Progress Notes features doctors and medical students across the country on the frontlines of our health care system. Our views and experiences are diverse, but we share common goals and values. We speak up to move toward a future where everyone can have access to affordable, high-quality health care. Please share our posts, and follow us on Facebook and Twitter!
I'm 62 years old, disabled but not eligible for Medicare until 2015. Because of my all too common preexisting conditions like arthritis from injuries, migraines and hay fever I was not able to buy health insurance for many years. The ACA required states to form insurance pools to provide a last ditch insurance vehicle for people like me. So I had health insurance for several years after my COBRA benefits expired. But in 2011 my rate rose by more than $150/month. Paying $785 a month for a $2500 deductible policy with a very narrow provider network was financially untenable and I dropped the insurance.
My doctors are in Colorado since its only 110 miles from Moab to Grand Junction. They continued to treat me as a cash pay patient. But I have a degenerative disease that is progressive. I have put off preventive procedures because of the expense. I need insurance.
The ACA web site's problems are frustrating. But I'm a patient adult. I was able to create an account the first week and was able to see my options by the third week.
I am not entirely happy with the insurance I chose. The state approach to regulating insurance means that people are mostly restricted to networks in their locales. But here in Utah that means I will be required to drive to Salt Lake City for specialty care, almost 300 miles while my neurologist, neurosurgeon, orthopedist and internist are all only 110 miles away over a much safer highway. I will have to choose one of four local doctors. All were colleagues. None of us are comfortable with this arrangement.
There are economic, social and ethical imperatives driving this social change. I am pleased to support the ACA despite losing my physicians. I expect to ask for exceptions to the network rule so this I can continue to see the people who have gotten me through crippling disease and 3 big procedures in 2 years. I expect to be denied and to appeal.
I used to stand in the midst of the chaos that is urban emergency medicine and propose that "anything is better than this". The ACA is better. My hope is that this is the first step toward reigning in the profiteering and marketing in medicine. Simply insuring everyone will improve the health of the nation. Reforming the way American physicians practice medicine, banning drug and procedure advertising and lifting the burden of debt newly trained physicians face are all parts of this puzzle.
Rebecca Love MD
PS. Someone needs to point out that the governors who rejected Medicaid expansion and refused to run state based exchanges bear much of the responsibility for the federal marketplace's problems. If they had acted responsibly there would have been no need for a federal marketplace. Low enrollment numbers in states that spent no money to promote the exchanges are to be expected. Withholding encouragement and information is a disservice to the public and yet another form of obstructionism from the Republican Party.
Access to insurance, YAY!!
Better coverage for substance related conditions, YAY!!
Access to care…?
We have much to cheer in the long awaited final federal regulations covering insurance for mental health and substance abuse care. The final rules declare mental health and substance abuse benefits to be part of the essential benefits package required by the exchanges. The regulations require the benefits to be real, that is, insurance companies may not apply different lifetime limits, pre-authorization requirements, or separate deductibles to mental health services. They also require insurers to maintain adequate networks of providers and to offer out-of-network benefits on the same terms as those offered for general medical care. Moreover, plans must now cover screening for depression and substance misuse/abuse without “cost sharing” (i.e., copayment) on the part of the patient. This provision will specially benefit generalists, who often see depressed or addicted people but cannot bill for identifying a problem and counseling a patient on what should be done about it.
Parity regulations also now clearly apply to partial hospitalization, which the insurance companies must treat the same way they treat other intermediate services (like rehabilitation and short term nursing care). Partial hospital programs provide intensive services to people who are not imminently dangerous, but still ill enough to need more than occasional outpatient visits. Partial hospitals and intensive outpatient programs have the potential to significantly reduce the discouraging (and costly) relapse and re-admission rates that occur when patients achieve remission of illness or abstinence from substance use in a tightly controlled setting, then return abruptly to the environment that induced and maintained their condition in the first place. Anything that helps disentangle the issues of providing care for people because they are ill, rather than controlling people because they might be dangerous, is cause for real celebration.
So why only two cheers? Access to insurance does not, unfortunately, equal access to care. The rules apply only to insurance companies. They do not reverse the trend of states draining mental health resources (inpatient or outpatient) from their budgets. Nor do they establish fee schedules or staffing patterns that would allow mental health professionals to be fairly reimbursed for their work. Currently, rates of reimbursement remain so low that mental health professionals outside of salary based systems like the VA often cannot afford to treat the patients who need them most, including those who have been the most responsible about buying insurance that should cover their care.
