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.

 

 

 

Health Reform and Why Words should matter

Ah, words! Especially to writers, they are more precious than jewels, as essential as air, and powerful enough to create entire worlds. We chase them, massage or mince them, we roll them around in our mouths, savoring every delicious subtlety. Mostly, we love them.

~Tammy Letherer

Ms. Letherer wrote these words on a blog entry entitled “Why Words Matter (In and Out of the Locker Room), on October 16, 2016.  In that post, she discussed her unhappiness with Donald Trump’s language regarding women.

In Iowa, former US Representative Bruce Braley lost his Senate race with Joni Ernst in large part to an audio tape of his words to political contributors in Texas disparaging our senior Senator, Chuck Grassley, describing him as “a farmer from Iowa who never went to law school.”

This year’s health care debate centered on the Republicans’ efforts to repeal the Affordable Care Act (ACA) has led to many statements by Republican leaders in Iowa which should come back to haunt them this Halloween season and for seasons to come, as Bruce Braley’s words haunted him.

US Representative David Young gave verbal support of a previous bill that passed the House but was rejected earlier this summer by the Senate. This was a bill that President Trump described as “mean”. Those words of support by Representative Young for a ‘mean’ health care bill should be remembered.

On September 26, the Senate bill that was pulled from consideration by Majority Leader Mitch McConnell because of a lack of support. However, Senator Chuck Grassley gave strong verbal support for the bill saying, “You know, I could maybe give you 10 reasons why this bill shouldn’t be considered, but Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

Senator Grassley’s verbal support for a bill that he believed had multiple reasons not to be considered should also be remembered by Iowans.

Iowa Governor Kim Reynolds also gave verbal support for this most recent bill even though it would take money from Iowa for health coverage when our for-profit Medicaid program is losing money and our individual insurance market is on life support.

She said, “People were sold a bill of goods with Obamacare.” Is taking money away from Iowa going to make Iowa healthcare better? Senator Grassley is saying, in so many words, that the Senate bill was also a ‘bill of goods.’ Iowans should also remember Kim Reynolds’ words.

Bruce Braley learned the hard way that words matter; will Representative Young, Senator Grassley, and Governor Reynolds also discover that their words matter? My underlying message, especially for Senator Grassley, is that campaign promises are not nearly as important as improving health care coverage for Iowans.

Finally, on the final day of September, my wife and I walked the Ledges State Park in Boone County. Due to a washed out road, access to the beautiful sandstone canyon was limited to pedestrian traffic. After walking past the washed out site, the road through the canyon was passable and we saw several empty parking spots. The symbolism of the empty parking spaces struck me as an analogy for health care in Iowa: if Medicaid is cut back and if the individual market implodes, I fear empty hospital beds, empty clinic exam rooms, and empty hospitals. The ‘road closed’ sign will be up for Iowa patients without health care coverage.

Iowans deserve health care and words should matter.

 

 

Health Reform and Spudnutz

I stood in line at 6:45 Sunday morning to purchase donuts at a very popular local donut shop—Spudnutz—at Lake Okoboji. The line of donut seekers stretched far out the door. I did not receive donuts until 7:50 am. I waited more than an hour for donuts (Yes, very good donuts). Nine people were working in that donut shop that once housed an auto mechanic shop.

If either the Senate bill or the House bill that was intended to repeal and replace the Affordable Care Act (ACA) became law, I fear none of those nine hard-working people would have health care coverage in the future. For many of my patients and for, I believe, the employees of Spudnutz, I give thanks for the defeat of the Senate “skinny” repeal legislation.

The fallout from the middle of night vote in the US Senate defeating the “skinny” repeal of the ACA includes statements from as the Republicans saying that the states need to be given the flexibility to decide health care for the residents of their states or the Republicans saying able-bodied individuals ought to work with the expectation that they could then have employer based health insurance. Both statements reveal neither Republicans do not know nor do they care about the health coverage for poor and middle-income Americans.

The ACA gave the states the ability to decide whether to run a state based exchange, gave the states via a Supreme Court ruling, the ability to expand Medicaid or not, continue to give the states the power to determine insurers in the Individual Market, and finally gave the states the ability to administer the Medicaid program even though the federal government is paying 90 percent of the cost of the expansion.

In Iowa, these state determinant elements of the ACA allowed Governor Terry Branstad’s administration and the Republican run Legislature to quash establishing an Iowa-specific Exchange, to trash talk the ACA at every available opportunity, and to withhold assistance to what was our new start-up cooperative insurance entity, CoOportunity Health, when it failed. The Republicans are now gladly propping up Medica, the only remaining health insurer in the Iowa Individual Marketplace. All the while President Trump continues to threaten to end insurance subsidies which would further destabilize the individual market not only in Iowa but across the country.

