Progress Notes

JAMA recently published an article on the career plans of internal medicine residents. The investigators found that even graduates of primary care training programs are more likely to pursue a subspecialty than a general internist path. Some may argue this is proof that primary care is a dying field, but I disagree. 

I am fourth year medical student and I don't think I'm alone in believing that primary care is experiencing a revival. Personally, I am psyched for a career in primary care. I want to get to know my patients, so I understand their values and can make sure they get the right care, in the right setting, by the most appropriate practitioner. 

We folks interested in relational, preventive medicine have a way of finding each other. Over the past 3 years, there's been a tremendous change in the climate around primary care at my school. A group of us coordinated a Health, Human Rights and Advocacy elective that became a human rights and social justice track. These efforts have organized a community of MD candidates with a social mission who can now easily connect to mentorship and local service- or advocacy-learning projects. I've seen my specialty-driven medical school transformed from a place with a good amount of condescension towards primary care - we were marginalized, it was something you questioned - to a place where the conversation, even among radiologists and specialists is "Ah yes, you want to do primary care - the new big thing." Well, it's kind of been around for a while...

Right now, I'm on the interview trail. I view the primary care residency programs I visit as organized communities of general internists who simply want to support anyone interested in primary care. At interviews, program directors don't want to make you feel like you're pigeon-holed, and will mention graduates who've matched in subspecialty fellowships. Whatever; that's the leadership simply attempting to make everyone feel like they aren't closing doors. I'd like to think that everyone, including specialists, benefits from training in a program that promotes primary care values.

What the JAMA study suggests is that something happens in residency that puts out the fire of say, an MS4 psyched for a career in primary care. Burn out is a very real part of that. Burn out happens to the resident, working tough hours with medically and socially complicated populations. Burn out also happens as part of the hidden curriculum - in our exhausted state, we are even more vulnerable to absorbing the at times burnt out attitudes of our seniors. This is precisely what I and my peers have been trying to address in medical school. Burn out can be a trickle down, collective experience, and I've devoted myself to energizing faculty to energize us in return.

Sure, the role of the physician in delivering primary care is changing. Nurse practitioners have a lot more responsibility. I've been told to pursue a subspecialty fellowship simply to distinguish myself from NPs in the primary care environment. Even where we practice will change: my peers are generally interested in academic primary care or community health centers without much mention of private practice. There is no doubt primary care will look different by the time I finish residency. I just feel like, with all this uncertainty and reform, we look to our mentors, who have a great opportunity to promote any efforts at progressive change. 

A concern I have is that a lot of primary care types flock to California and Boston/Cambridge, since those seem to be meccas for primary care innovation. Students naturally want to train in that supportive environment. I know there's good work being done all over, but the energy seems to be dense and silo-ed in the north east and California. I only hope that my generation will see the spread of these progressive movements to other communities in need.

I know many classmates who are genuinely committed to and optimistic about primary care. These are students who used to struggle to find mentorship, support, or respect for the values that brought them to medicine in the first place. Now, there's a palpable difference, post-Affordable Care Act (also known as “ObamaCare”) and post-acceptance of delivery and payment reforms. The train has left the station! It's certainly been an exciting time to go to medical school.

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Have you ever had to wonder what happens if you lose health insurance?  Have you ever needed to seek care in an emergency department?  What options exist for those without work-based health benefits?  Can you imagine going to a hospital’s emergency department if you don’t have health insurance? 