Many psychiatric conditions are chronic illnesses that require varying levels of intervention at different points in a person’s life. The draconian restriction of mental health care through intensive case management has been based on a model that that treatment must be time-limited, short term, and applied only to those who are imminently dangerous. Changing the terms of this oversight, though necessary, does not reset our priorities to create a system that provides appropriate care, at appropriate times, for disorders that may require lifetime intervention.
The recent atrocities perpetrated by mentally ill people expose the many weaknesses in our non system of mental health care. I rarely agree with Charles Krauthammer (a psychiatrist turned conservative pundit). He was, however, right on when he noted after the Navy Yard shooting that our ability to provide effective treatment is limited by overly restrictive commitment laws, huge gaps in the continuum of services, and lack of appropriate facilities and resources.
The resources that do exist are tragically mis-allocated. In 2006, 10 times as many mentally ill people were incarcerated than were in publically funded mental hospitals. Governments across the nation spend millions to house the disruptive mentally ill in jails and prisons, then starve the hospitals, clinics, and social programs that might help them resume productive lives. (Thanks to the sequester and the systematic erosion of funding for the agencies that collect this information, more current statistics about this and many other problems are simply unavailable.)
Discriminatory insurance coverage for mental health services is both a cause and an effect of the stigma and confusion that characterize society’s understanding of mental illness. Strengthening the regulations that combat insurance discrimination against the mentally ill (including many alcohol and drug users) is long overdue. Two cheers are certainly warranted. But correcting abuses in current forms of oversight will mean little if the facilities and services that patients need are unavailable, undervalued, and uncoordinated. Only when those problems are addressed, will I climb the pyramid, turn a cartwheel and shake my pom poms with mad enthusiasm.
‘Tis the season for apologies. Fellow Progress Note blogger and ACA advocate Dr. Chris Lillis fretted about any overstatements he had made in his advocacy for the new law. Then it was President Obama’s turn to take a public beating and say he was sorry he promised people that they could keep their current insurance if they liked it. But as for me, no lost sleep here.
President Obama probably should have been more careful. But it was probably inevitable, in light of our nation’s absurd reliance on 15-second sound bites as a substitute for thoughtful discourse on critical public policy issues, that he would put his foot securely in his mouth.
We Doctors for America advocates had a slightly less daunting task. We had a whole 30 minutes, and a couple dozen power point slides, to summarize one of the most complicated pieces of federal legislation ever promulgated. Or we had a few minutes to talk with someone on the street, answer tough questions, and summarize the important parts of the law. In my advocacy efforts I have always tried to honestly portray the law, warts and all, and not overstate what it would accomplish. I have observed my fellow advocates doing the same. But given the complexity of the subject and time limitations, generalizations, which could later be picked apart to show some exceptions, were unavoidable.
Anyone who truly understands the law, and understands insurance, should have known that the ACA would produce, at least short-term, financial winners and loser. Should we have stated that up front? Maybe. But we were unlikely to do so in light of the ferocity and untruthfulness of the attacks made by the ACA’s most vicious opponents. Maybe it is time for a soul searching discussion about the ethical responsibilities associated with advocacy related education.
So everyone is now apologizing to folks in the individual health insurance market who can’t renew their current cherished policies, some of which are so crummy that it is a stretch to call them insurance, and will be paying much more in the Marketplaces because they make too much money to qualify for a subsidy.
So, since repentance is the order of the day, here is mine.
To the woman who testified at my state’s Medicaid expansion hearings last July I’m sorry that you developed advanced breast cancer several years ago, lost your job during your radiation and chemotherapy treatments, couldn’t afford your COBRA payments to keep up your insurance, and had to stop your chemo prematurely. I’m glad you got a new job, albeit without health insurance benefits. I was so sorry, and sad, to learn that your breast cancer has returned, is metastatic, and that you have no insurance.
I’d like to apologize for a member of our legislature, a health care provider himself, who an hour after your testimony stated publically that he didn’t want to hear anymore testimony from patients. You see, his innate compassion for your situation is colliding with his anti-government ideology producing painful cognitive dissonance. His only option is avoidance.
Perhaps, if you are still alive, you can sit down with some of the folks who are going to have to pay more for their insurance and help them find a cheaper cell phone plan, alternatives to cable Ty, or more affordable vacation options. That is, of course, if you are still alive.
To the woman who sat at my table at our governor’s health care summit. I’m sorry I did not get a chance to meet and talk with you. I noted that you are wheelchair bound, carrying portable oxygen, that the skin around your face was terribly tight, that you looked ill, and that you ate none of lunch provided. It was only later that I learned about your terrible autoimmune disease, systemic sclerosis, and that you had no employment, no health insurance, and limited access to what you need to manage your illness.
