Health Reform and a Governor Hatch Administration

One of my proudest moments, which was photographed—the  photo is displayed in my office at the clinic—is the 1998 signing ceremony for the Healthy and Well Kids in Iowa (HAWK-I) program. I stood with representatives of several medical societies and an Iowa family that included a mom and three daughters while Governor Branstad signed into law a program that helped to make Iowa a leader in the nation in the percentage of insured children.

I worked long and hard with Democratic legislators, Republican Representative Brad Hansen, who also is in photo, and Republican Senator Nancy Boettger, to create a program made possible by federal funding that created a public-private system to insure children. For my efforts, in 1999, I received a national Public Health Award from the American Academy of Family Physicians. During the negotiations for the I-HAWK bill, I clearly remember that then Governor Branstad did not want a quasi-independent board to supervise the program.  He stated that in his administration he did not want to add “silos” that prevented him from overseeing the actions of state government.

Fast forward to 2013-2014. I am struck by the contrast between then Governor Branstad and current Governor Branstad, who initially tried to thwart by lawsuit, then tried to delay some portions, and with other portions refused to fully use available resources of the Affordable Care Act (ACA) for the good of Iowans. Now, it appears that seemingly every department of Iowa state government is a near independent silo, such that when the director of the Department of Public Health makes disparaging remarks regarding poor Iowans or the director of the Department of Administrative Services makes false claims before a Legislative committee. It appears that Governor Branstad can remove them from office without taking any responsibility for their actions while in high-level state director positions. After twenty years as governor, he has developed a new and different style of “overseeing” the actions of state government.

I am proud of the HAWK-I program and its results. I am proud of the intent and much of the content of the ACA. I wish Iowa had utilized the ACA to its full capacity to benefit every Iowan.

I believe a Governor Hatch (Senator Jack Hatch is currently running for the governorship of Iowa) administration would have acted differently and the effects on Iowans would have been both positive and profound. I would like to imagine what I believe a Governor Hatch administration would have done in 2013 and 2014 that would substantiate this claim.

Before starting this discussion, I make three provisions: 1) these actions that I propose are what I think a Governor Hatch should do and do not necessary mean a Governor Hatch would agree with each and every proposal, 2) what should have been done in 2013 does not necessarily predict what should be done in 2015 when a new administration will take office as factors have and will continue to change. Finally, 3) I attended the first 2014 Governor’s Debate, held this month in a cattle barn at the Iowa State Fair. A replay was shown that evening on Iowa Public Television. I was chagrined to witness a total absence of questions and discussion regarding health care in Iowa. Senator Hatch, who is acknowledged by even those who might not agree with him as one of the most active, engaged, and informed legislators regarding health care, left some of his best, strongest positions unsaid during the debate.

So let us begin. The nexus of this blog is Senator Hatch’s responses to my health care questions to candidates. Sadly, he was the only candidate to respond, despite personal promises from two other candidates. Senator Hatch’s responses were thorough and insightful. For his effort, I will contribute $1,000 to his campaign.

His answer to my question regarding a state-based health exchange clearly shows not only his support but also his leadership on the issue. Having created a commission which produced a report recommending and detailing a proposed state-based health exchange, he then used those recommendations to propose legislation in two different legislative sessions to create a state-based exchange. Previous blogs detail what I believe are the vital benefits of an Iowa-based exchange. The value is even greater when one realizes that Iowa’s current hybrid exchange ends, by federal mandate, in 2015 and will then force Iowans into a health exchange run totally by the federal government in 2016. A Federal Court ruled recently that individuals on the federal exchange are not eligible for federal subsidies for their health insurance premiums. For all these reasons, a Governor Hatch would have and should have had a state-based health exchange ready for the 2013 ACA open enrollment period.

I believe an Iowa state-based health exchange should be a quasi-independent entity with its own board of directors. Furthermore, such an entity should be housed in a newly structured Department of Health, which would include the current Department of Public Health and the Medicaid Division currently operating within the Department of Human Services. Combining these state efforts—both which pertain to health care—would align common interests and give state government tighter focus on health care. Such a state-based health exchange should mandate Navigators in every Iowa county and work directly with hospitals and primary care providers to have individuals such as health coaches in these institutions and offices who are able to enroll uninsured Iowa residents for health insurance or Medicaid. Only with efforts such as these will residents of rural Iowa be able to fully engage in making decisions regarding health care coverage options and be able to meet the individual mandate requirement of the ACA. I firmly believe a state-based exchange utilizing local health care provider offices would dramatically change the current negative connotations about the ACA found in many parts of rural Iowa. This new Department of Health should, in addition, have an Iowa Surgeon General: a physician who would be charged with making informed recommendations regarding various state health programs and issues to both the Legislature and Governor.

In a different venue of state government, an imagined Governor Hatch administration would have never allowed limited health insurance policies to be grandfathered into the 2014 individual insurance market and for the upcoming 2015 market. This action by the Iowa insurance commissioner, which many insurance commissioners throughout the country did not allow, allowed for the potential for adverse selection. As a regulator, opening the door for adverse selection seems to me to be inappropriate and not in the best interest of Iowans. Additionally, many Iowa residents who maintained their grandfathered-in limited policies would have met the criteria for federal subsidies. The loss of federal money to these individuals and the economy of Iowa is significant.

