never-had-any-justification-as-a-screening-test-in-asymptomatic-women pelvic exam (the part where the provider puts hands inside, as distinct from the Pap smear screening test for cancer of the cervix, Questioning the pelvic exam, by Jane Brody, New York Times, April 29, 2013).

Farther down the spectrum of health care interventions are the incredibly costly things we do to people at the end of their lives. Heroic things done that ultimately don’t make any positive difference, and often end up extending a poor quality of life, or have someone end their lives enduring continuous interventions, needle sticks, and harassment. Why do we do this? Maybe because we want it? Some of us do. A colleague relocated from Kansas to DC says that people in the East don’t seem to accept  that people die; she feels it is less of an issue in the Midwest, where farmers are used to animals dying, but I don’t know. I see it here. And, indeed, it is an extension of the observation by Marion Stone, the fictional hero of Abraham Verghese’s “Cutting for Stone”, that, in comparison to Ethiopia where he grew up and went to medical school, Americans seem to think of death as optional. But, of course, it is not.  Many Americans have come to realize that, and have advance directives limiting what is done to them. But some, or their families, keep bringing people whose bodies are trying to die, into the hospital where our interventional technology saves them – for the moment. Until the next admission, a month or a week or a day later. “We have created,” says an intensivist colleague, “a group of people who can only live in the ICU.”

But there is more. And that is that such high-tech, high-intervention, high-cost medicine makes money, for the doctors who do it and the hospitals that it takes place in. And, of course for the manufacturers of the devices that are used. This is why, in large part, we have a primary care/subspecialist imbalance, why the pyramid of health care is balanced on that knife-edge. If cardiac care makes the institution money, if cancer care or neurosurgery or orthopedics does, this is what those institutions want. These are the specialists that they will subsidize to be on their hospital staffs. These are the specialties in which teaching hospitals will voluntarily support residents and fellows, even if that creates an inappropriate mix of specialists for the community at large. I have often said that in medicine, unlike classical economics, supply drives demand as opposed to vice versa. But I have also said that, as insurers move to prospective payment, the former money-maker product lines become cost centers, and that primary care providers who can care for things themselves without lots of referrals will become profit centers.

There is already evidence that this financial situation is shifting. Health Leaders Media reports in a story by John Commins on May 20, 2013 that “A survey of hospital CFOs shows primary care physicians generated a combined average of $1,566,165 for their affiliated hospitals in the last year. Other specialties generated a combined annual average of $1,424,917, the lowest average in five years, data shows. Primary care physicians have emerged as key money makers for their affiliated hospitals and for the first time are generating more revenues on average than their specialist colleagues, a survey data from Merritt Hawkins (PDF) shows.” This has to be good for primary care doctors, and has to get the attention of both hospital administrators and subspecialists.

However, it may not necessarily be good for people’s health. I say this cautiously, because, as I think I have made clear above, I do not think that it is better to have more subspecialists doing more interventional procedures which do not improve the quality of life. But simply showing that primary care doctors generate more revenue for hospitals does not mean that things are that different; it may only mean that primary care doctors are referring more patients into hospitals for procedures. This is, in itself, not the goal.

There is a goal. The goal is improved health for the American (and all) people. The goal is everyone getting the care that they need that will benefit them, and no one getting care that will not benefit or might even harm them. The goal is the medical ethics principle of justice: that everyone has the same options for diagnosis and treatment open to them, based upon their disease and condition, and not their wealth. The goal is a society that provides the necessary basis for good health – food, housing, education.

We can achieve that goal. We have the resources. We just need the will.

Medicaid expansion will leave out many of the poorest: What is wrong with this picture?

In States’ Policies on Health Care Exclude Some of the Poorest, in the New York Times on May 25, 2013, Robert Pear describes how this bizarre situation has come to pass. Basically, it is because the programs established by the Affordable Care Act (ACA) of insurance exchanges and federal subsidies for low-income people, via tax credits, was never the ACA’s plan for the lowest-income Americans. They were supposed to be covered by expansion of the Medicaid program, a federal-state partnership that covers some poor people and varies widely, both in terms of who is covered and what that coverage consists of, from state to state. Recognizing that, coming out of the “Great Recession”, many states were strapped for money, the ACA also included a provision that the first 3 years of the expansion would be paid entirely by the federal government, and that the feds would pay 90% of the cost thereafter.