I would like to apologize to you for our state’s legislators. You see, the majority of them feel they are doing you a favor by not expanding Medicaid and thus preventing you from becoming dependent on government handouts and therefore motivating you to work and get your own insurance.
Perhaps, before your terrible disease turns your skin and internal tissues into rocks, you could discuss household budgeting with someone who is employed, insured, making over 400% of Federal Poverty Level but is complaining about a premium spike.
Finally, a shout out to the guy who sat next to me at the governor’s summit. I’m sorry that you got multiple sclerosis, lost your job as an electrician, lost your union benefits, your COBRA lapsed, you lost your house, and your marriage failed. It must be rather humiliating to now be living in your friend’s basement. I was really impressed when you ambled over to the governor’s table, got past his body guards, and explained to him why you can’t afford the expensive medication needed to manage your MS.
Let me apologize for the governor. It has been nearly two months and he still cannot decide whether expanding Medicaid is good for our state’s citizens. You see, he is fearful that the several hundred million federal dollars that our state will receive over the next few years will bankrupt the U.S. treasury and turn us into Greece.
But hey! Did you see the picture in the paper of our brand new nuclear aircraft carrier, the U.S.S. Gerald R. Ford? What a beauty and soon to be carrier number 12 in the fleet. I thought of you because although the federal government has already spent several billion on this state-of-art warship, they still need to spend a few more billion as they get her fitted out for sea trials. I’ll bet they will need some cracker-jack electrician like you. Maybe the governor could loan you the money to get your medicine and you could get working again. Just don’t tell him how much the ship costs ($13 billion) cause we don’t want to worry him.
Yes, the ACA is producing winners and losers. But in my mind the financial setbacks facing the few losers are greatly outweighed by the improved health, prolonged life, financial security and access to affordable insurance available to the many winners. It may never happen, but I hope that those who think they have lost financially will someday see that the health insurance security that the ACA will establish in 2014…guaranteed access, guaranteed continuation, and guaranteed limits on out-of-pocket costs…makes us all winners. The financial sacrifice by some is well worth the health insurance security gained by all.
If you have read some of my previous blog posts, you might think I add WAY too many links to my source material. I am not going to include any links in this piece.
The truth is, I have invested almost 5 years of blood, sweat and tears into ensuring that the Patient Protection and Affordable Care Act was written, passed by both houses of Congress, signed by the President of the United States and survived a Supreme Court Challenge. Now I am spending my time doing my best to see that the law is implemented. As much as anyone, I am terribly frustrated with the deficiencies of the website healthcare.gov. I am more frustrated that a few million Americans may see their health insurance premiums rise as their old policies are cancelled by insurers while making just too much income to qualify for offsetting tax subsidies. These folks, especially if they are healthy, may not feel that there is any benefit to them to purchase a more comprehensive health insurance policy that they rarely use.
But here’s the deal: we are all going to be better off. By expanding the individual health insurance marketplace, we will see health insurance premiums stabilize. This has not been the case for the past 30 years. We have seen double digit premium rate increases, year after year, through many presidential administrations, without any legislation passed to protect consumers. The Affordable Care Act finally protects consumers. The law mandates that insurance companies spend at least 80% of all premium dollars collected on your health care, a needed provision when all of the major insurers’ CEOs get paid tens of millions of dollars every year. The law forbids insurers from continuing the horrible practice of rescission, where policy holders are suddenly dropped once an illness is discovered. The law ensures that your policy is renewable even if you get sick. The law provides consumers access to an affordable policy, one that does not turn them away for having a pre-existing condition as trivial as heartburn or allergies. The law prevents an insurer from cutting off support for medical bills since annual and lifetime benefit caps are no longer.
The law has baked into it pilot projects attempting to revolutionize health care delivery systems. Currently, we have a fragmented system – hospitals, doctors’ offices, pharmacies, and other providers administered care without much coordination. The right hand of the health care system often was not aware of what its left hand was doing. But coordinated care is now the hottest topic in health care thanks to the dialog begun by the Affordable Care Act. The law has allocated funds for these pilot projects, although many coordinated care initiatives are being led by private hospitals, insurers and communities because of its transformative potential. This would not have been so without the national debate begun with the Affordable Care Act.
I must admit, the single greatest driving source inspiring me to advocate for the Affordable Care Act are the innumerable uninsured patients I have cared for in Emergency Rooms, Hospitals, Free Clinics, and my office – beginning in medical school over 17 years ago. I do not ever want to say to a patient, who is desperately asking me “how am I going to afford this,” that I am not sure how we will obtain a test, procedure or life saving medicine. I want to be able to say, “You’re covered.”
