Health Reform and Post-Truth Politics

As a physician, I have a hard time understanding post-truth politics.  Wikipedia defines the post-truth culture as “a political culture in which debate is framed largely by appeals to emotion disconnected from the details of policy and by the repeated assertion of talking points to which factual rebuttals are ignored. . . (it) differs from traditional contesting . . . falsifying of truth . . .(is viewed as) . .  . of  secondary  importance.”

I live in a world where the absolute values of lab tests such as INR levels, (prothrombin time (PT) is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio (INR) is calculated from a PT result and is used to monitor how well a blood-thinning medication is working to prevent blood clots); ejection fractions, (which is a measurement of the percentage of blood leaving the heart each time it contracts), Creatinine levels, (used to assess kidney function), and Hemoglobin levels (hemoglobin is the substance in red blood cells that carries oxygen), affect function, quality of life, and the potential life or death for my patients. I live in a world where for my geriatric patients, the commonly accept truth of gravity plays a huge role in falls. I spend much of my time as a geriatrician trying to prevent falls and treating the outcome of falls. In my 32 years of practice, I have seen how details of policy and falsifying of truth have tangible consequences.

Mortimer Adler, who died in 2001, was a philosopher in the Aristotelian and Thomistic traditions. He was the Chairman of the Board of Directors of the Encyclopaedia Britannica and Co-founder of the Center for the Study of Great Ideas. He wrote many books regarding what he called the Great Ideas, including a book called Six Great Ideas. While on the Encyclopaedia Britannica project, he worked with a principal professor of mine at the University of Notre Dame’s Program of Liberal Studies, a Great Books Program, the late Dr. Otto Bird. In this book, he wrote a chapter entitled, “The Pursuit of Truth,” where he made a distinction between truth and taste. He said “While the complete realization of the ideal that is the goal—the whole truth and nothing but the truth—will never be achieved in any stretch of time. We find that experts who are competent to judge—mathematicians, scientists, historians, each in their own departments of learning—have reached agreement about a host of judgments that they have come to be regarded as settled or established truths in their respective fields.”

Separately, regarding taste, he uses Latin, “De gustibus non disputandum est” or “About matters of taste, there is no point in arguing. Disputes are fruitless. . . On the contrary, we should wisely live with and gladly tolerate difference of opinion that express divergent tastes.” Finally, he said, “I am only saying that we should never abandon our effort to reach the agreement we ought to seek in all matters that fall within the sphere of truth rather than the sphere of taste. To give up is to abandon the pursuit of truth.”

In the Post-Truth Politics of 2016, we are told that we can eliminate the individual mandate of the Affordable Care Act (ACA) and substitute it with a world of voluntary individual insurance and high-risk pools with no loss of patients’ health or lives.

This week one of my patient who I have written about before on this blog came in for her annual exam.  She is a 57-year-old patient who has Type 1 Diabetes and due to her severe eye disease, she required frequent injections that cost $3,000 per injection. For years, she has been in the State of Iowa High-Risk Pool Insurance Program which has helped her pay for those injections, but then and now this insurance program does not pay for screening colonoscopies which an ACA-compliant policy is required to pay for.  My patient has chosen to stay in the High-Risk Pool against my advice and because of cost, has never had a screening colonoscopy. In the post-ACA world of the future, due to the cost, neither the individuals who do not have an individual health insurance policy nor those with an Iowa High-Risk Pool insurance policy will likely have screening colonoscopies.

According to Mortimer Adler’s definition of truth, where truth is determined by a collective group of appropriate experts, screening colonoscopies with the removal of pre-cancerous polyps will save people from a cancer diagnosis and potentially from dying from colon cancer. This is not a matter of taste; it is a matter of truth. I believe details of public policy matter.  Post-Truth Politics may use emotions to divide the electorate for the purpose of elections but the consequences of Post-Truth Politics will not save people’s lives. I hope we quickly advance beyond the age of Post-Truth Politics.