Peter Nicks’ thought-provoking documentary “The Waiting Room” sets out to give us a glimpse of that public hospital world, all too familiar and worrisome to certain members of our society and completely foreign to others.  Highland Hospital in Oakland, California, is a safety-net institution with a bustling Level II Emergency/Trauma Center which serves a large and diverse population.  The filming took place over five months in 2010 and was edited to depict events of a “typical” day in the hospital’s emergency department/waiting room.  The real patients who share their experiences are underserved, un/under-insured, vulnerable, and sick.   Many of them are hard workers who are trying to make ends meet, trying to get in to any medical system that will take them, and trying to achieve health or, at the very least, manage their illness to allow a semi-functional life.  They come to the ER from many backgrounds and with needs ranging from true emergencies (gunshot wounds and severe blood infections) to not-trivial-but-not-urgent issues (loss of insurance, chronic pain, and medication refills for long-term disease).   In short, many of the stories were from people needing primary continuity care who had no other options and so they showed up at the hospital of last resort and were forced to wait their turn, often for hours.

With the passage of the Affordable Care Act and the events of the recent elections, we have reduced or removed considerable obstacles faced when obtaining health care.  But, as the film depicts, there are still barriers and they loom high.

Assuming you believe in societal safety nets, social justice, and serving the underserved, the Affordable Care Act is a good thing, but it creates a demand for primary care in a national context of a primary care supply deficit and fails to adequately address the urgent need to bolster the primary care infrastructure.  This means that people will still continue to occupy waiting rooms like the one at Highland.  Patients will be waiting.  And waiting.  And waiting.  There are simply not enough doctors to guarantee available appointments.

What will happen in 2014?   The fight for change isn’t over.  We desperately need to recruit and retain primary care doctors.  Despite the fact that the ACA is here to stay, how will the nation support providing primary care services for all?  Recent studies have shown that Medicaid expansion leads to reductions in mortality.  Yet, that also means that we have to now grow our country’s capacity to enhance existing primary care structures and lure many new physicians to enter (and more importantly, to stay) in primary care.  Otherwise, the waiting room will only become a bigger and slower place.  Several articles that touch on many reasons for the primary care crisis: disparaging attitudes in medical schools, financial burdens from high student loans and low primary care reimbursement, misallocation of resources, the overwhelming expectations in the face of ever-increasing medical knowledge, paperwork paperwork paperwork, and high rates of burnout among front-line clinicians.  Some people can say that doctors are lazy or greedy; others can argue that the burdens of primary care are too demanding as things currently stand.  Regardless of which side clamors the loudest, we need to find a way to have more primary care doctors who can build longitudinal relationships with their patients, not have brand-new patients every 15 minutes due to frequent changes in insurance coverage (and the converse for the patients as well: to not have brand-new physicians at every visit because their last one left due to early retirement or leaving the system).

What options exist for those without work-based health benefits?  The non-reassuring reality is that we are a pink slip away from finding out. 

As a supporter of healthcare reform, as an employee at a safety-net institution, and as a physician committed to global underserved health, this film touched me with its elegant portrayal of the common experiences shared by patients and clinicians at most public hospitals.  The patients are sick, and they are waiting for hours to receive care, and for the most part they are grateful because if the public hospital didn’t exist (and indeed many safety-net institutions are going bankrupt after decades of underfunding), these patients would have no options, not even a last resort. 

For more information, please refer to the following:

The Film and Emergency Room Overcrowding:

“The Waiting Room” Film Website (with links to upcoming film screenings)

Filmmaker Peter Nicks’ Opinion Article in The New York Times: “Waiting for Health Care”

Pauline Chen’s Doctor-Patient Column in The New York Times: “When Hospital Overcrowding Becomes Personal”

John Maa’s “The Waits That Matter”

Medicaid Expansion:

Jonathan Oberlander’s “The Future of Obamacare” in last week’s New England Journal

Benjamin Sommers’ “Mortality and Access to Care among Adults after State Medicaid Expansions”

Primary Care Shortage:

Doctors for America on how the Affordable Care Act is beginning to address primary care shortages

Thomas Bodenheimer and Kevin Grumbach’s Perspective Article in the New England Journal of Medicine: “A Lifeline for Primary Care”

Robert Steinbrook’s “Easing the Shortage in Adult Primary Care — Is It All about Money?”