The Affordable Care Act has standardized – across Medicare, Medicaid, Tricare and private insurers – that preventive care is to be provided without out of pocket costs (co pay or deductible). My practice experience has made it crystal clear that out of pocket costs shape the decisions of patients. If it is unaffordable, they will delay needed care. Without out of pocket costs for preventive care, it’s not quite as much of a challenge to help patients participate in recommended disease screenings.
Underappreciated by all, The Affordable Care Act is going to encourage providers to focus much more on the costliest element of our health care system: those individuals who require complicated, ongoing, disease management. When chronic care is executed poorly, preventable complications occur in patients with skyrocketing downstream costs. Our sickest patients with the greatest need represent 84% of total health care expenditures – 99% of all Medicare spending. The Affordable Care Act is going to encourage providers to screen for chronic diseases and intervene early while those conditions are still easily manageable using effective and efficient coordinated care. This will allow us to reduce health care spending for all of us – everyone who pays taxes and everyone who pays health insurance premiums.
The mantra of the Affordable Care Act among “insiders” mirrors the mission of the Institute of Healthcare Improvement – better individual care, better population health, at a lower cost for all. This is the so-called “triple aim” drilled into us by Dr. Don Berwick. I strive for this, as I know the 16,000 members of Doctors for America do every day.
You cannot communicate all of this in a sound bite. Even harder is communicating all of the provisions in the law in a discrete period of time (think cable news). I can speak ad nauseum about our $2.3 Trillion dollar health care system – we spend more on health care than the size of the entire national economy of all but 6 other countries. It is remarkable, and discouraging, to know how complex our health care system is and just how complex this law is, meant to attempt to improve just about every aspect of it.
The Affordable Care Act will improve our health care system so long as it is allowed to work and provided some help in properly achieving implementation. I am privileged in my career to have been witness to the most affluent and high tech care in the Duke Medical Center Intensive Care Units and the most impoverished care on the trauma surgery service at the District of Columbia’s General Hospital. After taking care of thousands of patients in my lifetime, and immersing myself in health policy in the last 5 years, I want to see the Affordable Care Act succeed.
Success will depend on advocates like Doctors for America sticking with this effort – learning about loopholes and problems and applying the proper fixes to the law. This has a long tradition in our great nation. After Medicare’s passage in 1965, there have been both major and minor changes to the program every year to make it better. The Affordable Care Act has the same potential to improve year-after-year.
The Affordable Care Act is here to stay, but without better public education and understanding, the effectiveness of the law is in jeopardy. It would be foolish to abandon this critical law simply because a website is temporarily not functioning. A website can be fixed.
We need to meet the Americans who are losing their previous insurance policy and make too much to qualify for a subsidy. These folks are angry, and understandably so. I hope with good information, they will see that they will benefit in the long run. I hope they never have to learn of the protections of their new policies due to a devastating illness, but I am glad if they get sick they will avoid bankruptcy.
Every victory for this law brings new challenges, and that’s OK by me. The law was never going to be perfect and fix everything. It’s a start. I have a feeling that I and my colleagues at Doctors for America will need to continue to work to improve our healthcare system for quite some time to come. We plan to see this through.
All day today, the EPA is holding a public hearing for comments regarding proposals to cut carbon emissions from existing power plants. Here is what I plan to say during my speaking slot tonight:
Existing power plants create 38 percent of the carbon pollution in the United States, making them the largest single source of carbon in our environment. They also create 32 percent of the total greenhouse gases produced in this nation. I applaud the EPA’s efforts to regulate the toxins, acid gases, heavy metals, and smog-forming and soot-forming emissions from newly built power plants, but there should be standards for existing power plants as well.
I see the results of carbon pollution in my practice, especially during the summer months. I can predict which of my patients will come to see me on hot and humid days. My patients with asthma, who normally can live a healthy life with the help of maintenance inhalers, will come see me on those days. I take care of a 21 year old female, who is normally full of life. She was a cheerleader in high school and now is pursuing her college education. Her smile brightens everyone’s day around her. But on a hot and humid day in my home state of Virginia, I know she will call. She will come in to my office, gasping for air, with wheezing I don’t need a stethoscope to hear. She does not smile on these days. I know she is coming in on the hot and humid days because the soot (a.k.a. fine particulate air pollution) that is produced by coal fired power plants will enter into her airway and cause intense inflammation that even her usual asthma inhalers cannot control. I think the American Lung Association has said it best - the inflammation caused in the small airways from soot is like a sunburn inside your lungs. Now, since I do not have asthma, that sunburn is survivable for me. But for someone with asthma, emphysema or other lung disease, that sunburn can lead to lost days of school, work, doctor’s visits, ER visits, or death.
