Prescriptions from the Doctor

It’s interesting that most of the public opposition to the Affordable Care Act has come from politicians–not infrequently, from politicians whose most generous donors have a vested interest in the medical status quo–and not from providers of medical care.

Perhaps we should listen to the people on the front lines–the doctors. This is from my cousin, a cardiologist whom I often quote here:

As a physician who had been in practice for many years, I remember the hardships suffered by many of my elderly patients prior to the initiation of Medicare in 1965. During that time, I was forced to sit painfully by as many unfortunate sufferers lamented that, even though they desperately needed to be hospitalized or needed expensive tests and additional services, they had only received small monthly social security payments with or without a small pension that barely sustained them at a subsistence level. In short, that situation afforded not only insufficient medical care, but threatened their financial security during those so-called “golden years.”

Then, in 1965, something abruptly and miraculously changed the landscape—the advent of Medicare. Suddenly our elderly could receive a standard level of medical care, which included, among others, diagnostic tests and hospitalizations. The financial burden was lifted from both the patients and us physicians, because we were no longer confronted with agonizing daily decisions about how we could provide decent medical care on a shoestring budget without threatening our patients’ health or survival.

He writes that two other doctors have recently weighed in via the New England Journal of Medicine (November 20, 2014). In “Civil Disobedience and Physicians—Protesting the Blockade of Medicaid,” C. van der Horst, MD, wrote that, when he anticipated passage of the Affordable Care Act, he thought he would no longer need to worry about patients’ affording necessary medications, preventive care services and hospitalizations.

But then van der Horst’s home State of North Carolina (like Indiana) blocked Medicaid expansion (even though, as it bears repeating, the federal government would pay 100% of the costs for the first 3 years and 90% thereafter). Over the protests of health care workers, teachers, union workers, immigrants, environmentalists, and people of all races and religions, North Carolina lawmakers have stubbornly refused to expand coverage.

The second article–written by Michael Stillman, MD–detailed the very different experience of Kentucky. Kentucky approved Medicaid expansion and “fundamentally altered our medical practice, allowing us to provide data-driven and thorough care without first considering our patients’ ability to pay” and giving 650,000 Kentuckians access to decent, comprehensive medical care. Most had previously lacked health insurance, had avoided routine preventive care—and worried that a medical emergency would leave them bankrupt. Medicaid expansion lightened their financial and emotional burden–and as a bonus, provided better physician education.  (Previously, doctors in training had become accustomed to offering substandard and incomplete care to indigent populations.) Now they are able to provide appropriate, evidence-based care.

As my cousin concludes:

This country will eventually—and inevitably—support decent medical care for all its constituents. Perhaps the process would be enhanced if our politicians were forced to spend time on the “front lines” of medical care in our clinics and hospitals and actually have dialog with those patients who are most vulnerable and under-served.

Listen to the doctor.


  1. I suspect our governor would think it more “Noble” to die from poverty. That boy is quite the deep thinker. Three Cheers for Kentucky. …Taking care of it people.

  2. America has spent historically almost 2X what the next most wasteful country in the world of it’s health care dollars spends. For decidedly mediocre outcomes. Plus many in the country didn’t have means for any health care at all. A shameful incomprehensible condition for one of the wealthiest countries in the world. So shameful that under President Reagan a law was passed giving those without health care means free health care at hospitals.

    Of course even with that improvement things could have been even worse but for Medicare that allowed people to prepay for their retirement healthcare during their working years. And Medicaid that allowed some with provenly inadequate paying jobs some access.

    But there was no collective cost control input to the medical profession at all. We jointly told them that we, all of us, would pay whatever they cared to charge for whatever services they cared to suggest.

    Medicare attempted to add some cost control sanity to our desperate situation but generally all that did was subtly shift some of the costs for caring for the health of the elderly to other patients with insurance.

    All the while of course health care was becoming more and more expensive due to both better diagnostic and treatment technology as well as treatment of more and more marginal issues.

    We managed with this chewing gum and bailing wire non system until the conservative contagion infected business, at which time many companies decided to lower worker compensation by lowering or removing entirely the part of compensation devoted to health care. A disaster.

    From this disaster came ACA. The most modest improvement possible given the conservative infection of politics at the time. Now we had meager but at least some means of cost control over enough of the private health care non system to make some difference.

    That should have been the beginning of better days but it offended the oligarchy who reasoned that one of the advantages of wealth ought to be healthier longer lives and this new kid on the block was compromising their advantages. So they lawyered up and bought politicians right and left and attempted to stamp out progress. An ongoing but so far at least a thankfully big waste of their money. Boo hoo.

    Assuming that this mash up continues to survive oligarchy’s assignation attempts, what’s next?

    As Drs are fond of telling us, for this next thing we are going to feel a little pinch. Generally a precursor of 8 level pain on the 10 point scale.

    We have to address the cost of marginal comfort based diagnoses and treatments as an entitlement. Probably continually in the form of higher copays and more cost sharing between our personal pockets and our collective pockets.

    Uncomfortable but perhaps leading to satisfying the oligarchs that the wealth that they redistributed does confer some royalty benefits.

  3. Yes, our Governor of Indiana and our Indiana lawmakers have stubbornly refused to expand the Medicaid coverage by blocking the Affordable Care Act’s Medicaid expansion. It is disgraceful, and it is bad business, and the Medicaid expansion will continue to be blocked if young people don’t vote.

  4. Even I, as low as my standards are, have to apologize for my torture of the English language today. Pitiful.

    My only excuse continues to be that, as an engineer, English is my second language, way behind math.

  5. Phil; this governor and law makers have also blocked access to ACA for who knows how many applicants because they must first apply through the state system and wait till they are denied by all coverages offered. The state system in February stopped accepting applications till after March 31st, the ACA deadline. My daughter-in-law was finally notified of acceptance in late June for a policy costing $1,200 monthly (3 times what she was paying) with a $12,000 annual deductible which is higher than her current $9,600 deductible. So; she opted to maintain her current policy, pays her monthly $450 plus all medical expenses, including medications, for her family. She is a custodian in a Catholic church and school; my son is a brick mason which is seasonable. They are not exactly in the upper income bracket. Indiana did more than refuse to expand Medicaid, they refuse to allow residents to qualify for reasonable state system health care other than some early applicants who were accepted – probably to set a false example of state largesse.

  6. Oh, what’s data, the testimony of thousands of people who are now alive and well and all those doctors that serve as support for the ACA when you have silly ideology to back you up? Meanwhile, our politicians can continue to serve as excellent models for the Dunning Kruger effect in which unskilled individuals believe their their abilities are much higher than is the case. They know nothing, but think they are wiser and know more than anyone else. The “news” they listen to serves to confirm their bias, and their belief that they are right. The only thing that will save us from this problem is an election in which people understand that this is a bad idea.

  7. Sometime in the future we may have to cede some states to the mindless neo-cons and move ourselves to places where there is still some recognition, reasonable discourse and debate on issues that are critical to the future of the USA. Maybe we’ll look back at Indiana in a decade or two and be happy we moved.

  8. Our General Assembly considered rounding “Pi” to the numeral three. Since a majority of the astronauts (up to some point) and who knows how many NASA (not “Nassau”) engineers were graduates of Purdue, what would that have done to our accuracy at landing on the Moon? We are proud to be Hoosiers.

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