This, however, was not sufficient inducement for many states to agree to expand Medicaid. They might have if the Supreme Court decision that found the ACA constitutional had not excluded one provision – that, unless the states’ expanded Medicaid they would lose all their current Medicaid funding. The result was the decision in many states to not participate in Medicaid expansion, thus effectively leaving out the mechanism for covering the poorest; tax credits were designed to provide subsidies for those who earned from the poverty level to 4 times the poverty level ($11,490 to $45,960 for a single person) with Medicaid expansion covering those below it. However, many states (virtually all Republican-controlled, although not all those that are Republican controlled) have opted out of this program, leaving those below the poverty level uncovered. The head of the Louisiana Primary Care Association notes that “If the breadwinner in a family of four works full time at a job that pays $14 an hour and the family has no other income, he or she will be eligible for insurance subsidies. But if they make $10 an hour, they will not be eligible for anything.”

 While these states may not have more than half the country’s total population, they do, according to the Times, have more than half the uninsured (they include Texas, the nation’s second most populous state, which has an uninsured rate of about 30%, and Florida, the fourth most-populous, whose legislature has decided not to expand Medicaid despite the support of Republican governor Rick Scott for expansion).  “The Congressional Budget Office estimates that 25 million people will gain insurance under the new health care law. Researchers at the Urban Institute estimate that 5.7 million uninsured adults with incomes below the poverty level could also gain coverage except that they live in states that are not expanding Medicaid.”

The state “featured” in Pear’s article is my home state of Kansas, possibly because of the willingness of the state’s insurance commissioner, Sandy Praeger (pictured here with Secretary of Health and Human Services Kathleen Sebelius, who, the Times does not indicate, was formerly Governor of Kansas, and, before that, Praeger’s predecessor as insurance commissioner), to discuss the situation. Kansas, historically not one of the more generous states for Medicaid, “…provides no coverage for able-bodied childless adults. And adults with dependent children are generally ineligible if their income exceeds 32 percent of the poverty level.” Thus, Ms. Praeger said, “In most cases, she said, adults with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) ‘will have no assistance.’ They will see advertisements promoting new insurance options, but in most cases will not learn that they are ineligible until they apply.” Whoops. Gotta fix that.

Or not. There is no plan, in Kansas, Texas, Florida, or any of the other states not opting for Medicaid expansion to help to cover these people. Most of the arguments you will hear against doing so cite “costs too much money”, but this is, simply, baloney. The governors and legislatures currently running these states do not, actually, believe in covering anyone (except, of course, themselves and their friends). They believe this is “socialism”. What they believe in is cutting taxes, particularly on the wealthiest individuals and corporations, which Kansas has  aggressively done since Governor Brownback was elected in 2010. The ostensible argument, from the governor, is that low taxes will lead to greater business growth, which will benefit the economy, and help to balance the budget. The first is your basic “trickle down”, proved wrong in every instance since it was first made popular in the 1980s, and the second is a negative tautology – even if business does grow, the extremely low tax rates will make balancing the budget very hard. Indeed, this year Governor Brownback is stumping the state to drum up support for not cutting the higher education budget, but this seems to be falling on deaf ears in the legislature, which sees such spending cuts as yet another opportunity to cut taxes.

Praeger, as insurance commissioner, does not make the decision about Medicaid expansion, but her office is responsible for informing the public about its opportunities to gain insurance on the exchanges (that will be federally-run, because Kansas has also opted out of running its own) and also informing those “poorest of the poor” that the ads for coverage will not be for them. It is obvious that she feels very badly about it; this former state senator and mayor of Lawrence, and former chair of the National Association of Insurance Commissioners (NAIC) is a person with a heart and a concern for people (yes, Virginia, there are Republicans with a heart, and Kansas used to be full of them!). The insurance commissioner does make some decisions; Sebelius, in 2002, blocked the sale of Blue Cross/Blue Shield of Kansas to the for-profit Anthem, stating it would not be in the best interest of the people of Kansas. Many credit that very popular decision for helping her to win the governorship later that year (yes, Virginia, we sometimes elected Democrats as governor!).