Pauline Chen’s Doctor-Patient Column in The New York Times: “Primary Care’s Image Problem”

Tait Shanafelt’s recent article in the Archives of Internal Medicine “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population”

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Like passengers on a runaway train, we cannot tear our horrified eyes away from the approaching edge of the so-called “fiscal cliff,” drastic, across the board funding cuts that will occur in January unless Congress  accepts  some version of the Bowles Simpson commission recommendations of modest tax increases and rational reductions in spending.  Meanwhile, current  conversation resounds with calls to shovel in more coal to increase our speed. We are careening past alternate tracks laid by wiser congresses than the one that just adjourned. Changing the terms of our investment in health care in general-- and behavioral health care in particular-- could avoid the calamity and achieve the impossible dream: raising revenue without raising taxes and cutting costs without decimating essential services.

How is this possible? The 2008 Paul Wellstone and Peter Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) extended 1996 mental health parity legislation. The MHPAEA requires insurance companies that offer mental health benefits to cover addiction services as well, without unique constraints. The Patient Protection and Affordable Care Act (PPACA) of 2010 further strengthens this by requiring that insurers reimburse for mental health expenses at the same rate as other medical expenses. The economic analysis of implementing this act shows that health care is not, as current debate implies, merely an unsustainable drain on public coffers.

Addictions cost society, and the government, billions.   Investing in addiction treatment brings enormous savings.  According to the most recent SAMSHA analysis, every dollar spent on addiction treatment returns seven dollars in value. Three factors-- reduction in other health care costs, reducing the costs of crime,  and increasing productivity --more than offset the cost of care.

Simply put, the criminal justice system, now the de facto mental health and addictions treatment system, costs much more per person than the system it replaced, with far less favorable outcomes. Substance abusers tend to be younger than other chronically ill populations, with longer potential for productive life, if successfully treated.  Increasing productivity means increasing government revenue, without raising a single tax rate for anyone.  Returning the majority of substance users and mentally ill people to a system of care rather than punishment would reduce government expenditures in the criminal justice sector, at both the state and federal level.

Unfortunately, the potential savings of the MHPAEA and PPACA have yet to be realized. While waiting for DHHS to issue final regulations, insurers have actually reduced their support for residential drug treatment programs and many other behavioral health services. They continue to separate case management for psychiatric and addiction services from the standards applied to other services (“mental health carveouts”). Behavioral care case managers conceal the protocols by which they make decisions, making it impossible for providers to know which treatments are covered and undermining government enforcement.

In a data driven fashion, the current administration is moving towards creating final regulations that would force health insurance providers to support a broad range of addiction services. Wellstone and Domenici together laid the tracks to a safer and more just society. The upcoming months will tell us whether we will ignore the signals or switch to the track that leads not to a cliff, but to a society where the government can invest in people who repay the  support they receive, with interest.

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A reoccurring idea among some politicians of late in the fiscal cliff negotiations is to raise the Medicare eligibility age from 65 to 67. The argument, at first glance, seems simple enough: Medicare as a program can be left unchanged (thus averting--for now--a deeply divisive philosophical disagreement between Republicans and Democrats), but government expenditures can be reduced by reducing the number of seniors eligible for the program.   Indeed, the Congressional Budget Office (CBO) has estimated that raising the Medicare eligibility age would cut federal Medicare expenditures by $148 billion over a ten-year period.  What’s not to like about such an easy, painless solution?  Plenty, when you look at the consequences of such a change.

There’s a prevailing belief, often perpetuated by those who oppose the expansion of Medicare and Medicaid, that a prime reason for our exploding health care costs is because of excessive benefits or inefficient government purchasing practices.  These are the same voices that continually lament public sector waste and categorically extol the virtues of a far more efficient private sector.  And while this narrative makes it convenient to oppose more government involvement in health care and intuitive to support privatization, it ignores some important realities.

