Doctors Fighting for the ACA in Flyover Country — Dr. Pat S.

Below, a guest post by a longtime HealtlhBeat Reader, Dr. Pat S.

When people talk about organizing physicians, they invariably speak of “herding cats.”  But the story Pat tells illustrates that if just one or two physicians stand up to support health care reform, they can and will draw an answering response from other health care professionals. 

Pat and his colleagues are practicing in what has become an increasingly conservative part of the country. There, the voices of the Tea Party are loud.  Physicians, nurses, nurse practitioners must make their voices heard above the din.  They know, better than anyone, what is wrong with our health care system. They know that if you’re sick in America, and don’t have insurance, chances are you won’t receive care. And they are in a better position than many to appreciate how the reforms in the Affordable Care Act could help their patients.     

This is why health care professionals need to band together to lead reform– and to educate the public about what the Affordable Care Act will mean for them. Some might want to join a large national organization.  By many may be more comfortable working in their communities, forming local networks like the “Friends of Al” that Pat describes below. Doctors, hospital administrators, nurses and pharmacists can get a grassroots movement rolling by writing an Op-ed for their local newspapers, talking to their neighbors, their colleagues, their customers and their patients, reassuring them that the myths that Tea Partiers have been broadcasting just aren’t true.

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A few days ago I was sitting in a very nice house with a stunning view of Lake Superior, the guest of a husband and wife doctor couple who were hosting a meeting for what we were calling “Northland Health Care Providers for Health Care Reform.”  The group was made up of local doctors, with a few nurse practitioners and physicians’ assistants, a couple of pharmacists, a chiropractor-turned-hospital-chaplain, and one lonely administrator.  We were there trying to figure out ways we could educate the public about what the Affordable Care Act really means and convince them that they should support politicians who support the law.

This group was new, having started out late this March when the Obama campaign contacted a local political activist to ask if she could find people who would be willing to speak in support of the ACA, possibly at a news conference.  As it happened, she did; her husband Al is a semi-retired doctor, a general internist who works for the large regional health care organization based in town.  He quickly pulled together a group of eight “friends of Al” who turned up one morning at the local Democratic headquarters to meet the local press, say a few words, and answer questions.  The press conference went well and was covered by all the local TV news outlets and the newspaper.  No one anticipated what would happen next.

In the next few weeks, over 80 local health professionals called or e-mailed to join the group.  We were helped immensely by an opposition op-ed in the local paper, nominally written by a local orthopedist whose wife happens to be the leader of the Tea Party in town.  The article was severely factually challenged, to phrase it politely.  It annoyed people, and doctors came out of the woodwork to ask us to publish a rebuttal.  We responded by asking them to join the group themselves and write their own rebuttals.  The result was a rain of letters to the editor and two new op-eds, challenging the article and talking about the need for health care reform in America.

Many of the doctors and providers, — especially those in front line positions in emergency medicine, internal medicine, pediatrics, family practice, general surgery, and gynecology – were motivated to become involved by their own personal experience with patients who were harmed by lack of health insurance.  It turns out that you do not have to practice here for very long before you will see women presenting with huge bleeding untreatable cervical cancers which could have been found early with pap smears and pelvic exams, children suffering from infectious diseases easily avoided by vaccination, people who have lost their hearing due to neglected ear infections and people in the intensive care unit with severe respiratory failure from pneumonias who could have been treated with a few cents worth of oral antibiotics if they had just come to the office on time.  Al tells a story of a patient of his, a woman who died in her mid-fifties after a struggle with a combination of neglected health problems following a life during which she had worked at least forty hours a week every week starting at age 16, but never was able to get a job that included health insurance, and who never made enough to pay for her own health care – or little enough to get care through Medicaid.  It seems that seeing that sort of thing wears down the tendency to think American health care is doing just fine, or that attempts to change it are socialist efforts to destroy our way of life or unfair impositions on the elite of our society.

Our area is poor.  The ACA provisions for expansion of Medicaid are critical up here, where our small city has a median household income of $34,000 a year and 20,000 households that have incomes of less than $30,000 a year.  A national magazine once described one of our neighborhoods as the “largest white poverty ghetto in the United States. “ Lives spent doing manual work and with chronic neglect of preventative care and timely treatment of illnesses and injuries have left additional thousands of people with “pre-existing conditions” that prevent access to insurance. 

However, I don’t think we are unique in our experience.  Atul Gawande wrote a column for the New Yorker following the Court decision that recounted his own experience with other physicians writing to him with stories about patients suffering from severe preventable health care problems due to inability to get care, or asking if he had any ideas about how to obtain treatment for people with cancer or other severe health problems and no insurance.  He responds to them by saying he does not know what to do for those people.

I have an idea what to do.

Al started out his short slide presentation that evening with a slide showing the Milky Way Galaxy.   He told us that the local Obama organizer had told him that not only were we the only health care provider group in the state organized to provide education about and support of the ACA, but that we were the only one in the country, or even in the whole galaxy.

               What Doctors, Residents Nurses and Others Can Do

 I would like to urge other health care professionals who care about protecting their patients from the health disaster of being uninsured, protecting health care organizations from the burden of unpaid care that interferes with their mission, protecting insured people and businesses from the costs insurance pays to cover that uninsured care, and protecting American health care from the stigma of being inexplicably both the most expensive and least effective in the developed world to form their own little groups. 

Talk about health reform with people you meet socially.  Tell about your own experiences with patients.  Be willing to address church groups and civic clubs.  Be willing to appear in news conferences or to respond to reporters looking for local people to discuss the ACA.  Write letters to the editor and op eds.  Stand quietly on street corners wearing your white coat or scrubs and holding signs.  Even be willing to be on panels to debate opponents of the law.  Educate yourself to be able to answer questions and to refute imaginary objections.  It is hard at first, but I think you will soon find yourself motivated and eager.  After all, up here we live in the heart of Garrison Keillor’s “shy people” country, and we are managing to do it. 

