Health Reform and “We the middling people”

I have just read Walter Isaacson’s biography of Benjamin Franklin, Benjamin Franklin: an American Life, and was struck by Franklin’s “great rallying cry for the new American middle class,” according to the author, or as Franklin in his pamphlet, Plain Truth, said “We the middling class people. The tradesmen, shopkeepers, and farmers of the province and city!.” I contrast this emphasis with the recent Iowa Democratic gubernatorial debate and the five candidates running in next Tuesday’s primary and separately, this past Wednesday when Governor Kim Reynolds signed Iowa’s new tax reform law.

The middle is suffering form a lack of real wage increase, declining service of state supported programs such as public and higher education, the worsening availability of health insurance that is either of little value or that is affordable, and a new set of federal and state income tax changes that reward the rich and will ultimately harm the middle class. I agree with Franklin that the spotlight needs to shine on the middle class.

As Isaacson writes, “Through it all, he trusted the hearts and minds of his fellow leather aprons more than he did those of any inbred elite. He saw middle class value as a source of social strength, not as something to be derided. His guiding principle was a ‘dislike of everything that tended to debase the spirit of the common people.’ Few of his fellow founder felt this comfort of democracy so fully, and none so intuitively.”

In a country where the courts rule that corporations are citizens and Republicans further grant them privileges that we human citizens do not receive; preferential treatment regarding taxes; and the avoidance of oversight; American corporations are our new inbred elite. Our society and the Democratic Party need to follow Franklin’s advice. We need to support and enhance our middle class, which, as Franklin believed, would make America a great country. With the federal and state income tax changes the middle class will suffer twice; once from a titled tax structure and a second time from reduced spending for public programs. A strong middle class will support and fund a government that will nurture our people, allow them to rise out of their circumstance, and provide services for those in need.

Health reform is a necessary corollary to a strong middle class, Benjamin
Franklin would have applauded the health care co-op that Iowa started–Co-Oportunity Health–because he started several associations predicated on public service such as public libraries and fire departments.

The Iowa Primary Election is Tuesday, June 5. My hope is that the Iowa Democratic Governor nominee who is elected on November 6, 2018, will understand this dynamic and articulate it as well as Benjamin Franklin did.




Health Reform and   Primum Non Nocere Revisited        

Several months ago in this space, I discussed my concerns about a Trump presidency regarding the Latin phrase, “Primum Non Nocere,” which means, “First Do No Harm.” Now, at the end of the 2018 Iowa Legislative session, I revisit this phrase to discuss my concerns about the results that this Republican-dominated Legislature and the Republican governor have or are creating.

Given a budget deficit that required cuts for the current fiscal year and a poor farm economy that may worsen, the Republicans have announced the “largest” ever tax cut for Iowans. This will surely lead to even less money for government services in years to come. For health care specifically, Republicans have ignored and continued a flawed private for-profit Medicaid managed care system as well as passed a new law allowing associations to create health plans that will discriminate against people with existing healthcare conditions. This plan, which was pushed by the Farm Bureau and Blue Cross/Blue Shield’s Wellmark, will undermine the insurance market and destroy vital aspects of the vision and gains of the Affordable Care Act (ACA). The plans to be offered will not include ACA-mandated healthcare requirements such as maternity care and mental health care.

Healthcare in Iowa will suffer because of these developments.

On Tuesday night, I will attend a fundraiser for Dr. Andy McGuire who is a Democratic candidate for governor. She is making health care a major focus of her campaign. On Thursday, I will attend a federally-mandated Medicaid Assistance Advisory Council (MAAC) meeting which has the responsibility to critique this Iowa version of Medicaid.

I know examples of patients not receiving services and of some healthcare entities that are owed millions of dollars by these private for-profit managed care companies.

I fear that 2018 will go down as a watershed year for health care in Iowa. I hope that the fall elections will be a referendum on what kind of health care we Iowans want for ourselves and our families and that 2019 will undo some of the damage that is being perpetrated upon Iowans this year.




Health Reform and Mental Health

School shooting and other mass gun murders, the opioid crisis, homelessness; these social ills all could be improved with adequate attention to the mental health infrastructure in America. What is missing in most of this current national discussion is that mental health evaluation and treatment should be a primary part of the solution.

As a family physician, I contend that mental health evaluation and treatment is too late if we only concentrate on the prospective shooter, the addict, or the schizophrenic person who is living on the street. Do not misunderstand me: we need to help these individuals. What I am specifically saying is that we need to help them as well as the vast number of people with mental health diseases when the disease first occurs or even before they occur.

