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.




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.