Iowa chose to expand Medicaid for which I applauded them. Governor Branstad and the Iowa Legislature then chose to turn the entire state Medicaid operation over to three for-profit manage care companies. I argued strongly against for profit corporations taking this role (see previous blog posts). These companies suffered a cumulative loss in the first year of $224 million for which the state of Iowa was billed only an additional $10 million. I do not know how much the federal government was billed. In addition, both patients and providers have complained about how the managed care companies have administered Medicaid in Iowa.

Nineteen states chose not to expand Medicaid thereby withholding health care coverage for more than four million US citizens.

In Iowa, a well run State Exchange with the full backing of the state government and state assistance for Co-Oportunity Health in the manner and amount that Medica is now receiving state assistance would have led to a much more stable individual insurance market. Additionally, I believe a state administered Medicaid program, the type of program we had prior to the managed care corporations taking over, would have been a much better use of taxpayer dollars and provided a better system for both patients and providers.

I believe there is every justification in calling the Iowa experience with the ACA “TerryCare,” with   its state imposed limitations.

Given Iowa’s experience and the 19 states that chose not to expand Medicaid; a belief that states did not have the power nor use the power to affect the ACA is simply wrong. It also calls into question whether states should be given more flexibility regarding health care coverage decisions.

I do believe able body individuals should work; I also believe that under a Republican plan for health care for those on the lower rungs of the income ladder, that their usual jobs would not have health insurance as a benefit or that the options for health insurance would be limited and cost far too much. The current system of Medicaid for individuals working at the very lowest paying jobs and government subsidies for individuals at the next higher level of paying jobs are not only desirable but are necessary.

As we move forward in this fight for health reform, I think our goal should be to keep affordable, accessible health care for employees such as those working at Spudnutz. The “skinny” repeal would not have allowed for such coverage.

Hopefully, a bipartisan approach will bring stable and ongoing health care to Americans. There are currently many thoughts, plans, and ideas floating around in Washington. Please see the blog entry entitled, “Health Reform and Nick Bath”, March 2017, for some solid ideas.

 

 

 

Health Reform and Blood Money

In 2003, Iowa used part of its portion of the 1998 Tobacco Settlement monies to help build a new Supreme Court Building. During those years and later, Iowa Republican legislators sought to reduce the funding and scope of the Iowa Tobacco Commission, which was created to use the settlement monies to help Iowans to either quit smoking or not start. I said at that time, that using the tobacco settlement monies for any use other than health care was wrong. As a former Chair of the Tobacco Commission, I viewed this money as blood money because it was being paid out to partially compensate for the death and disease that cigarettes had caused Iowans for many decades.

Similarly, I use the same term, blood money, today regarding the U.S. Republican House and Senate efforts to repeal and replace the Affordable Health Care Act with a plan that will reduce wealthy individuals’ taxes by over $600 billion over ten years by taking a similar amount of money from the Medicaid program and from subsidies used to supplement poor and low-income individuals’ effort to pay for premiums in the health individual insurance market. If this effort is successful, people (the Congressional Budget Office (CBO) estimates 23 million Americans under the House Bill and 22 million under the Senate Bill) will lose health care coverage. Additionally, regarding the individual insurance market the CBO said, “Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan . . . will be a significantly higher percentage of income, also making such a plan unattractive . . . as a result, despite being eligible for premium tax credits, few low-income people would purchase any plans.”

Some of those people will die and many will suffer without health care coverage. Both the House bill and the proposed Senate bill will transfer money to the wealthy at the expense of the lives of others. This is the new explanation of “blood money”.

As Paul Krugman said in today’s New York Times, “More than 40 percent of the Senate bill’s tax cuts would go to people with annual incomes over $1 million . . . while . . . according to best estimates, around 200,000 preventable deaths” would occur with the loss of health care coverage for 22 to 23 million Americans.

How do you have a credible public relation campaign with this stark contrast between greed and suffering? Rod Whitlock, a lobbyist for hospitals and individual with disabilities, who I knew when he worked with Iowa’s U. S. Senator Chuck Grassley, said on National Public Radio last Saturday that both House and Senate Republicans explain and sell this idea by separating the tax cuts immediately and forestalling the Medicaid cuts for a few years.

The separation of tax cuts and Medicaid cuts by a period of time is designed to distract the public from the connection.  The other way to hide this transfer of wealth from low and moderate income Americans to the wealthy is by couching the effort as a way to eliminate the individual mandate, which works, and which the CBO supports, and which Medicaid patients and low-income Americans buying into the individual health insurance market are not affected by because they are exempt from paying the income tax penalty fee.” Warren Buffet, one of the wealthiest men in the US, described it best saying the Senate bill was the “Relief for the Rich Act”.

As I have said before regarding the ill- fated Co-Oportunity Health—the Iowa and Nebraska health care cooperative which sold policies on the Exchange in the individual market—after three months of operation, this health insurance company had requests for 24 solid organ transplants (hearts, lungs, kidney, liver, etc.). People with these conditions will again be without health care coverage and subsequently without health care if either the House or Senate Bill passes.