Studies indicate that at least 20 percent of Americans will have a diagnosable mental health condition sometimes in their life. In my family medicine practice, 40 percent of my patient visits involve patients with either a primary or secondary mental health diagnosis. Appropriate mental health care begins with universal health care which would enable access to medical care, including having a primary care physician.

As a family physician, using a questionnaire and as part of developing a relationship with my patient, I evaluate his or her mental health status at every encounter. Additionally, my physician-patient relationship hopefully creates the trust that the patient and the patient’s family can contact me if any signs of a mental health disease develop or a mental health crisis occurs.

Beyond primary care interaction with patients with mental health diseases, universe health coverage would allow patients with mental health diagnoses to access counselors, therapists, psychiatrists, psychiatric medications, and when necessary, outpatient and inpatient mental health programs.

Efforts by Republicans to block even discussions on universal health coverage leave vulnerable people without access to mental health services, either via primary care or other services. The end result is a greater likelihood for more school shootings such as the massacre that recently happened in the Parkland, Florida high school which left 17 people dead and 14 wounded, and the 63,600 opioid deaths that occurred in 2016 throughout America.

Even in the best scenario for universal health coverage—ready access to primary care and a good mental health infrastructure— some individuals with serious mental health issues will seek to harm other people on a grand scale. In these situations, we need a society that supports comprehensive background checks (with no loopholes), reasonable limits on the types of guns that can be purchased, elimination of kits and devices that convert a hunting rifle into a semi-automatic weapon, and strict limits on high capacities magazines. Finally, we must have a system where mental health specialists can, when necessary, interact with the appropriate authorities regarding specific individuals who own or have access to guns and could be a danger to themselves or others.

These types of efforts instituted by other countries prevent or minimize mass casualty shooting. A gun massacre in a primary school in Dunblane, Scotland in 1996 drastically changed gun regulations there. Strict limits were placed on guns of all types and magazines of any type. Licensing requires a comprehensive background investigation. Since comprehensive gun laws were implemented, no mass shootings have occurred in Scotland.

Our children are suffering and dying because of the societal deficiencies mentioned above. Children, their parents, and all voters must demand we enact more stringent gun control regulations.

Too many lives depend on it.

Health Reform and Myalgic Encephalomyelitis

For a few days of my recent vacation, I was laid low by a viral infection which, along with other localized symptoms, included overwhelming tiredness and emptiness. That ennui which I felt to my bones was all-consuming. I have recovered, thankfully. Regarding the malaise which I had for a few days, has given me greater empathy for two of my patients who have had a similar malaise for years. These two patients, who were independently diagnosed, one at the University of Iowa in Iowa City, and the other diagnosed by a national expert in North Carolina, have a condition now called myalgic encephalomyelitis (ME).

It used to be called chronic fatigue syndrome. (CFS). Below I give you the US Centers for Disease Control’ad s (CDC) definition for ME/CFS:

Myalgic Encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious, long-term illness that affects many body systems. People with ME/CFS are often not able to do their usual activities. At times, ME/CFS may confine them to bed. People with ME/CFS have severe fatigue and sleep problems. ME/CFS may get worse after people with the illness try to do as much as they want or need to do. This symptom is known as post-exertional malaise (PEM). Other symptoms can include problems with thinking, concentrating, pain, and dizziness. 

I have three other patients who may have the currently poorly treated condition. Both my diagnosed patients have gone through what one patient call her “brain crashes.”

During my 33-year career as a family physician, I can testify that previously patients with this condition have been tested thoroughly and when no other diagnosis was found, had been referred to a mental health specialist for an assumed mental health diagnosis. The stigma was an additional burden to these patients.

Having the CDC recognize this disease in July last year was a significant advance in at least providing these patients with a legitimate medical diagnosis to call their own.

We fight for universal health care coverage every day so these patients will have the ability to seek medical evaluation and care in a timely manner. We fight for universal health care coverage so this illness can be researched, understood, and ultimately, be well treated at a minimum, or cured.

Finally, how do people with this diagnosis affect health reform? The new twist of the Republican knife at the state level is a mandated work requirement for Medicaid recipients. My patient with the diagnosis made in North Carolina went to a disability medical evaluation and was denied. The medical examiner did not believe in the diagnosis. She is appealing the decision but it usually takes two years for a successful appeal to be granted. In the uncompromising Republican world of Medicaid, my patient, who can marginally function during the four hours a day when she is not in bed would be required to work in order to receive Medicaid. Unbelievable!

It is clearly time for universal health care.

Health Reform and $2,000 per Month Health Insurance with a $10,000 Deductible (which is only going to get worse)

(My year-end post was delayed by technical issues with my editor. Thanks for your patience.) 