Conservative estimates show that regulation carbon pollution will lead to 20,000 fewer hospital and ER visits for those with lung disease, 3,000 fewer heart attacks and 30,000 fewer deaths annually. Reducing carbon emissions will cut asthma exacerbations by 1.4 million cases per year, and prevent 2.4 million missed days of work and school. This is a health imperative, and an economic imperative as I likely don’t need to inform you of the costs of health care considering our recent public debates.
As recently as 2 days ago, it was reported in the New York Times that an 8 year old in China was diagnosed with lung cancer. 8 years old. Her physician attributed her lung cancer to air pollution since she lived in close proximity to busy roads. The province where she lives has been shrouded in a haze of smog in the last month. How many more children need to get lung cancer before we act? Lung cancer is the #1 cause of cancer in China, fastest growing in individuals between the ages of 3 up to 50 regardless of their smoking status. This 8 year old girl was not a cigarette smoker, but rather a victim of her environment. In fact, the World Health Organization estimates that air pollution is responsible for 40% of premature deaths worldwide. The National Academy of Sciences has estimated that air pollution has shortened the lifespan of Chinese citizens by 5 years.
The Clean Air Act has led to longer life expectancies for Americans since it was passed. All of us have something to gain from reducing carbon emissions:
fewer cases of lung cancer and heart disease for non-smokers
fewer ER visits and hospital stays for those with lung disease, reducing our health care costs
fewer missed days of school and work for those with asthma and other lung diseases, leading to a more productive society
I took the time to drive here tonight from my home about an hour away in Fredericksburg, Virginia to advocate for my patients, to advocate for our strained and expensive health system, and most of all, to advocate for my 3 year old son who I do not want to end up like that poor 8 year old in China.
EPA Public Hearing
November 7, 2013
Christopher Lillis, MD, FACP
Member, Board of Directors, Doctors for America www.drsforamerica.org/
Member, Health and Public Policy Committee, Virginia Chapter American College of Physicians
Columnist, Free Lance Star Newspaper, Fredericksburg, VA
I posed the following questions to a few trusted sources, and pasted below are the responses back I have so far. If I get more responses, I will follow again with another post.
1) Is it safe to assume that the worst case scenario will be about 5 million people will fall into the "gap" of getting their old insurance dropped AND having an income too high to obtain a tax subsidy?
2) Can we do some "real" calculations for these folks? How much will these folks save when they no longer need to pay out-of-pocket for preventive care? Can we quantify the savings for someone who has a catastrophic illness who will now have the benefit of an out-of-pocket maximum?
3) What would the impact be on the insurance market as a whole if insurers were permitted to write policies that DO NOT cover pregnancy for individuals over the age of 50? It seems this element of the minimum benefits package is especially onerous for those who do not qualify for subsidies and have higher premiums.
Daniel Polsky, Executive Director, Leonard Davis Institute of Health Economics at UPenn replied:
“There are good questions. I don't know the answer to any of them except that I can't imagine coverage for pregnancy for women over 50 having any relationship to the final premium.
I would frame question 2 differently. The folks getting the letters were clearly very price sensitive when they purchased their last policy, but were they "rational" in the sense that they understood the benefits and chose a lower cost policy as their optimal plan? I think the administration's point of view is that these individuals did not make a rational purchase in that they would have regretted their choice in hind site after getting sick because they would have only then realized that they did not really purchase a product that offered the type of protection from loss that they had originally thought. If the individual market was a failed market because of the information problems then the paternal minimum benefits will improve welfare. But if the market was working, eliminating these plans will create some real losers in the trade, particularly among those who don't get compensated with a subsidy. But as I said to my friend who will have to pay $300 more a month, what you are buying is real insurance. If, God forbid, something happened to someone in your family your insurance may cover you until the end of the policy year, but you'd have a tough time getting a policy for that same price (if at all) the following year. So that extra $300 is buying you real insurance for the first time….in my mind, the most important added value will be the guaranteed issue and renewability at premium rates that are not determined by health status. Much of the focus has been the added value within the given plan year, but the real value only gets discovered when the healthy folks get sick and would have found themselves with few options within the individual market. ”
Henry Aaron, Bruce and Virginia MacLaury Senior Fellow, The Brookings Institution responded:
“3. I would be amazed if the impact of covering pregnancies for women over 50 were more than .01 percent. But this coverage strikes me as particularly important for pre-menopausal women over 50, as their pregnancies, rare though they surely are, are extremely high risk. That is the sort of thing we have insurance for. And once one starts saying that particular groups will not be covered for selective conditions that they cannot or are unlikely to have, one is on the road to de-pooling and risk selection.”
This piece does a masterful job of concisely showing, through video evidence, of why the ACA has had a no good, very bad day.
