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.


When Success is Failure…

There are lies, damn lies and (misrepresentation of) statistics.

Before the Affordable Care Act passed–when the country was debating the whys and wherefores of reform–proponents of major change (of whom I was one) pointed to the undeniable problems with America’s patchwork health delivery: the fact that we spent more per-person than any other country (by massive amounts) with significantly worse outcomes; that millions of Americans couldn’t obtain coverage either because they couldn’t afford it or due to pre-existing conditions; and that millions of people were stuck in jobs they hated because they’d lose coverage if they quit. 

How many new businesses, we asked, weren’t started because the would-be entrepreneur had a child with a pre-existing condition? How many people of a “certain age” wanted to cut back, but couldn’t because they’d lose their health coverage? How many Americans were effectively “slaves” to a job they didn’t want, staying solely for the health insurance?

Eliminating that “slavery” was a major goal of reform. It was one reason that many of us argued for decoupling health insurance from employment entirely, and making it part of social security, as it is elsewhere. We didn’t get that done, but the ACA is at least a step in the right direction.

A couple of days ago, the Congressional Budget Office issued a report showing real progress toward that goal of freeing people from jobs they hated:

With the expansion of insurance coverage, more workers will choose not to work and others will choose to work fewer hours than they might have otherwise, according to the Congressional Budget Office.

The usual suspects immediately went into propaganda mode. “See,” they screamed, “Obamacare is killing jobs.”

Of course, that isn’t what the CBO said. It said people were voluntarily leaving jobs. The jobs are still there, and will need to be filled when the newly-freed depart–which should be good news to unemployed folks looking for work.

Somehow, in the fevered imaginations of the uninformed–and the dishonest rhetoric of the politically self-serving–meeting one of the original goals of health reform is evidence that it doesn’t work.

I’m getting dizzy from the spin cycle.


Bottom-line Ideology Bites

The news-magazine show Sunday Morning had a fascinating piece this week on a new approach to debt collection. The story reported on a collection company that refuses to employ the typical tactics–harassing phone calls, threats and the like. Instead, the collectors work respectfully with the debtors, helping them to renegotiate what they owe and manage their finances more prudently. The founder’s basic premise: people would pay their bills if they had the money, and hounding them is unlikely to give them the means to pay.

According to the company’s owner, his firm is twice as profitable as those using the more traditional tactics.

Respect for people–what a concept!

Respect for the worth of one’s employees can also boost profits, no matter how counter-intuitive some “hard headed” businesses might find that simple premise.

I’ve written before about the difference between the approach of Costco and Sam’s Club to  their workers. Costco pays its workers, on average, twice as much per hour as Sam’s Club, and provides them with health insurance to boot. Yet it is far more profitable.

There is a self-defeating belief among some businesspeople to the effect that a healthy bottom line depends on cutting costs wherever possible, especially personnel costs. There is plenty of evidence to the contrary: employee turnover and disaffection can cost more than skimpy payrolls can save. That is a lesson that even Walmart appears to be learning. The company recently announced that some 35,000 part-time workers will be returned to full-time status–entitling them, not so coincidentally, to heath coverage as required by  the Affordable Care Act.

As Forbes reported, Walmart’s unwillingness to pay most of its workers a living wage has left the company without enough full-time workers to properly run a retail outlet. The result has been that the company has placed dead last among department and discount stores in the Customer Satisfaction Index for the last six years.

Furthermore, again according to Forbes, Walmart sales have been “sinking dramatically”–a state of affairs that even Walmart has concluded is the result of its relentless effort to avoid paying decent wages and offering health insurance.

This was a lesson learned by Home Depot in the early 2000s, when its CEO cut full-time staffing in hopes that the savings would boost the bottom line. It worked–briefly. Then customer service declined, and with it, same-store sales. Home Depot reversed course–and profits rose.

As the Forbes columnist noted,

Who  would have guessed that a well-staffed store filled with competent and reasonably paid employees might actually have an impact on the success of a company?


Talking the Talk, Avoiding the Walk

Tea Party types love to talk about the Constitution. Evidently, the only thing they like more is evading its requirements.

George W. Bush showed the way. With his aggressive use of signing statements, he avoided that pesky “veto override” problem. (Recall the tactic: he would sign a bill he didn’t like, rather than vetoing it, but he’d issue a signing statement to the effect that he wouldn’t enforce the law if he didn’t feel like doing so. That “veto by another name” avoided an override vote by Congress.  Mission–i.e., end run around the Constitution– accomplished!)

Today’s Congressional zealots are doing George one better. As Robert Reich recently pointed out,

The Constitution of the United States does not allow a majority of the House of Representatives to repeal the law of the land by de-funding it (and threatening to close the entire government, or default on the nation’s full faith and credit, if the Senate and the President don’t come around).

If that were permissible, no law on the books would be safe. A majority of the House could get rid of unemployment insurance, federal aid to education, Social Security, Medicare, or any other law they didn’t like merely by deciding not to fund them.

Like it or hate it, the Affordable Care Act was passed into law by affirmative votes of both Houses of Congress. It was signed (without the crossed fingers of a Signing Statement) by the President, who subsequently ran for re-election on a record that prominently included it and who handily won. Its constitutionality has been upheld by the Supreme Court.  There are not nearly enough votes to repeal it using the proper process.

But none of that matters to the arrogant ideologues who want to circumvent the Constitution they claim to revere by failing to fund the law of the land.

The truth of the matter is, the only Constitutional provision they really care about is (their version of) the Second Amendment.


More Horrors of Obamacare

Well, I see that the Star has a story quoting one of Governor Pence’s political appointees; said employee is predicting a huge increase in health insurance premiums, caused, of course, by the hated “Obamacare.”

The prediction is interesting in light of recent news from elsewhere. On July 17, Reuters reported  “Many New York state residents who buy health insurance next year will most likely see their premiums cut by half as President Barack Obama’s healthcare law creates subsidies that may increase the number of people in this market by the hundreds of thousands.”

News reports suggest that other states anticipate similar decreases. Evidently, officials in other states know something ours don’t.

Even if you are stuck in backward Indiana–even if you don’t live in New York, or one of the other states anticipating reduced premiums, you still may be one of the 8.5 million people who will get a check from their health insurance companies this summer. The checks are rebates required by the Affordable Care Act (aka Obamacare) from companies that failed to spend at least 80% of premiums received on actual medical care.  Insurance companies that fail to pay out 80% on claims are obliged to send the difference between what they did spend and 80% back to the policyholders.

Has there ever been such an outrageous assault on the American Way of Life?

But never fear, policyholders–the House GOP just took its 39th vote to repeal this affront to liberty, and to protect you from its horrors. In fact, protecting you from Obamacare is so important, they haven’t done anything else.