First and foremost, when it comes to controlling the cost of health care, is the government’s scale as a health care purchaser. The leverage that Medicare has, as the single largest bulk buyer of health care services in the country, allows it to negotiate much lower prices than any private insurer.  And since Medicare provides coverage to around 50 million beneficiaries, the sheer volume of patients with this coverage forces most providers to accept these payments, even though they make more money seeing higher paying, privately-insured patients.

Unfortunately the 2003 Medicare Modernization Act (which expanded Medicare to cover prescription drugs starting in 2006) specifically prohibited the government from negotiating bulk prescription prices, and the Obama administration agreed to keep this restriction in place in exchange for pharmaceutical industry support of the Affordable Care Act (ACA)^[1].  While the drug benefit has cost less than originally projected (for a variety of reasons), the added savings from using Medicare's purchasing power to negotiate lower prescription drug prices for could be a major source of possible savings for Medicare beneficiaries.

In the big picture, our nation’s problems with deficits will not be solved simply by capping spending. Costs will continue to rise, and health care rationing as it exists today -- by ability to pay -- will merely be exacerbated. This is another reason why raising the Medicare eligibility age makes little sense. Moving 65 and 66-year-old patients from Medicare to the private market doesn’t only shifts costs from the government to the patient, it also leads to a marked increase in costs.

Many proponents of delaying Medicare eligibility assume that all seniors who would be pushed out of Medicare would be able to afford private insurance, which is far from a sure thing.  A substantial number would be left uninsured, and there’s clear evidence that Americans, in the years before becoming Medicare-eligible, already routinely postpone needed care.  As a consequence, these individuals become more expensive Medicare recipients once they do become eligible.

The nonpartisan Kaiser Family Foundation has projected that 5 million people would be affected in 2014 by an eligibility shift to age 67, leading to a gross savings of $31.1 billion to Medicare in 2014.  However, the amount would be offset by $7 billion in lost premiums from the 65 and 66-year-olds; $9.4 billion for subsidies for those who enroll in public exchanges; and $8.9 billion in new federal reimbursements to states to care for the lowest income 65 and 66-year-olds who would enroll in Medicaid.  The latter figure assumes that all 50 states implement the ACA, though many heavily Republican states have said they’ll turn down the expansion.  That scenario would leave the 65 and 66-year-old seniors unable to afford coverage in health insurance exchanges uninsured.  Factoring in these additional governmental expenditures, the net savings to the federal government would be about $5.7 billion in its first year of implementation.

However, these savings would be offset by an additional $11.4 billion in spending by other parties.  This includes $3.7 billion in higher out-of-pocket costs for 65 and 66 year-olds, $4.5 billion from employers who would have to primarily cover their retirees for two additional years, $700 million to cover the shift of Medicare enrollees to Medicaid, which is funded by the federal government and states, and higher average premiums for third party health insurance due to the entry of the higher risk 65 and 66-year-olds from Medicare into the general population.

If anything, we should be lowering the Medicare eligibility age (ideally to birth), to take advantage of the enormous potential cost savings we could have by bringing more people into the program.  Short of this reasonable, but somehow radical idea, we should at the very least bring back the ‘public option,’ which would provide a choice in the new ACA-mandated health insurance exchanges starting in 2014 for individuals to basically buy into Medicare, regardless of age.  The CBO estimated that such a public option could save the federal government about $68 billion in reduced subsidies over 10 years while also reducing out-of-pocket costs.

There are no shortcuts or easy fixes to substantively addressing our fiscal problems, which are largely related to the rising costs of health care. And while there are many problems in our healthcare system contributing to uncontrolled spending, Medicare is in a unique position to be part of the solution.

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Tracing our history back to the Revolutionary War and the drafting and adoption of our Constitution, there has always been a tension of ideas resulting in a vigorous debate.  Our revered Founding Fathers had raucous disagreements over the course of nearly four months in their efforts to craft the Constitution of the United States, which has survived the test of time, and provided an example for governance for the rest of the world.