It is way too early to know how these decisions will affect elections at either the state or national level. The Times article indicates that “Administration officials said they worried that frustrated consumers might blame President Obama rather than Republicans like Gov. Rick Perry of Texas and Gov. Bobby Jindal of Louisiana [and one might add Kansas], who have resisted the expansion of Medicaid.” However, and very unfortunately, the poorest of the poor do not vote in high numbers. Perhaps the opposite will happen, with those slightly more well-off, who vote at slightly higher rates, crediting the Obama administration for their new coverage, and blaming the state governors and legislatures.

And, of course, this does not even take into account undocumented people living in the US, many of them the breadwinners for families that are composed of citizens, “legal” and “illegal” members.  Children who were born here are citizens (and eligible for programs such as Medicaid and the State Children’s Health Insurance Program, S-CHIP) while often their parents are eligible for nothing. This is not the way to improve health, or to foster family values. But it is consistent with another, anti-immigrant, agenda.

Other first-world countries cover everyone. Not some, many or most people. Everyone. They do it in different ways: Britain has a National Health Service, Canada a single-payer health system which is the government, Switzerland a multi-payer (private) system with a required benefits package and pricing structure. Other countries, Japan and Taiwan, France and Germany, do it differently, but they all cover everyone. We could too.

It’s sad for all of us that we won’t. And it’s life and death for the neediest.
___________________________________________
More data from American Medical News: Millions uninsured on patchwork Medicaid expansion map

Keeping immigrants and all of us healthy is a social task

The Health Toll of Immigration, by Sabrina Tavernise in the May 19 New York Times, documents the decreased life expectancy and worse overall health that accompany immigration to the United States. Focusing on Mexican immigrants in the border city of Brownsville, Texas, but drawing on data about other ethnicities and even time periods, the article provides convincing data that descendants of people who immigrate from Mexico and other, poorer, countries, have, in general, worse health, greater rates of obesity and diabetes, and shorter life expectancies than their parents or those who stayed. The numbers are impressive:  “A 2006 analysis by Gopal K. Singh, a researcher at the Department of Health and Human Services, and Robert A. Hiatt, a professor of epidemiology and biostatistics at the University of California, San Francisco, found that immigrants had at least a 20% lower overall cancer mortality rate than their American-born counterparts. Mortality rates from heart disease were about 16%  lower, for kidney disease 18%  lower, and for liver cirrhosis 24% lower.” It seems to get worse for later generations; “Elizabeth Arias, a demographer at the National Center for Health Statistics, has made exploratory estimates based on data from 2007 to 2009, which show that Hispanic immigrants live 2.9 years longer than American-born Hispanics.”

Some, perhaps most, of this is related to the prosperity of the US, and the easy availability of cheap, high fat, high sugar, high calorie food. One woman, who came to the US at 26 and has since developed diabetes, says she was amazed at seeing hamburgers as big as dinner plates; “I thought this really is a country of opportunity! Look at the size of the food!” Grueling work hours, both parents working (when both are here) make time for preparation of healthful food scarce, and more cash in their pockets allows the purchase of tasty-but-bad-for-you fast food. In addition, there is evidence of increased smoking and drinking as immigrants move into the US underclass, a group particularly targeted by marketing efforts for these substances of abuse.

Traditional diets for most people, including Mexicans, are based on food that is grown or found wild (vegetables, cactus) or bought in bulk (rice and beans). These are high fiber and low in empty calories. Robert Valdez, from the Department of Family and Community Medicine and Economics at the University of New Mexico, is quoted as saying “All the things we tell people to do from a clinical perspective today — a lot of fiber and less meat — were exactly the lifestyle habits that immigrants were normally keeping.” There is some evidence that there may be a genetic predisposition to diabetes in some Latinos, particularly Mexicans, as there is in American Indians; after all, Mexicans are largely a mestizo people with much Indian “blood”. Of course, these observations may be related; the natural diet of native peoples did not provide the environmental  factors (high calories, obesity) needed to trigger clinical diabetes, and so the genes for this did not “die out” as readily as in other groups. The same model is seen in South America; the remote Xingu Indians of the Amazon now have extremely high rates of diabetes where it never existed before the introduction of “white” food (used to refer to the color of the food as well as of the people who introduced it).

