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 a.m. 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 hardworking 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.

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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 Use Prevention and Control 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 Care Act with a plan that will reduce wealthy individuals’ taxes by more than $600 billion over 10 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 individual health-insurance market.

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Health Reform and the Orphan Called the Individual Health-Insurance Market

Last week, the buzz in Washington, D.C., 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.

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Health Reform and High-Risk Pools

United States House of Representatives Speaker Paul Ryan is right. High-risk pools could be the solution that solves some of the current problems with our health-care system.

Even though high-risk pools have not worked in the past (most immediate for me is the example of my home state, Iowa); even though I believe that states have neither the expertise, the competency, nor the will to run high-risk pools; even though I have railed time and again against high-risk pools as being anti-universal coverage, I now propose a new concept for high-risk pools.

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Health Reform and Nick Bath

Nick Bath is the senior health-policy aide to Senator Pat Murray (D) of Washington. I met Nick several times when he was a health-policy aide to now retired Senator Tom Harkin (D) of Iowa.

Nick is a Harvard law graduate and a classical pianist (according to his bio), and he reminds me in both looks and mannerism of British actor Hugh Grant when Grant was a younger man.

Senator Murray is one of the primary health-care advocates and strategists in the Senate. Because of my previous association with Nick and Senator Murray’s important health-care advocacy, I compose the following letter to Nick regarding the current health-care crisis and unknown future of health care, which evolved from the recently failed partisan attempt to repeal and replace the Affordable Care Act (ACA).

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Health Reform and Motive

My dad — whom I admire, respect, and love dearly — for my taste, watches too much Fox News. He criticized the Affordable Care Act (ACA) for years. He talked exclusively about its shortcomings. He talked about the 3,000 pages of the Act that none of the members of Congress had read. After listening to him for a while, I rebutted him on only one point. I said you could never criticize the ACA’s authors’ motive — to improve health-care coverage for Americans. With my comment, he quickly changed the topic of discussion. During many conversations with him over several years, he never changed the topic as quickly as he did that time. My rebuttal hit home. We can argue over method, but it is far more difficult to argue over motive.

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Health Reform and Incremental Primary Care through the Eyes and Experience of Atul Gawande, MD

Wading through the onslaught of presidential executive orders in search of a future of health reform in our country, I became weary and disheartened. Then, two people reached out to me regarding a feature article in the January 23, 2017, issue of The New Yorker by Atul Gawande, a surgeon, public-health researcher, and staff writer for The New Yorker. The article is titled The Heroism of Incremental Care. Dr. Gawande is the premier medical thinker and writer of our time. He has produced an excellent summary of my thoughts regarding Primary Care — both in theory and in how I seek to practice. A sincere thanks to Chris, my friend from Connecticut, and David, a patient and reader of my blog, for this remarkable find. I will defer this blog with the recommendation to read Dr. Gawande’s article, which is linked below with sincere appreciation and credit to The New Yorker.

 

The Heroism of Incremental Care, by Atul Gawande, as published in The New Yorker.

Next month I will return refreshed and invigorated and attempt humbly to carry out the spirit of Atul Gawande and his insightful article in the context of health reform.

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 (the international normalized ratio (INR) is calculated from the result of a prothrombin time (PT) test, which is used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is used to monitor how well a blood-thinning medication is working to prevent blood clots), ejection fractions (which measure 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 accepted 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.

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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 opposed to only playing defense. And we should move forward.

For starters, let’s discuss the dual action of repealing the Affordable 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.

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