John Adams once said, “Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the facts and evidence.” As a physician, a husband, a father, grandfather, and a hopeful American, I would have us listen to Mortimer Adler and John Adams and continue to pursue truth.

Health Reform and Pre-existing Conditions

I was tempted to titled this blog entry, “Health Reform and ‘I won’t let people die in the streets.” I also was tempted to describe the November 8 election as the day health reform died. One retort could be that the Republicans are now in charge of health reform. They need to play offense as oppose to only playing defense. And, we should move forward.

For starters, let’s discuss the dual action of repealing the Accountable Care Act (ACA) and maintaining the Republican pledge not have individuals with pre-existing conditions be excluded from health insurance in the post-ACA world.

Making health insurance available to individuals with pre-existing conditions provision is one of the key pieces of how health reform works or does not work.  The choices available for the country are single payer or private insurance with an individual mandate. The choice is not high-risk pools which, even in a well-insured state such as Iowa, did not work in pre-ACA days. Unfortunately, high-risk pools appear to be in strong consideration if one reads  proposals from Speaker Paul Ryan and the nominee for Secretary of Health and Human Service Tom Price. High-risk pools concentrate very sick individuals in a single category that will be extraordinarily expensive. Even worse, in a world of employer group health insurance, individuals without a mandate and without a business connection will avoid buying health insurance or will not be able to afford health insurance and will go without health care coverage. We will go back to the days of uninsured patients, free medical clinics, delayed medical diagnoses, and lack of early diagnosis now made possible by preventive evaluations.

I have live at a time when my previously insured patients, patients I was seeing in a free medical clinic; or one of my diabetic patients in Iowa’s High-Risk Pool were not receiving top-notch health care due to the cost. I had patients coming in to see me too late with health conditions I could have resolved in my office had I seen them sooner.

What to do? As I said in a previous post on this blog, my first proposal would be to open up Medicare to individuals 55 years of age and older. I have also said the ACA needs to be “tweaked,” not eliminated.

This is the time to speak out for a future that moves health care forward for all Americans. We cannot go backward. Twenty million people now have health care insurance because of the ACA. More Americans are now insured than ever before. We need to continue to move health care forward. Speak out. We all must do it. We all must do it now.

Health Reform and Primum non Nocere

Following the admonition to “First do no harm,” I will refrain from sharing a post I wrote before the Presidential Election that would not promote a productive conversation regarding the future of health reform.  Instead, I will share some immediate thoughts regarding the future President Donald Trump.

Twenty-one years ago tonight, I was installed as the President of the Iowa Academy of Family Physicians. In my President’s Address, I said that having grown up in Denison, in rural Iowa and similarly, begun my practice as a family physician in Titonka and Algona, both in rural Iowa, I was going to “dedicate my actions this year to promoting rural family physicians. Furthermore, by protecting rural medicine, I think in part, we  help to protect that which is rural in Iowa and in America, a goal worthy in and of itself.”

Donald Trump won because rural America wanted to send a message to Washington,     D. C. The flyover country–the land between the two coasts, or the “deplorables” as Secretary Clinton so crudely mocked–extracted its revenge. My efforts for health reform have always been geared to the underlying goal of protecting rural America and rural Americans who I view as “the salt of the earth.”  If Donald Trump is listening to rural America, if he cares about rural America, and if he wants to protect rural America, he needs to acknowledge the rural Americans who have obtained health care coverage through Medicaid, the Exchange, or as a child under the age of 26 through the Accountable Care Act and find an alternative way to protect their health care coverage.

If Donald Trump takes us back to a world of pre-existing conditions and significantly higher rates of uninsured people, then the massive red color that illustrated his electoral success across the national map, as well as nearly every state’s rural counties on election night will symbolize the bleeding and suffering of rural Americans’ unmet health needs.

I hope and pray that he achieves the same success in the world of public policy that he has achieved in the world of politics. I plan to offer my advice and as appropriate, my criticism in this process. My final thought for Donald Trump is “First do no harm.”