Finally, a Governor Hatch administration would have set a positive tone for the state’s actions and response to the ACA. Individuals who need health coverage and chose not to receive it due to the negative connotations of the ACA as portrayed by various groups and individuals might have reconsider their positions and attitudes if the state had a positive approach to the ACA. Currently, these individuals are suffering and in some cases, dying due to a lack of health coverage. That is an Iowa tragedy.

In summary, I began this blog referring to a photograph of the signing ceremony for HAWK-I. This photograph included a family with three daughters. My personal “poster” family for HAWK-I is currently in my medical practice. The family includes three daughters and one son. Sixteen years after the signing, two of the children are still on HAWK-I receiving necessary health services, while two older girls attend Iowa State University. The lives of all these children were measurably improved by the medical care they received under HAWK-I coverage. Their mother has thanked me many times for the existence of the program. This was a program then Governor Branstad signed into law. I guarantee that there are thousands of Iowans who should now be receiving the benefits of the ACA but are not.

Contrary to the actions of the current Governor Branstad administration, I believe the discussed actions of this imagined Governor Hatch administration would have allowed for them to obtain health care coverage. In terms of health care, I believe the contrast between Governor Branstad and Senator Hatch is stark and telling, and requires serious consideration by Iowans.

Health Reform and Reminiscences of Hospice Patients

This blog is dedicated to a good friend and patient of mine who died last month in hospice. I had taken care of her for 15 years. We had many remarkable and enjoyable conversations regarding her growing up in a home where her father was a physician. She thought very highly of her father and the profession of medicine. She knew the value of good medical care and how much it means to all of us, even physicians and their families. She had seen the human side of medicine in its affects on her father and her family.

Earlier this year she contracted lung cancer and fought valiantly against it. She endured multiple pulmonary emboli (blood clots), pneumonia, and finally, terminal pleural effusions (fluid between the lungs and chest cavity), which, despite the best chemo therapy, were all too much for her. The last time I saw her, we discussed hospice as an option. My file note says it all, “had a frank discussion with patient regarding her limited options and she chose to enter hospice.” She entered hospice care and I left for a family reunion. She died in hospice before I returned. I will remember that final conversation I had with her until the day I die. As a hospice physician, I have had thousands of conversations with patients with terminal health conditions over my 30 years of practice. This particular conversation was wide-ranging.  It included her fond memories and recent regrets; her hopes for the future and her concerns for her love ones. She just had her pleural effusions temporarily drained and for the first time in days could talk without gasping. She had chosen to fight until there was no hope and now, she accepted her reality and chose to relinquish the fight. She now was focused on her family and their needs. She spoke soberly but with great wisdom and clarity. I am proud to have known her and honored to have her as my friend and patient. From many previous conversations, I know this patient was excited about the Affordable Care Act (ACA) with its promise of offering health care to decent, hard-working people who were suffering and too often dying from their inability to see physicians like her father and me. She was frustrated with the stuttering roll out of the ACA but was active in trying to maximize its positive affects as well as supportive of improving it where it needed to be improved. As a physician, I have a moral and legal obligation to stop at the scene of a motor vehicle accident and offer care; as a physician, I have a moral and legal obligation to report abuse and neglect that I witness while providing care to my pediatric patients and my impaired adult patients. Neither I nor my now-deceased patient could ever understand how, when medical care through Medicaid or health care coverage through the Exchange is available, that we, as a state and as a society, allow so many citizens not to have access to medical care. Is there not a moral   obligation—a moral imperative—in this situation? In Iowa, thousands are without health care coverage because they believe either that the ACA is simply “wrong,” or they lack the means to enroll for health care. A year into writing this blog, this realization saddens me most. Across the nation, millions now have health care that was previously unavailable to them. In Iowa, almost 100,000 more people now have Medicaid because of the ACA. In Iowa and Nebraska, 86,000 individuals are insured by a nonprofit cooperative insurance entity, CoOportunity Health, which was created with loans from our government as enacted through the ACA. These 86,000 policy holders now own CoOportunity Health, because of its cooperative structure. As a recent study again proved health care coverage through Medicaid or insurance purchased through the Exchange, saves lives. My late patient knew that. I know that. The challenge and my patient’s legacy are for Iowans who are eligible for health care, is that they receive health care. We need to promote it, publicize it, support it, cheer it on, simplify it, and make available the means for people to easily enroll in these health care programs. In the upcoming November election, there is one question we should all ask before we vote for any candidate: Will this candidate, once elected, seek to more easily allow individuals to receive medical care or will they seek to deny or remove medical care from those who desperately need medical care? Writing this blog over the past year, we have discussed several issues including patient-centered medical home, insurance exchanges, the peace of mind that comes with obtaining health insurance, and the benefit of establishing an Iowa-based exchange. I look forward to continuing these conversations. I have several more issues to examine in this forum. Yesterday I met the daughter of a another hospice patient. She had moved her dad into her home in the country to care for him in his final weeks. He loved to be outside or look out the windows to observe the beautiful surroundings at her daughter’s rural residence. In home visits with him, I would marvel at the pond and woods this patient could observe and enjoy from his bedroom windows. He would describe to me the wildlife he saw. His daughter told me that since her dad’s death, a red-tailed hawk had been present regularly outside her house; sitting on the roof with a mate or perched on a fence post. Once it tried to fly into the house. She saw the presence of the hawk as significant. I am sure that both of my patients I mentioned in this blog are observing our collective actions on Earth and cheering  for their favorite endeavors, be it a viable health care system available to everyone, or the rich state of wildlife in Story County. Similarly, I too, am cheering for both of these righteous endeavors.