The other big factor is physical activity. While many immigrants work in physically demanding jobs, the prevalence of physical activity is not as great as for those living on farms in Mexico. One man talks about losing 75 pounds motivated by the image on the wall of his grandfather, who is 93 and still rides his bicycle every day. Yet, 4 of the 6 siblings of the grandson are obese and have diabetes. Another immigrant talks about walking in her early years in the US and feeling so conspicuous (“a bean in rice”) that she was afraid people would think she was here illegally. This has also been described in African-Americans moving from the agricultural (and very poor) South to a more prosperous, but sedentary, life in the North, and in most families a generation or two removed from farms, whatever their ethnicity. Concepts of what is “enough” food, what is a “good” breakfast or dinner for our children, did not change as quickly as lifestyles did. Our culture does not require physical activity as part of daily life the way farming, including subsistence farming, did, but we fed our children the same number of calories as we did (if we were prosperous farmers) or would have liked to, or more, because it is more easily available. Indeed, these changes are not limited to the US; things are changing for the worse (in terms of health) in Mexico as well; citing the fact that up to 40% of the rural diet in Mexico comes from packaged foods, “Researchers are beginning to wonder how long better numbers for the foreign-born will last.”

These are all factors in the “social determinants of health” – how we eat, how we exercise, how poverty grinds us down and how marketing of harmful substances like tobacco, alcohol, and high-sugar foods take their toll at even greater rates on the poor. This is not to romanticize rural poverty, of people, including children, having to do excessive physical labor in order to survive and thus burn up more calories than they consumed, or to minimize the difference between a rural/farming life which provided enough income to supply those calories and those in which malnutrition claimed lives and health. It is, rather, to point out that some of these terrible conditions ironically protected the health of its victims. This has been observed in the past; beri-beri occurred more in wealthy Chinese who ate hulled white rice than in the poor who ate the rice with hulls that contained the thiamine. In England in the early 20^th century alcoholic cirrhosis was a disease of the rich who could afford highly-taxed spirits, while workers drank watered beer. The image of the wealthy many as obese – and suffering from gout, "The disease of kings1" (all that high-protein food) persists in cartoons.

Dr. Arias, cited above, observes that the health status of immigrant families “…may indeed improve as they rise in socioeconomic status, which in the United States is strongly correlated with better health.” Of course, there is no guarantee that longer time in this country will cause a rise in socioeconomic status; the last decade shows a persistent decrease in the socioeconomic status of most Americans, despite a “recovery” measured by Wall St. stock prices. The answer is not to regress to rural poverty, but it is to address these social determinants. It is to build towns that encourage walking and other physical activity. It should be to make fresh, healthful food widely available. It should involve education in schools about healthful eating, not undercut by junk food available in machines. It should limit advertising for poisons such as tobacco and alcohol. It should make clean air and water a priority, and ensure everyone has access to good health care.

 It should be a no-brainer, but in the politics of the US today, it may not be. Charles Blow in his May 18, 2013 column “Resonance Resistant”, notes that “We all know that anything with ‘social’ in its name activates the conservative gag reflex.” This is crazy; we are social beings. We can do better, and we should.

Hospital charge variation and Medicare equipment fraud: two forms of gaming the "non-system"

There has been extensive coverage of the recently published report from the Center for Medicare and Medicaid Services (CMS) that revealed dramatic differences in the prices charged for medical services between hospitals, not only between regions but also within the same city. “Hospital Billing Varies Wildly, Government Data Shows”, in the NY Times May 8, 2013, reports that “A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945…In Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,00. …In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.” 