Health Reform and Uber and Food Trucks

Recent economic trends nationally and in Iowa include the proliferation of Uber contract driver taxi services and owner-operated food trucks. Both of these services rely on individuals starting a small private business in the competitive world of commerce.

My brother, my father, and my grandfather have all been owners of their own small businesses. The gumption and personal sacrifices needed to take on all the requirements necessary to run a successful small business have always humbled me. From advertising and marketing to hiring and personnel management, to municipal, state and federal regulations to eventual retirement, a small business person needs to consider every aspect of their business. Despite this, many individuals crave the freedom and independence that running their own business or being an independent contractor allows. Given the other options of being someone else’s employee in a large business or a government worker, I sympathize with and support individuals who are willing to risk their time, resources, and self in these challenging endeavors.

Unless a small business owner or freelancer is independently wealthy, one of the primary barriers for these new entrepreneurs is health insurance, which for many of these individuals makes the health insurance exchanges critically important. The current status of health insurance, with significant premium increases, higher deductibles and copays, and fewer plan options from which to choose because of insurers leaving the health exchanges, make these people’s situation more tenuous.

The difference in what these small businesses and independent contractors have to do to navigate the health care insurance system is daunting, especially when I consider my patients who work for Iowa State University. The difference reminds me of one of my favorite patients, who at the age of 65, retired as a janitorial worker at Iowa State. She retired with good retirement benefits and was happy and content. Since her retirement, I have seen her and enjoyed hearing her positive experiences with retirement. In this world of outsourcing and fewer benefits for individuals working at jobs such as janitors, I am sure many janitors in the United States would not be able to retire at 65 as my patient did. It is this contrast between the benefits—be it retirement benefits, on-site child care, or health insurance—that government and major corporations can offer their employees compared with small business persons or independent contractors that I continually rail against.

In the few years since the enactment of the Accountable Care Act (ACA), I sense two economic orbs rapidly moving away from each other. On one hand, with independent professionals such as Uber drivers, food truck operators, and microbrewers, we see more and more people choosing a small business or independent contractor approach. Yet, the individual health insurance orb seems to be moving headlong toward higher premiums, and higher deductibles and copays with fewer and fewer  choices in the marketplace.

The Presidential and Congressional elections will decide the course of the nation for the next four years for many essential elements of American life including health care coverage. Either tweaking the existing ACA or totally replacing it will be a necessary task for the next Congress and President. Many years ago, our country  wisely created Social Security and Medicare. Both are celebrated examples of economic protection for our citizens. The ACA was created as another mechanism for economic and health protection for Americans. It has dramatically helped millions of American but I firmly believe it must, just as Social Security and Medicare were, be adapted over time. For individuals driving Uber taxis and operating food trucks, if we do not change the course of the ACA, they will not have health care coverage in the future. This blog is dedicated to preventing that future.

I look forward to working to create a different and better future after the November elections. Who you vote for is a personal choice but your vote will have a profound impact on the future health care of many, many Americans.

Health Reform and a $10,000 Neighborly Visit

A friend of mine, a family physician, told me about a visit he had with his 93-year-old neighbor recently. This neighbor had known my friend for more than 20 years and was my friend’s patient.  His neighbor is a wonderful man and a big basketball fan. He grew up on a farm in northeast Iowa and remembers when his farm received electricity in the 1930s. He was the electric power supervisor for the district that included downtown Chicago in the 1960s and remembers the riots following the  1968 Democratic Convention there.

The neighbor had a heart valve procedure earlier this year and because of complications, had an evaluation with his cardiologist the day before my friend’s visit. At the cardiologist’s evaluation, the neighbor’s cardiac drug regime was significantly changed. My friend was called by the neighbor’s wife and asked to come over to her home when her husband, the neighbor, was having chest pressure and nausea. The wife had called First Nurse, a 24-hour nurse hotline, and was told to call for an ambulance. My friend, knowing the patient’s previous work up and having been told of the change in the cardiac meds, evaluated the neighbor. Based on the evaluation, my friend had the neighbor lowered his cardiac meds and by the next day, the neighbor was back to the baseline of his cardiac status.