As an advocate for the ACA, I too am guilty of repeating the phrase, “if you like your plan, you can keep it.” However, as several journalists wrote about yesterday, turns out that ignored the reality that many health insurance plans individuals purchased on the open market prior to the ACA would not exist after implementation of the ACA.
Data existed in 2010 showing that health insurance policies bought by individuals prior to enactment of the ACA would not comply with the minimum benefits standards of the ACA. That data led experts to predict that anywhere from 50-75% of those policies - purchased by individuals - would not comply with the ACA. Prior to the ACA, roughly 14 million Americans bought their own insurance representing 4.5% of the population. Using worst case scenario numbers, as many as 10 million Americans may get a cancellation notice from their insurer prior to January 1, when their insurers will then need to comply with the minimum benefits packages. Turns out the slogan, “If you like your plan, you can keep it,” applied to those on Medicare, Medicaid, Tricare, the Veterans Administration, Department of Defense, Employer based insurance and of course, the uninsured - roughly 95% of the American people – but not the small percentage of Americans that already purchased an individual policy.
This has caused a great deal of anger and a great deal of fodder for opponents of the ACA. Some reasonable conservative writers are taking a more measured approach. As an advocate of the ACA, I must admit, these are not the Americans I was fighting for to get the ACA passed. The general impression of the individual market, all true, was that policies were too expensive, inaccessible to those with pre-existing conditions, and flimsy to the point of barely covering medical expenses incurred. Many in health policy circles refer to the prior policies purchased on the individual market appropriately as “junk insurance.” Deductibles in those policies were climbing, prescriptions may not have been covered, and one medical catastrophe would lead to bankruptcy despite having “health insurance.”
I was fighting for those I care for in the Free Clinics of Virginia. The 30 million people who have the potential of gaining access to health insurance if the ACA is completely implemented as designed (I’m looking at you, Governors unwilling to expand Medicaid). I was, and still fight, for those who were denied insurance due to pre-existing conditions or reached their annual or lifetime coverage caps only be told they are on their own with their medical bills.
But the fact remains that change is jarring. Kitchen table economics are very different from Washington, DC economics. Those 10 million people who may see their policy cancelled are looking at the sticker price of the new proposed policy and see often that it is higher. They remember those words, “if you like your plan you can keep it” and feel betrayed.
There is reason to hope, though. Those same individuals, in large numbers, will qualify for tax subsidies to afford their insurance. All of those individuals will be protected by more robust insurance, free from the threat of rescission, free from annual or lifetime caps, making preventive care free from out of pocket cost and ensuring that for-profit health insurers spend 80% of your premiums dollars on your health care. Looking at one of the most prominent media stories about this controversy is a Florida woman who will lose her $50 a month insurance policy. However, there is ample evidence she will be better off. You don’t have to take my word for it, just look at individuals who have done their own math.
But the media narrative will be focused on those who understandably feel betrayed who are receiving cancellation notices. Many will qualify for subsidies. All will be protected from bankruptcy if a serious illness occurs. All will have preventive care without out-of-pocket costs which saves lives. But there is going to be a population who will experience the broken promise of “if you like your plan you can keep it.” Those individuals will be middle class, making more than 400% of the federal poverty limit ($46K for an individual, $94K for a family of four) thereby missing the cut off for federal income tax subsidies. They will be among the 10 million Americans with a cancellation notice for their previous individual policy that does not comply with the minimum benefits standard of the ACA. I do not know how many Americans will fall into this trap of losing their prior policy and making too much money for a subsidy. Maybe some health economists can figure this out, but I suspect those calculations will be very difficult. We, as the advocacy community for the ACA, need to acknowledge this population and make an appeal akin to this pitch perfect piece from my favorite health care journalist Jonathan Cohn. The big picture is that our country’s health care system will be much more stable and much better off in the long run, but how much a consolation this is for those who make too much for a subsidy and lose their prior coverage is hard to predict. The most direct benefit may not be felt by those who remain healthy – they will never face the specter of financial ruin for a catastrophic illness.
With all sincerity, I apologize to those who have heard over and over again, including from me, that “if you like your plan, you can keep it” if you are among those that experiences a different reality. It remains my belief that we will be better off as a nation with the Affordable Care Act and even those who do not qualify for subsidies will directly and indirectly benefit in the years to come.
While the Affordable Care Act ends the era of denying people with pre-existing conditions access to health care, it allows insurance companies to charge tobacco users up to 50% more for their monthly premiums. Tobacco use for this purpose is defined as any self-reported tobacco use four or more times a week within the past six months. There are excellent intentions behind this policy – smoking is the number one preventable cause of death and smokers disproportionately incur health care costs due to the debilitating diseases that result from the habit. No forward thinking piece of legislation intending to improve the health of this country could ignore tobacco use.