Bloomberg News notes that treatment of psychoses ‘showed the greatest price discrepancies, with the most expensive hospital charging $144,523, more than 52 times its cheapest peer,’ and the ‘most common procedure in the data, treatment of simple pneumonia and lung inflammation with complications, had prices ranging from $5,093 to as much as $124,051.’” The Kansas City Star reports, in “New data reveal puzzling differences in hospital charges”, that “… the hip replacement surgery that one hospital in Ada, Okla., charges at $5,304 cost $223,373 at a hospital in Monterey Park, Calif.,” and giving a local example, “In Kansas City, charges for that surgery range from $24,874 at Truman Medical Center Lakewood to $66,268 at the University of Kansas Hospital.”  Among the many other news sources covering this are Wall Street Journal (“Data shine light on hospital bills”), USA Today, AP,  Los Angeles Times, Washington Post, and others.  The LA Times article notes that the data call “into question medical billing practices just as U.S. officials try to rein in rising costs.”

But, of course, this information should come as no surprise; it confirms something not only well-known by hospitals and physicians for a very long time, but repeated reports by investigative journalists over the last several years. These have included  Atul Gawande’s article, “The Cost Conundrum” in The New Yorker June 1, 2009 (my blog coverage in Medicare Costs: "All Politics are Local", June 11, 2009) and Steven Brill’s February 2013 Time magazine piece “Bitter Pill: Why Medical Bills are Killing Us”, which I discussed in Squeezing the needy: a truly flawed financing system for healthcare, March 2, 2013. Hospitals’ “charge masters” list “list prices” for any number of procedures and equipment which, as noted above, vary wildly. Although Medicare performed the study, in fact Medicare does not pay those prices or anything close to them; it sets its own payment schedule for these procedures which does not vary much between hospitals. However, as Gawande makes clear in “The Cost Conundrum”, there is a second problem arising from the fact that some hospitals seem to do – and bill Medicare for – a far larger number of procedures than are done by other hospitals caring for similar populations.

So why do they have these charges and why do they vary so widely? They vary because different amounts of “fixed costs”, the expenses that hospitals have that are not for the individual patient (staff, building maintenance, equipment, etc.) are loaded into these charges, as are more or less profit. They are high because there are occasional payers (fewer all the time) who do link their payments to charges, such as Worker’s Compensation. While Reuters quotes HHS Secretary Kathleen Sebelius as saying "When consumers easily compare the prices of goods and services, (providers) have strong incentives to keep those prices low. But even basic information about health premiums and hospital charges has long been hidden from consumers. These rates can vary dramatically in ways that can't be easily explained," it is not clear that posting the prices, or having smaller differences, would be of much help to most people. 

Large health insurers, like CMS, do not pay the posted “charges”; although they pay more than Medicare or Medicaid, their payments to hospitals are usually tied to Medicare charges as a multiple (e.g., they might pay 2 times Medicare). Of course, the group that most clearly gets screwed are people with no insurance at all, who are in fact billed for the entire list charge. They are, also of course, very unlikely to be able to pay any significant portion of those charges (minus the rare sheik or hedge fund manager who might show up). Therefore, the difference between owing $24,874 to Truman Medical Center Lakewood or $66,268 to the University of Kansas Hospital for hip replacement surgery may be largely theoretical to them, but in the meantime, it can, and frequently does, absorb their life savings, ruin their credit, and throw them into bankruptcy. And there are “middle class” uninsured families who might be able to pay off $24,874 over a few years, but for whom $66,268 is more than they could pay in a lifetime. (Fortunately, most hospitals, including I know the University of Kansas Hospital, do develop payment plans for patients, which, if they make payments that are agreed on can preserve their credit.)

Meanwhile, in “Medicare anti-fraud effort has Missouri roots” (Kansas City Star May 7, 2013), Lindsey Wise, the paper’s Washington correspondent, describes how the concerns of a St. Louis physician that she was receiving requests from medical device sellers for approval of medical equipment that she hadn’t ordered, and that it turns out her patients hadn’t requested, led her senator, Claire McCaskill, to hold federal hearings. As noted by Sen. McCaskill, “Most Americans have seen ads on TV or received calls or letters promising medical equipment ‘at little or no cost to you,’”  but, as she adds, “there is always a cost to you, because it is paid for by federal tax dollars.”  Both Dr. Kennedy’s patients and others testifying before McCaskill’s committee said they often receive several calls per day from device retailers. Investigations of two companies that had faxed unsolicited requests to Dr. Kennedy discovered, respectively, a 68% and 92% “error rate”, a euphemism for what may well be fraud.