I am not delusional enough to compare myself to one of our Founding Fathers, but I cannot help but see the parallels to the modern day debate in regards to how we lower the health care costs for the nation.  I had the honor of being invited to participate in a debate hosted by the Benjamin Rush Society, and this exercise was instructive in many ways. 

The physicians who belong to the Benjamin Rush Society (BRS) advocate for using the free market to solve the problem of our soaring costs in healthcare.  Ideas like Direct Patient Care (a successful example here), Health Savings Accounts and returning the Practice of Medicine to one where patients pay for their own care – largely eliminating insurance and eliminating the role of the Government almost altogether.  Some of the docs I debated with advocate coupling Direct Patient Care with catastrophic insurance, acknowledging that a 100% cash solution would likely leave many advances of medicine out of reach for a large part of our population – but having patients negotiate for prices (prices that have been made transparent) will allow the principles of the free market to drive prices down.   Transparency in pricing of healthcare is critical to their ideals, as this would lead to a more naturally competitive environment between practices, between hospitals, between drug manufacturers, etc.  Their ideals have merit, and as such, we have had innumerable politicians embrace this free market perspective – you will know they have embraced it when you hear the phrase, “Everyone needs skin in the game.”  Patients, with a more free market, will choose care that is less expensive, just as they would in shopping for a new electronic device.  

One small example of this principle working is in the Medicare Part D program.  Patients are given formularies by their Part D carrier, and those formularies allow a patient some small piece of price transparency through the tiers of medicines in the formulary.  Many of my patients will bring in to my office their formularies in order to work with me to choose generic medicines for them, thereby lowering their copayment and out of pocket costs.  This is a very regular occurrence in my practice, and my patients are very appreciative of reduced costs while preserving clinical value.  It has been postulated that this aspect of the doctor-patient relationship (i.e. finding generics) has helped bring Medicare Part D program costs under what was originally projected, although there are many reasons for this welcome news.     

In our debate, I agreed with my BRS colleagues that we need much greater price transparency in health care to aid cost control.  I agreed that this price transparency would lead to greater patient awareness, and physician awareness, of the cost implications of the decisions we make every day.  I applaud my colleagues at Costs of Care for their mission of bringing cost awareness to clinicians – if doctors truly knew the financial impact of our orders would we make the same decisions?

However, where I disagreed most with my BRS colleagues was the assumption that Health Care is able to function as an ideal free market.   An ideal free market assumes an equilibrium that results from supply and demand, and the competition of suppliers to meet the demands of consumers.  But what an ideal free market requires to reach this equilibrium is symmetry of information between suppliers and consumers as well.

In shopping for a television, I would guess I followed a path that would fit with the ideals of a free market.   I conducted my own research – researched prices of various televisions from different suppliers, their quality reports, customer satisfaction scores, etc.  And weighing the costs and quality I was able to arrive at my decision in a matter of days. 

Imagine the same scenario for a patient.  There is no price transparency in Medicine.  One cannot hop on Google and find “cost of appendectomy” at various hospitals.  There is no quality transparency in Medicine – although we are trying to move in this direction, physicians and policy makers are understandably arguing about how to measure quality at all.  Physician groups traditionally bristle at the idea of public reporting of quality, as an improper measure of quality could ruin the career of a well meaning, otherwise talented physician.  And the assumption of any of this in a medical emergency is obviously a non-starter.  In the middle of chest pain, do we expect patients to research quality scores and search for the lowest cost provider?