President Trump called the House Bill “mean.” If the Senate Bill forces 22 million people off of health care coverage instead of 23 million Americans can that be considered less “mean”?   Polls regarding the Senate bill seem to agree with the “mean” assessment. I prefer Paul Krugman’s “cruel and immoral” assessment.

Wikipedia says, “After the crucifixion of Christ, Judas returned the payment to the chief priest, who took the silver pieces and said, “It is not lawful for to put them into the treasury because it is the price of blood.”  This quote is drawn from Matthew 27:6

For me, using Tobacco Settlement money for an Iowa Supreme Court Building while trying to cut funding to help Iowans quit smoking defined the price of blood in 2003 by our state government.  Similarly, exchanging tax cuts for the rich with the loss of health care coverage and subsequent morbidity and mortality for the poor and low income is the 2017 definition of “price of blood,” this time by the Federal Government

Two addendums: One) If the Republicans actually wanted to lower the cost of health care and improve health care coverage for Americans, their bill would address the travesty of the ever increasing cost of medicines. The recent obscene jump in the price of long-acting insulin is only one of hundreds of examples.

Two) As I have said before, health care coverage helps create a society where mental health needs are met; where individuals with addictions to various legal and illegal substances such as alcohol, tobacco, opioids, and methamphetamines are addressed; where cancer is prevented or caught early; and where the effects of chronic illnesses are lessened.The overall effect is a safer, less violent, happier, healthier society, from the youngest to the most elder among us.

To the wealthy, I say the taxes you pay to support health care coverage under the Affordable Care Act (ACA) is a great investment.  It is time to let our conscious and morality guide us to do what is right.

Health Reform and the Orphan called Individual Health Insurance Market

Last week, the buzz in Washington, DC where I heard numerous lectures and personally talked to two U. S. Representatives and two U. S. Senators was about impending health care legislation in the Senate and particularly focused on the imminent crisis in Iowa where there probably will be no insurers for the individual insurance market in 94 of its 99 counties in 2018.

Seventy thousand Iowans may not have health insurance next year in a state that prides itself as an insurance state. Iowa is the poster child for the deficiencies in the individual insurance market. Across the nation, only a few counties in Tennessee have that known potential for 2018, though several potential fixes are being discussed at the federal and state levels.

I discussed my idea to stabilize the individual insurance market by allowing individuals ages 55 to 65 years old to buy into Medicare (see my blog entry titled, “Health Reform and Nick Bath”).

My point today is that the individual insurance Market was a mess before the Affordable Care Act (ACA). The individual insurance market is a mess now, under the ACA.  And, it will continue to be a mess if the House’s  American Health Care Act should become law as it currently exists without significant changes by the Senate. One of the imperatives of the ACA was that because of pre-existing condition exclusions, the individual market worked for the healthy but left many people with chronic diseases uninsured or placed those policyholders in unsatisfactory High-Risk Pools (I have had patients in that Iowa High-Risk Pool).

Now, with the continuation of the ACA and after the filure of Co-Opportunity Health—a federally established cooperative health insurance company—the existing companies could not survive the cost of the individuals with chronic illnesses and the lack of a majority of healthy policy holders.

I contend that the lack of the federally promised protections for Co-Opportunity Health, the lack of support from the State of Iowa to establish a state-based Exchange and having an inadequate public out-reach effort for insurance enrollment helped create the current crisis.

Furthermore, I believe the House’s proposal to allow states to re-establish exclusions for pre-existing conditions, change the essential benefits requirements, force older policyholders to pay higher premiums, and re-establish High-Risk Pools will simply place us in a time warp with the same inadequacies that we had in the pre-ACA world.

I fear we have two false premises driving the Republican efforts for health reform. One is the belief that unfettered capitalism with unrestricted free markets will succeed in the health insurance market. Unfortunately, such capitalism has winners and losers. This time the losers will be individuals with chronic illnesses and older Americans. The second false premise is that if we only had a health care system like we had in the 1950s, we would be happy.  Unfortunately, health care advancements that save lives, extend lives, and significantly improve the quality of life costs money. In the 1950s, people died of cancer, heart disease, and strokes. Today, people with those and similar conditions live well but at significant expense.

I recently traveled to France and I was struck by how many famous and gifted men and women in history died or suffered because of health problems that are now easily treated. My best example is my favorite painter, the impressionist Claude Monet, whose later work in the early 1900s was undoubtedly lessened by severe cataracts.

I hope the moderate Senate Republicans understand these thoughts regarding the inherently unstable individual insurance market. It has no parents and no one to care for it. It is orphaned. I hope the moderate Senate Republicans believe government exists to protect those who will lose in an otherwise unfettered free market system. I hope that moderate Senate Republicans realize that we are not living in the 1950s anymore. I hope that moderate Senate Republicans realize we live in the wealthiest nation in the world. I hope that moderate Senate Republicans realizes that no one should be without healthcare.