Why mention these two separate issues, Medicare fraud by medical device companies and huge charge disparities among hospitals for the same procedures, in the same blog post? While definitely different – the device sellers, at least those who are guilty of such practices (“Please don’t convict the entire industry,” says the executive director a trade association that represents medical equipment companies), are unscrupulous and perhaps committing fraud, while the hospitals are not – they share they key characteristic of seeking profit by “gaming” the system. Medicare pays for medically necessary equipment (including scooters, oxygen, diabetes monitors, etc.) for patients who need them, and some companies selling them do aggressive direct-to-consumer marketing (as do pharmaceutical companies), to try to increase their sales. Hospitals post exorbitant “prices” for their services that bear little relationship to the cost of providing them (as proven by the wide variation) in hopes that the occasional payer will pay them, or at least pay a percentage of them (unlike Medicare’s fixed reimbursement). What they have in common is the exploitation of a nonsensical non-system of health care in which profit is pursued by taking advantage of its intrinsic disorganization.

For medical supplies, while Sen. McCaskill’s committee discovered many cases where patients did not want the equipment physicians were asked to approve, there are many others cases in which the patient is convinced that it would be good to have, say, a scooter that they don’t have to pay for --  even when the doctor thinks it is not necessary or might even be harmful (for example, when a person who doesn’t exercise because of their weight gets a scooter and does even less activity and thus gains more weight). Fraud is fraud, should be investigated, and it appears that it is being done.

For hospital charges, however, the solution is different. It would be to have a national payment system that, possibly with regional differences based on the cost of labor and other variables, pays a fixed amount for services, as does Medicare – a single payer system. It probably needs fixes (Medicare may currently pay too little, requiring private insurers to subsidize that care; certainly the law should allow the uninsured to be billed at no more than Medicare would pay), but a little rationality would go a long way.

Medicaid Expansion: Do we care for people or not?

A cornerstone of the health coverage reforms in the 2010 Affordable Care Act (ACA) was the expansion of Medicaid to a large population currently ineligible for this benefit. This was intended to cover those who work but have low wage jobs that neither offer health insurance nor sufficient pay to buy health insurance on the private market. (This latter is, in itself, a a very large obstacle; most people in “high-wage” jobs – considered by the Department of Labor to be above about $45,000 a year -- would have great difficulty paying for private health insurance.) In most states, Medicaid covers two populations: children in very poor families and their mothers (in general, if there is a father in the home, the family is not eligible) and poor people in nursing homes (who may well not have been poor until they spent time in a nursing home). Although the first group is much larger, the latter costs much more money because the health care services that they require are so much greater.

The standards for income eligibility vary from state to state, but in many states, including Kansas and Missouri (the states on either side of the Kansas City metropolitan area) it is well below the poverty level. Childless adults, unless they qualify for physical or mental disability, are rarely eligible for Medicaid no matter how poor. Medicaid is a federal/state shared program; depending upon mean state income, the federal government pays 60-80% of the cost. In order to make expansion more acceptable to many states that are already financially strapped, ACA provides for the federal government to pay 100% of the cost of the expansion for the first 3 years, and 90% thereafter. But, nonetheless, this expansion is in jeopardy in many states, because, essentially, the governor, legislative leaders, or both, oppose having the government insure most people. The decision by the Supreme Court that upheld ACA struck down the plan to pull all Medicaid funding from states that did not opt for expansion, thus seriously weakening the leverage that the federal government has to encourage it.