Price and quality measures – if transparent and readily available – could move us closer in Medicine towards free market ideals.  However, the practice of medicine, in my opinion, can never reach an ideal free market because of the one variable that will never reach an ideal equilibrium: clinical knowledge.  I spent 4 years in college to learn Biology, and some of the basics of life science.  I spent another 4 years in medical school – just to learn enough to start treating patients.  I then spent 3 years in Internship and Residency in order to be Board Certified in my field of Primary Care.  And I continue to learn more each and every day since completing residency 8 years ago about medical science through reading journals, and attending continuing medical education lectures.   I have invested – as all physicians have – an incredible amount of time into learning in order to know which medicine to choose to treat an ailment, or which test to order to confirm a diagnosis.  I have invested that time to be able to interpret my patients’ symptoms and physical exam findings to arrive at a proper diagnosis.  Patients who are not trained as physicians themselves, or nurses, or other health professional – no matter how intelligent – cannot reach this level of understanding in order to make pure free market decisions about their care. 

An easy example that any physician reading this will understand – just how accurate are the self-diagnoses your patients bring to you after researching their symptoms on Google?  Patients depend on our medical decision making because of the immense asymmetry of information. 

Please don’t assume however, that I am a classic paternalist.  I believe in Patient Centered Care.  I seek, in my interactions with patients, to eliminate (as best I can) that information asymmetry through education.  In teaching my patients about their diagnosis, I hope to empower them to make decisions about their care that actually do conform to free market ideals.  My patients will choose generic medicines if I teach them about generic alternatives and offer choices after explaining Evidence Based Medicine.   They will choose less testing if there is no clinical benefit.  They will choose less invasive care, if it has evidence to support its efficacy.  Nothing trumps my patients’ autonomous decisions about their own care, so long as those decisions are informed ones.  It is my responsibility as their healer to provide that information.

Ironically, to move the Practice of Medicine closer to a free market, there needs to be more readily available information to guide clinicians and patients in their medical decision making.  Panels of experts, such as the proposed Independent Payment Advisory Board (IPAB), are tasked with precisely that: study treatments - their efficacy, their cost - and synthesize massive amounts of information to make more readily available the information we need to make the best decisions in medicine.  This type of panel is exactly what my colleagues at BRS are against – although not because they want to see less information available, but rather a fear of having some bureaucratic panel dictate what treatments physicians prescribe.  Lucky for all of us the IPAB is prohibited from doing so.   

As our Founding Fathers worked out in those four months of debate, compromise is critical so long as it comes from the vigorous exchange of ideas between two poles of an ideological spectrum.  I am always eager to engage in that debate. 

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If you’ve ever been hospitalized, you know that the best part of the experience is getting to go home. But what happens if you’re homeless? For many, they return to the street or a shelter or the car from which they came, attempting to recover without the warmth and comfort of home. It’s a struggle but they have no choice. There are some who need more than being sent back to the street: people with open wounds, people with trouble walking after a stroke, people who have been hospitalized for so long that they need time to regain their strength. For far too long they’ve been sent to the street without concern for their outcomes. Otherwise they get sent to a nursing home for a week, that way the hospital has ‘done its duty,’ and then the nursing home sends them to the street. Either way, the homeless suffer and then often end up in the emergency room again.

There’s a little known network of providers around the country who are dedicated to filling this gap. Medical respite providers care for homeless people who are well enough to be discharged from a hospital but are not well enough to be on the streets. They can be located in homeless shelters, nursing homes, transitional housing or any other facility.

I know because I see patients at the respite care facility in Baltimore. Our respite care is located on the third floor of the city’s emergency shelter and we accept people from all over the greater Baltimore area.  For the man with a large surgical wound on his abdomen medical respite care is a life saver. The hospital couldn’t keep him any longer because his acute health care needs had resolved but they couldn’t discharge him to the street with a wound that would be sure to become infected. Medical respite was the best option for him as it gave him a place to stay and heal until he was well enough to brave the streets.

For the man who had one of his arms amputated due to an infection, staying with us gave him the chance to have the surgical wound heal. Having that safe space was critical for his ability to learn how to care for himself so that he would be able to do so safely in the streets.
Respite care also brings down the cost of care. A day’s stay in respite care costs 5-10% the cost of a day as an inpatient. The availability of respite care decreases length of stay as an inpatient by over 4 days since patients can be safely discharged earlier in their stay. Respite care also decreases utilization of the emergency room and increases utilization of primary care.