2017. The year Health Reform took it on the chin. The year the middle-class individual health insurance buyer was abused by President Donald Trump and the entire Republican Party

In Iowa, where we almost had no insurers in the individual market, we were left with one for 2018, Medica. One is not a choice. Who knows if we will have insurers in 2019.

All year the Republicans attempted, in one way or another,  to repeal the Affordable Care Act (ACA). Over time, their more than 50 attempts failed, in large part because of projections that up to 20 million individuals would lose health care coverage. Because “The Tax Cuts and Jobs Act,” otherwise known as the tax reform bill, was projected to lead to only 12 million people losing coverage with the repeal of the individual mandate of health insurance, the Republicans were able to move forward with passage of the tax bill by only 3 votes in the Senate.

Take these actions down to the patient level. A patient of mine is a small business owner and his level of income does not allow him to receive a subsidy through the ACA. He is paying a $2,000 monthly premium for himself, his wife, and their twenty-two-year-old daughter and the policy has a $10,000 deductible. As I have said before, I do not think high deductibles for health insurance allow for adequate health care coverage. People do not seek health care to avoid paying high deductibles. Given the consequences of the tax bill, with fewer individuals signing up for individual health insurance, every health economist is projecting higher premiums for 2019. My patient is frustrated; I am frustrated.

I believe 2017 will be the year that sealed the deal for single-payer health care coverage in the United States.  It will not happen this year or next, but it will happen. The combined efforts of the insurance industry which for years has not cared about the individual marketplace and the Republicans who either do not understand or care about individual insurance buyers has led to unmitigated calamity for the individual health insurer for years to come.  Sooner or later, in my opinion, the only solution is single- payer health care. In the meantime, hold on. It will be a wild ride where Americans, including some of my patients, will surely suffer and may well not survive.  This is not supposed to happen in America—the wealthiest country in the world.

One final thought: House Speaker Paul Ryan wants to cut or otherwise curtail Medicare and Medicaid benefits in 2018.



Health Reform and Continuity of Care

In the chaos of health care efforts both nationally and in Iowa, today I seek to go back to two basic beliefs: 1) the hope of future generations to learn from past generations’ mistakes and 2) the value of continuity of care for primary health care and ultimately, health care in general.

Given that the U. S. Senate is now debating a tax cut bill that includes eliminating the Affordable Care Act (ACA) individual mandate for health care coverage—a basic tenet for true health care reform—and in Iowa, the for-profit managed health care Medicaid fiasco, which now has one managed care organization (MCO) leaving the state and another MCO not able to take new patients. These actions leave the state with only one MCO left to serve Medicaid patients, I shift gears by presenting to you a guest blogger.

She is a third-year medical student who recently spent a month with me in my clinic. She plans to be a pediatrician. I choose not to provide her name. Although she would allow it, I am not sure her medical school would.

She is a wonderful example of a new generation of physicians who hopefully will help lead our country into universal health care coverage. I fear my generation will fail at that goal. She is caring, intelligent, dedicated, and well-taught.  She writes about continuity of care which I believe is fundamental to good health care and is necessary for true health reform. I share her thoughts below.

This rotation was a wonderful opportunity for me to see continuity of patient care and the benefits that it can offer both the physician and the patient. Dr. Carlyle has a practice of approximately 2300 patients. He started working at McFarland Clinic in Ames 24 years ago and some of his patients today have been with him that long! He has developed special relationships with his patients. They respect him, value his opinion, and trust his judgment. Nearly all of his patients come in for an annual physical exam. Most of his patients get an annual flu shot. This relationship allows the patients to have better care. It also allows Dr. Carlyle to enjoy his work with patients that he knows and truly cares about on a personal level.

When Dr. Carlyle’s patients are hospitalized at Mary Greeley Medical Center, Dr. Carlyle is the physician responsible for caring for them. He orders tests, consults, and prescribes appropriate medications. He routinely has one or two patients in the hospital.

When his patients are discharged, he sees them in his office one week later. I think this continuity of care was really remarkable. It allowed Dr. Carlyle to be tremendously more familiar with the patient’s hospital course than he would have been if another provider had been caring for the patients.