“Paul Nelson works for $10 an hour at a Kansas City car shop, suffers from diabetes and can’t afford the medicine to deal with it,” write Steve Kraske and Jason Hancock in the Kansas City Star, April 27, 2013. In “Nixon’s pleas for Medicaid expansion go unheeded”, they describe how “The working father still earns too much to be eligible for Missouri’s Medicaid program. That’s why he was hoping — praying may be a better word — for an expansion of the program this year so that he could get health coverage.” Nelson is the kind of person who might benefit from Medicaid expansion, but is probably not going to get it because the Republican-controlled Missouri legislature is so opposed to expansion, despite the strong lobbying efforts of Democratic Governor Jay Nixon, who “…displayed more gusto for the cause than any issue since he became governor in 2009…”  is now regarded as “…dead, buried, gone.” Nixon had considered the federally-funded expansion a “no-brainer”, and the fact that “An early February poll by American Viewpoint, which usually surveys for Republicans, found that voters backed expansion by 56-35 percent once they heard ‘a balanced set of arguments for and against the proposal,’” has not swayed the legislature.

In Kansas, Republican governor Sam Brownback has been playing it close to the vest regarding this issue, but Kansas legislative leaders are very strongly opposed to expansion. Brownback engineered the elimination of any opposition to his very conservative policies by running opponents to “moderate” GOP senators (the House was already in the control of the far right) in the 2012 primaries. With major funding from the Koch brothers, abetted by the traditionally low and skewed-to-the-base turnout in primaries, almost all were victorious; even the President of the Senate, Steve Morris, a rancher from far southwestern Kansas, was defeated by a young and inexperienced, but well-financed, challenger. On one issue, funding for higher education, Brownback is currently staking himself out as a relative moderate, compared to legislative leaders, as he is opposing the cuts that they have proposed. If perhaps a bit suspect, since not only did he engineer their victories but his prior budgets have significantly cut higher education, it could potentially signal a willingness to do something similar with Medicaid.

Meanwhile, as the continuation headline for the Star article, “Obama’s switch hurt efforts here”, makes clear, the administration has added its own disincentive to that of the Supreme Court by backing off on cutting Disproportionate Share (DSH) payments to hospitals that take care of a high percentage of Medicaid and uninsured patients. This weakened the commitment of hospitals and their agents, the state hospital associations (and, even more the Chambers of Commerce, which never really support publicly-funded health insurance expansion in any form) to supporting Medicaid expansion. Most still do, though, because they have been counting on expansion of Medicaid to increase their revenue from patients (like, say, Paul Nelson) who were previously uninsured and make up for cuts in Medicare payments, which are already taking place.

But much more important than the financial interests of hospitals or doctors, much more important than the posturing of politicians, is the impact on actual people. Paul Nelson is one person, but there are hundreds of thousands of people in his position in Kansas and Missouri, and many millions in the US. Their numbers are increasing; in an article in the Washington Post about the “Governments may push workers out of employer health care and into health exchange”, cited by Don McCanne’s “Quote of the Day” for April 26, “The owner of Olive Garden and Red Lobster restaurants, for example, began experimenting last year with putting more workers on part-time status.” While the focus of the article is on insurance exchanges, the probability is that low-wage workers who are put on part-time status would be more likely to qualify for Medicaid expansion.

Opponents of Medicaid expansion, in Missouri, Kansas, and elsewhere, often sound concerns about the cost, despite the fact that the federal government will pick up almost all of it. On the finances, they are wrong. But of greater concern they are not really motivated by their flawed understanding of economics, they are motivated by a lack of concern for people who are not like them, and a commitment to policies which expand the wealth of the richest individuals and biggest corporations at the expense of regular people. As the “American Viewpoint” survey points out, it is not the belief of most people, who do care about the health needs of themselves, their friends and neighbors and relatives. And, maybe even, other people who they don’t know.

The ACA, even with Medicaid expansion, even with insurance exchanges, even without changes to DSH or Medicare, does not cover everyone. Glaringly missing are those who, although without papers, are here, working in our community, living by our sides, often paying in through taxes (sales for sure, and frequently income) and sometimes needing health care, as well as others who fall outside the complexities of health insurance coverage. What we really need is an expanded Medicare-for-all, “everyone in, nobody out”. This is the real rational plan. But ACA does cover children up to the age of 26, it will prevent insurance companies from denying coverage to those with pre-existing conditions, and if states proceed with Medicaid expansion, will cover a whole lot more people who desperately need it.

People like Paul Nelson. People like the folks across the street. Maybe people like you. Our people.