Respite care is one of those rare birds in health care that simultaneously improves care and decreases costs. Addressing the needs of the most vulnerable in society should always be our priority and when it also saves us money, it should be a no-brainer.

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Silence. 

And waiting. 

That is all I am able to answer when asked what the ACA nuances mean for Pennsylvania.  And the only answers that the state administration has provided.  A hard deadline comes soon, forcing a decision on setting up a state-lead insurance exchange.  But a much more tenuous quandary has seemingly no time frame- will the state accept the largely federally bank-rolled Medicaid expansion, or leave potentially hundreds of thousands of people off the health care rolls? 

Sentiment in the state seems mixed at best, with editorials summing up the results of working with the federal government on the ACA as, “ Once fully realized, ObamaCare will have all the appeal of a perpetual flu.” [1] While the governor's official position is still undecided as it waits for further communication with HHS, Governor Corbett at a recent press conference said "I don’t think there’s any way we can absorb this,” on the costs to the state of expansion.  The governor’s office anticipates the expansion state would cost the around $350 million in its first year and a total of 2-4 billion over 5 years, citing further concerns that the Medicaid budget (and other social services) already encompasses between 35-40% of the state budget.[2]

But let’s be quite clear what this money, from a relatively wealthy state, would be covering.  The current Medicaid eligibility levels are set at 46% of the federal poverty level for single adults.  To be blunt:  that is $5,138 a year.  The full federal expansion would cover everyone up to 133% of the federal poverty level, nearly tripling the eligibility level to $14404 for a single person.   

That’s an additional 550-750,000 people who will have access to medical care in the state.  An additional half to three-quarters of a million people who will not be forced to forego necessary preventative care leading to much worse health outcomes in the long run.   

That additional 4 billion dollars in state spending(which does not take into account all the cost-improving initiatives going on at all levels of medical care) can sound overwhelming.  But if we look at absolute costs, it can seem almost trivial in comparison to what the state would gain. Over the next 10 years Pennsylvania is expected to spend $133.4 billion dollars without expanding coverage to 750,000 citizens. The cost with the expansion?  $136.3 billion.  That is a state-level difference of 2.1%, over the course of 10 years.  The federal government foots the bill for 100% of the initial expansion, and it declines by only 10% over the course of the next decade.[3]

There is no question that as healthcare providers, patients, and a political unit we must continue to find innovative ways to lower costs while continuing to provide quality care.  But one way this is not done is by increasing the barriers to access for needed medical care.  By getting almost a million people plugged into a system that can help encourage both prevention and treatment before circumstances become dire, it can help bring down long term costs.  We must be careful to remember that if the state is not helping to fund this access, someone in the long term will.  Medical needs are not something that go away.  They only fester, and grow with time.  This is also important for the hospitals that provide uncompensated care for those who might be denied access if these programs are not embraced.  As the ACA anticipated the number of patients being treated in this category, the funds meant to help replenish those coffers are going down.  In addition to patients, care facilities stand to gain a great deal from this expansion. 

But now let’s step back, and ask a larger question:  in this game of numbers, what is it that we are really buying?   

We are buying a sense of security for citizens of this state, and this country.  We are creating a baseline for the more vulnerable members of our country, a footing for them to start striving for more.  Data has now shown access to Medicaid in particular improves mortality outcomes, and at rates comparable if not better than private coverage.  It also removes the burden for people to forego seeking medical treatment, as increasing cost sharing and lacking coverage often does.  People do not choose to forego care of questionable value, or that more expensive luxury treatment.  Data instead also indicates it is the lower income brackets who forego the most, and they go without recommended services.  We cannot guarantee outcomes for any of our citizens, but we can come closer to guaranteeing them a fair chance.  