I guarantee you that if the neighbor had been taken to the Emergency Room by ambulance, he would have been admitted to the hospital.  From my experience, I believe a ninety-three-year-old patient with a history of heart valve surgery who was experiencing chest pressure and nausea would always be admitted to the hospital by the emergency department physician.

The rule of thumb is that a physician clinic appointment costs $100; an Emergency Department visit costs $1,000, and a hospitalization costs $10,000. My friend, in evaluating his neighbor, saved Medicare $10,000.

As I said in a previous blog entry, my clinic is in a Medicare Accountable Care Organization (ACO), as well as a Blue Cross Blue Shield ACO. One of the key aspects regarding ACOs is the prevention of unnecessary Emergency Department visits and hospitalizations. In that blog entry, I promoted how the relationship between the family physician and patient would be invaluable in this ACO effort.

In my family medicine practice, I try my best to see my patients on the same day if they call in with an acute illness, which is what we call open access scheduling.  Recently, a patient called in with significant back pain and asked to be seen. I told my nurse to get her into the clinic that day. My nurse told a temporary receptionist who, unfortunately, did not know my policy and scheduled the patient for the next day. Sure enough, the patient went to the Emergency Room that night.

In the world of ACOs, my friend’s intervention was successful; my intervention failed.

At a meeting of different Medicare ACO representatives from across the state of Iowa, I heard that one Medicare ACO was considering using a company that creates a mobile physician service that allows for an enhanced home visit to sick elderly patients on weekends, thus a house call just like Marcus Welby MD, a popular television family physician in the 1960s and 70s.

In the world of higher and higher health care costs leading to higher health insurance premiums and the eventual inability of some individuals to afford health care coverage, I return to my roots believing that good primary care relationships and services are key to helping correct these problems.



Health Reform and “Yuge”

Former Vermont Governor Howard Dean speaking this week at the 2016 Democratic National Convention quoted Donald Trump. According to Governor Dean, Donald Trump said that he’s going to replace the Affordable Care Act (ACA) with ‘something so much better’— something ‘Yuge,’ no doubt.”

In researching this “something so much better,” I could find only a mismatched set of random ideas such as buying health insurance across state lines, establishing Medicaid block grants for each state to administer, allowing Americans to import medications, eliminating the individual mandate but still preventing insurance companies from excluding patients based on pre-existing conditions, and expanding tax exemptions for corporate health insurance to individuals.

Contrast this hodgepodge of convoluted, disconnected ideas from an individual who apparently was caught off guard when asked during this year’s primary campaign about health care to the years of experience Secretary Clinton has in promoting and planning successful health reform. She did it in Arkansas when former President Bill Clinton was governor; she did it when she passed the Children’s Health Insurance Program in 1994, and she did it when she was a senator from New York. She watched as the Affordable Care Act was passed when she was a member of President Obama’s Cabinet. Her health care reform efforts, past and present, certify her convictions.

Yes, the ACA definitely needs to be tweaked. Medicare needed to be tweaked.  Medicaid needed to be tweaked. Both Medicare and Medicaid resulted from a bill President Lyndon Johnson signed into law in 1968.  Medicare and Medicaid have been tweaked and will continue to be tweaked and evolve in the coming years. I fully believe that if anyone can successfully tweak the ACA, I trust Secretary Clinton to do it. I trust Secretary Clinton to tweak and refine the ACA in the years to come. I simply would not trust Donald Trump to eliminate the ACA and create a new, replacement health care system that would continue the coverage of the more than 20 million Americans who have enrolled since October 1, 2013, when the first open enrollment began for the ACA, commonly referred to as Obamacare.

Under a President Hillary Clinton administration, I think we can discuss solid ideas such as the expansion of Medicare to individuals older than 55, the importation of prescription medications, allowing Medicare to negotiate medication prices with pharmaceutical companies, and immigration reform which would allow health care coverage for  undocumented workers.

Let’s await the election results in November and see which way health reform goes. Whatever the outcome,  it will make a “Yuge” difference for many of us.