However, this smoking surcharge makes the crucial assumption that continuing to smoke is a choice. Charging a higher premium for established smokers will either at best encourage people to stop smoking immediately in order to access health insurance or at worst deter smokers from signing up for health insurance in the first place. Nicotine is one of the most addictive substances known to man and counseling a patient to quit smoking is one of the most impactful services a doctor can provide. Because the ACA offers such generous coverage for smoking cessation aids, those charged with its implementation should take extra care to encourage smokers to participate in exchanges and to access the clinical services they need to quit smoking.
The stubborn presence of tobacco use is frustrating considering the plethora of studies that link it to so many debilitating diseases. Last month, I rotated in the Bronx at a federally qualified health center. There, I saw firsthand the incredibly high rate of smoking in a population that was mostly hidden from me in my everyday life. Though I still occasionally meet someone who smokes, the behavior has mostly retreated from populations of higher socioeconomic status and has burrowed itself and its destruction in low income families. Furthermore, since most people who smoke are of lower income, this results in an additional barrier to coverage when they have to pay an extra premium to receive coverage.
As the fight against tobacco continues to evolve, so should our policy ideas. The tobacco industry needs 5,000 new smokers every day to stay afloat. 88% of smokers began smoking before age 18. Though smoking is often seen as an adult issue, we should continue to support the many excellent anti-smoking campaigns and participate in research that helps us understand how to encourage adolescents that have started smoking to kick some butt.
Earlier this week the CDC reported that obesity levels have plateaued over the past few years. In 2012, about 34.9% of the people in this country were obese as compared to 35.7% in 2010. While some may take solace or even rejoice in this news, I can’t help but be cynical in thinking this is really not something to celebrate. This is sobering reminder that we're not seeing a change in adult obesity. The fact remains that nearly one third of U.S. children and about two thirds of U.S. adults are overweight or obese and therefore at increased risk for hypertension, diabetes, and musculoskeletal disease. Despite new campaign efforts, increased awareness among health care providers, and increased attention in the media, we are unable to budge the bulge and obesity remains a massive problem (pun intended on both counts).
Whether or not obesity itself is, in fact, its own disease entity is a topic for another day, but the fact that it increases the risk of numerous chronic illnesses is indisputable. And the fact that the health care system is in no way optimally equipped to manage obese patients is also indisputable. Tackling obesity requires engagement with the social, economic, and psychological determinants of health in each and every patient. Instead we take a piece meal approach in bandaging the chronic sequelae of obesity with medications and surgery.
Of course, given the multitude of factors at work in the obesity epidemic, there is no one group on whom to place the blame. With regard to health care providers, there are multiple financial forces and time pressures working against coordinated care and counseling for the obese patient. Not only is it more profitable to prescribe a pill or do a tummy tuck, but it is much easier both time-wise and emotionally than motivating someone towards weight loss. Behavior change is the holy grail of health care in the 21st century and given the circumstances of health care today, it remains largely elusive. It is not a fix that the doctor can prescribe, but rather it relies on the willingness and compliance of the patient—a surrender of control than many who desire to heal have difficulty accepting and attempting. However, most doctors are truly caring people with a desire to help their patients towards health and wellness. One major problem is that they lack the skills and practice to do just this.
Medical education is entirely outdated in that it does not teach how to best manage the lion’s share of today’s health burden—obesity and related chronic illnesses—that are crippling our nation’s physical and fiscal health. By and large, physicians lack the necessary skill set to motivate, encourage, and act as health coaches in partnership with patients. In a perspective published in the New England Journal of Medicine last week, researchers argue that part of the blame for the obesity epidemic lies with the way physicians are trained (1). Weight, specifically overweight, is not a topic breached in medical school, and therefore it is not on our radar as a crucial vital sign. A 2005 study of doctors-in-training found that only a small percentage even noted obesity in heavy patients’ medical histories, indicating that weight was not a priority in assessing their health (2). And while many of us can recognize overweight when we see it, probing the root causes of that overweight is akin to opening Pandora’s box…
“Information overload! Find quick fix and abort mission.”