Likewise, we can also provide reassurance to people living in the middle classes, a comfortable life which is subject to the same trepidations of a health catastrophe as everyone else.  We can give the entrepreneur a promise of a soft landing, as some well-meant endeavors invariably fail.  That is part of the beauty of this country- we should feel secure enough to take risks, knowing that if those risks fail, we have a chance for reinvention.  Choosing to invest money on the front end for programs such as the Medicaid expansion allow us to align our budgets with our values. 

And for the sake of those who stand to benefit around the state and the country, I hope Pennsylvania soon stops waiting, and chooses to embrace this generous program  which costs the state little compared to both the financial and social good it can do.

[1] ObamaCare's reality: Perpetual flu

[2] Corbett: State can't absorb Medicaid expansion

[3] Kaiser Commission on Medicaid and the Uninsured

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Dr. Chris Lillis, a Doctors for America Board Member and Virginia State Director, loves primary care medicine because “you really get to know your patients. … I get to help them stay healthy through good times and navigate the health care system through difficult times.” Of his patients ranging in age from 14-102, about 40% are Medicare enrollees.

Dr. Lillis has already seen the Affordable Care Act (also known as “Obamacare”) begin to help his patients. “The Affordable Care Act absolutely is making a difference for my patients—the young folks who can stay on their parents’ insurance plans [and] my Medicare beneficiaries who can now afford their medicines more easily, especially when they fall into the coverage gap, the so-called ‘donut hole,’” said Dr. Lillis.

Fewer and fewer of his patients are having to decide between food and their prescription medications thanks to the Affordable Care Act’s (ACA) current 50% discount on Medicare enrollees’ brand name prescription medications that fall into the “donut hole.” That donut hole will eventually completely close in 2014.

“In years past, I can remember patients who chose to avoid their screening mammogram or their screening colonoscopy because a deductible or copay was just too high and they had to make a decision between [paying] for the gas in the tank of their car or [getting] a preventive screening that could potentially save their life,” Dr. Lillis says. “Thanks to the Affordable Care Act, people don’t have to make those choices any more. They can receive their preventive care screenings without out-of-pocket costs, which is the best kind of care we can deliver as primary care doctors.”

Like all members of Doctors for America, Dr. Lillis is ready for a health care system that focuses on quality, not quanitity: “I want my patients to get the health care I think they need. The Affordable Care Act does that. It’s knocking down barriers to care.”

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This Thanksgiving Doctors for America is thankful for our thousands of supporters made up of health care providers, health care experts, and patients. Dr. Laura Davies sums up our thanks the best: “I am thankful for people fighting for access to health care, and for people providing quality health care." (Join us.)

Also, it’s also no secret that Doctors for America’s 16,000 doctors and medical students are thankful for the Affordable Care Act (also known as “Obamacare”).

Now we can do a rundown of the statistics:

• Almost 54 million additional Americans now have access to free preventive care like checkups and mammograms
• Over 5.2 million seniors have saved almost $4 billion on prescription drugs, beginning to close the “donut hole”
• 12.8 million Americans received $1.1 billion in rebates from insurance companies that overcharged them

And our doctors and med students are all very thankful for those numbers and all the other benefits of the ACA.

But what DFA doctors and med students are most thankful for is seeing the Affordable Care Act/Obamacare beginning to help their patients every day. Thankful their patients will have better access to the high-quality, affordable health care their patients deserve.

So this Thanksgiving, many Doctors for America’s members will be covering at hospitals and being on-call—just like our Executive Director, Dr. Alice Chen—and they’re thankful to finally be able to reassure their patients and say “Don’t worry, turkey fryer and cranberry sauce injuries are no longer a pre-existing condition.”

Happy Thanksgiving!

Need help answering questions about the Affordable Care Act/Obamacare over your Thanksgiving meal? Check out this handy info.

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