One patient, in particular, stood out to me. He was a 60 something-year-old man who was admitted for pericarditis with effusion and cardiac tamponade. He seemed to be doing well initially but ended up transferring to the ICU. He had his effusion drained and began to improve. While he was hospitalized, he experienced anxiety and was given lorazepam a couple of times to help him to calm down and get a good night’s sleep. When the patient returned to the clinic one week after discharge, he seemed to be doing great. He really had no complaints of shortness of breath or chest pain. However, he was having continued anxiety at night. He felt anxious about lying flat in his bed, so he was avoiding getting in bed at night and ultimately not sleeping well over the last week. Dr. Carlyle has known this patient for many years, and this man has never had a problem with anxiety or depression, and other than the lorazepam in the hospital, the patient had not been treated for anxiety before. Because Dr. Carlyle knew the full history of this patient, including the details of his recent hospital course, he was able to safely prescribe a short course of lorazepam to take at bedtime. This will significantly improve the patient’s sleep, which will ultimately make a big difference in the patient’s quality of life overall and aid in his recovery from pericarditis.

I think it is because of the relationship that Dr. Carlyle has with his patients that they receive such good care, both inside the hospital and as outpatients. His patients keep coming back to him, and I definitely believe this continuity results in better outcomes. As a future general outpatient pediatrician, I can’t wait to develop these sorts of relationships with my own patients because I’ve seen firsthand how rewarding they are on so many levels.

Health Reform and IQOS

Recently I was on a panel of experts at an American Cancer Society’s Cancer Action Network (ACSCAN) program that focused on tobacco. As a former member and chairperson of Iowa’s Tobacco Use and Prevention Commission, I sat with a long time friend, Cathy Calloway, who is one of the national associate directors of the State and Local Campaign Team for ACSCAN. As panelists, we discussed the current status and remedies regarding tobacco use and abuse in Iowa

I’ll share some background on the initial efforts to end smoking in the United States.

In 1964 the United States Surgeon General’s Report on Smoking and Health began suggesting the relationship between smoking and cancer.

In the mid-1990s, more than 40 states commenced litigation against the tobacco industry, seeking monetary, equitable, and injunctive relief under various consumer-protection and antitrust laws. The general theory of these lawsuits was that the cigarettes produced by the tobacco industry contributed to health problems in the population, which in turn resulted in significant costs to the states’ public health systems. The lawsuit was premised on a simple notion: you (the tobacco industry) caused the health crisis; therefore, you pay for it. The states alleged a wide range of deceptive and fraudulent practices by the tobacco companies over decades of cigarette and other tobacco product sales. Other states soon followed. The state lawsuits sought recovery for Medicaid and other public health expenses incurred in the treatment of smoking-induced illnesses.

In November 1998, the Attorneys General of 46 states, as well as of the District of Columbia, Puerto Rico, and the Virgin Islands, entered into the Master Financial Settlement Agreement (the Tobacco Settlement) with the four largest manufacturers of cigarettes in the United States.

My friend Cathy had recently returned from a work trip to Columbia in South America. She told me of learning about IQOS (purported IQOS stands for I Quit Ordinary Smoking). IQOS is a new tobacco delivery system by Phillip Morris, one of the world’s leading producers of cigarettes, which heats tobacco via an electronic system without burning the tobacco. Some people know a device such as this as a “vape.” The IQOS, according to Phillip Morris, allows the tobacco taste with nicotine without harmful chemicals being released.

Historically, as cigarette use in the United States has declined, tobacco companies have begun to look for new nicotine delivery devices and worldwide for growth.

Drawing on their experiences in the United States, Big Tobacco is having great success abroad. The United States is now home to two of the world’s three largest multinational cigarette companies and is the world’s largest exporter of cigarettes. These companies use advertising and marketing techniques that have long been banned or restricted in the United States. They also apply political and economic pressure to circumvent other countries’ public health laws, often under the guise of “free trade.” And, in countries where market access is difficult due to government regulations, the multinational tobacco companies are allegedly complicit in cigarette smuggling in an attempt to gain market share.

The Federal Drug Administration (FDA) is now reviewing the IQOS device for use in the US. The device is being used in many other countries around the world, just as it is now used in Columbia.

Given the ravages of tobacco on our citizens and our health care system, I have considerable skepticism about this new tobacco use product. I have seen Big Tobacco consistently fight efforts to reduce tobacco use while we use the three pillars of tobacco prevention efforts: 1) consistent, major increases in tobacco excise taxes, 2) strong tobacco prevention and cessation programs, and 3) major restrictions on the use of tobacco in public and worksite locations.

Tobacco use has diminished in Iowa with these efforts from adult use of 26 percent to 17 percent but major efforts are still needed in the area of smoking cessation for people with mental health illnesses, as well as maintenance of prevention and cessation programs. Big Tobacco has been successful in decreasing the state funds for these efforts from $12 million when I was on the Commission in the mid-2000s to $4 million now.

We must be vigilant and wary of new tobacco products and tobacco use devices. At a time when health care coverage is declining in Iowa as well across the country, we cannot afford to see tobacco use increase. On this Halloween, I warn: Beware of IQOS.