Now finished with the preclinical portion of my medical education, I can speak to this. In total, I received approximately two hours of training in nutrition. And when I say nutrition, I mean research nutrition—a bombardment of results from studies that focus on one micronutrient and forget the rest of the food and the people who consume it. Unhelpful to say the least. I filled out a few online modules (that I could repeat over and over again until I received a passing score) and then moved on with my life, feeling completely inept at addressing dietary and weight management concerns with future patients. And this is coming from someone who has already invested countless hours reading about the latest trends and evidence in nutrition and fitness. I feel particularly bad for many of my classmates who will get questions from patients wanting to lose weight, and will have no idea how to address these concerns. And exercise prescriptions? The American College of Sports Medicine exercise recommendations (3) are nowhere to be found in our curriculum, nor are they asked on National Board Exams, so why would we bother learning them? There are already enough esoteric minutia to memorize, so I certainly cannot blame my classmates for turning a blind eye to lifestyle factors, even though they have greater relevance to the diseases and comorbidities they will encounter in practice.
Despite my persistent frustrations, there are glimmers of hope and the tide is beginning to turn. More medical education programs are incorporating what’s called motivational interviewing techniques into their curricula. This strategy helps doctors ask more effective questions to elicit meaningful answers from patients about what factors are contributing to their lifestyle choices, their attitudes towards change, and next steps towards progress. At the University of California San Francisco School of Medicine, first year students are encouraged to educate elementary and high school students about nutrition and physical activity, and the health consequences of obesity. In real-life clinical settings, students hone their interviewing and relationship skills in discussing the delicate issue of weight with patients. Finally, sessions on cultural competence and diversity in many medical schools are providing a deeper understanding of the social contributors to health, including socioeconomic and ethnic influences, which are powerful factors in diseases like obesity.
Yet as we layer on more and more elements to medical training, we must not forget that more work does not always translate to more skill and better outcomes. Indeed, the workaholic culture of medicine is often antithetical to health itself as evidenced by the high rates of physician burnout. Numerous studies have shown that “soft skills” like compassion, empathy, and communication—those exact skills needed to encourage behavior change—have been shown to diminish over the course of medical training (4,5). Hence, a core component of preclinical medical education should be empowering students to achieve balance in order to preserve their own sense of “humanness” in what is a humane calling. Pursuing balance and practicing wellness, which encompasses anything from exercise and cooking to spiritual practice and the arts, sharpens the relevance of health promotion for our patients. Doctors can be models the behaviors we desire in our patients. The physician who leads a fulfilled and balanced life is more likely bring a more preventative and integrative approach to patient care. Perhaps then we can shift the gears of that drive obesity from neutral into reverse.
1. Colbert JA, Jangi S. Training physicians to manage obesity--back to the drawing board. N Engl J Med. 2013 Oct 10;369(15):1389-91.
2. Ruser CB, Sanders L, Brescia GR, Talbot M, Hartman K, Vivieros K, Bravata DM. Identification and management of overweight and obesity by internal medicine residents. J Gen Intern Med. 2005 Dec;20(12):1139-41
3. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59
4. Chopra SS, Sotile WM, Sotile MO. Physician burnout. J Am Med Assoc 2004;291(5):633
5. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ 2004;38(9):934-941
Great fleas have little fleas upon their back to bite 'em
And little fleas have lesser fleas, and so ad infinitum
Who knew? This famous couplet, which the mathematician Augustus DeMorgan apparently expropriated from the poet and social critic Jonathan Swift, comes from a book whose title originally (and now again) captures the essence of complex interdependency, a “budget of paradoxes”. The lines came to mind unbidden during the recent government shutdown, when I learned that in DC, where I teach and practice, hospitals were surviving on reserve funds the city tapped to pay bills normally covered by the federal government under Medicaid. By the early part of last week, those funds were nearly tapped out.
Republicans in Congress seem inclined to treat those depend upon the federal government to pay its debts as no more than pesky fleas. But for DC hospitals that provide care to a large Medicaid population, the threatened interruption of reimbursement was of great concern. Our local hospital system is already under enormous stress. With a shortage of beds, patients are “boarding” in emergency departments, sleeping on stretchers or in recliners in hallways for days on end. At my own hospital, our once beautifully appointed space now resembles a train station waiting room, with nurses, physicians, and social workers clacking away at keyboards and pleading on telephones to find places for weary patients-in-waiting. From the halls of congress to the hallways of the emergency department is a very short step, at least in this city.
Many municipal hospitals operate on a slim economic margin. If the government had defaulted on its obligations, hospitals would not have been able to pay their staff or suppliers on time. Like the bigger and lesser fleas, this process would have transferred the economic burden inexorably down a line that begins with businesses and professionals and lands squarely on the backs of patients. Delay in reimbursement would have meant more beds would close, and the people now crammed into hospital hallways would have been sleeping, or dying, in homes, attics and on subway grates.
The infinite regression of suffering that would follow from a governmental failure to pay its debts, like the bites of fleas, is something none of us, but especially those of us involved in healthcare, can ignore.