I would be the first to admit that the ACA is not the ideal health care reform that could be imagined, but to paraphrase Donald Rumsfeld, “you go to war with the health reform law you have, not the health reform law you wish to have.”  There are millions of people in this country for whom the survival of this law literally is a matter of life and death.

When you want to talk to your friends about this and can’t figure out how to start, steal an idea from another group organized to help people deal with their health problems.

Tell them you’re a friend of Al.

17 thoughts on “Doctors Fighting for the ACA in Flyover Country — Dr. Pat S.

  1. I am a MD and likely need a liver transplant in a couple of years. The removal of lifetime maximums (mine was $1.4M, of which a substantial amount has been used already) will probably save my life. Prior to my illness, this single change would not have had a huge impact on ME. It can only happen to others, right? I’m one insurance denial away from ‘the end’ (but perhaps not so if high-risk pools are allowed; they will probably charge a fortune). It’s undeniably ‘good’ business (measured purely in profits) and underscores why USA-USA does so well in that sphere.
    As for strident opponents of ACA, I sincerely hope that they stop paying the Medicare tax (if legal) and choose to go the ‘free market’ route instead. Many will require underwriting….and very good luck. Consistency of values will be respected.
    Is an opponent of ACA a hypocrite if they refuse to relinquish Medicare, and can one be in trouble with the IRS if Medicare taxes are refused?
    Since we all pay those taxes, why can’t Medicare be for everybody? Would it cost more than the last decade of errant warfare, or the banker bailouts, for example?

    • Ruth —

      Thank you for sharing your personal story. You are evidence that even for people in upper income brackets a severe health care crisis can break the bank and make critical care impossible to afford.

      The country has three types of people when it comes to the ACA: people who need the ACA right now — sometimes desperately; people who WILL need the the ACA when their health status or employment situation changes; and a lucky minority who don’t need it.

      This year the annual Kaiser Foundation Survey found for the first time that more than half of Americans reported that financial issues had prevented them from getting health care they needed. Without reform — and especially if the Ryan/Romney ideas about Medicare and Medicaid are passed — this is just going to get worse and worse, until health care is a a luxury most low income and middle class people can’t afford.

  2. I live in “fly over” country and I really detest that term. The rest of the post was meaningless to me when I read the title.

    • I used the term ironically. Most of us who live out here consider it a joke about the narrow viewpoint of people on the coasts, not an insult to us.

      My point, however, was that the battle for access, cost control, quality, and justice in American health care is going to be won in the heart of the country, not in the power centers of the East and West. Supporting the ACA and election of politicians who support health care reform instead of politicians who are trying to limit access to care to people who can pay for it themselves is much more important than quibbling about jokes, since it is going to our votes that make the difference.

      Of course quibbling about things is one of the favorite ways the health excluders try to change the topic to avoid discussing real issues.

  3. Inspiring post, Pat. One perception that needs to be changed is that doctors are united in their opposition to the ACA. As you point out, this is just not true. But there are clear-cut differences between the specialties, I think. Most of the primary care physicians I know favor the ACA, warts and all, regarding it as a starting point. The high-flying specialists (i.e., the highly paid ones) seem to be mostly against it. Not a surprise. Lately I’ve been waging political guerilla war in a small way by going into the surgeon’s lounge and changing the TV channel, which is perenially set to Fox News, to something else.

    • Thanks Chris.

      Our group is about 70% primary care, 30% specialists, but we do have support from some pretty heavy hitters in the local specialty scene — the cardiovascular surgeon who started the open heart surgery program here, one of the most respected local oncologists, a general surgeon who was also the CEO of our largest regional health care system, and many others, including a diagnostic radiologist (me.)

      Although primary care people, ER, and OBGyn people see a lot more of the problems related to insurance exclusion, in an area like ours the specialists soon become aware of patients who need their services, often on a life saving basis, but who do not have a way of paying. Specialists have often proven to be as interested in this as anyone.

      From polling I have seen (excluding on-line polls that are completely meaningless because of ridiculously poor technique,) only a couple of specialties are opposed to the ideas contained in the ACA in large numbers. Of course many physicians are no better informed on this than the general public, and consequently have all sorts of incorrect ideas about what is happening.

      Filling the massive information deficit and combatting the equally massive load of myths that the media and the opposition have created around the ACA is what we see as our major goal. People support the goals of the ACA in large majorities, but have been misinformed as to what it really means.

  4. Ruth, Chris, Pat

    Ruth,
    The lifetime (and annual) limits on spending are both cruel and arbitrary. I’m very glad that you now know that you will be able to get the transplant
    when you need it.

    I would like to see some version of “Medicare for all” as a public option– an alternative to private sector insurance. But first, we need to reform
    Medicare. Right now, it is extremely wasteful, covering many tests and treatments that we know are not effective,while not covering things that are needed– for example, regular eye exams. Moreover, Medicare also
    has liftetime limits; you can run out of coverage.

    When we have improved Medicare,I would like to see it available to everyone, but I would want other options. There is always a real danger
    that down the road, we would elect an extremely conservative government that would begin reducing funding for Medicare. Think of what Thatcher did to the UK’s national health service. At that point I would want alternatives, though ideally they would be non-profit insurers.

    Chris–

    I love the image of you quietly coming into the surgeon’s lounge and turning the channel.(I have been told that in doctors’ lounges in many
    hospitals, the TV is always turned to FOX).

    Pat- I’d be curious to hear more about good surveys of physicians’ views of the ACA. Which are the specialities that are opposed?

  5. Pat:

    Madeline Island in Lake Superior and just off Bayfield is beautiful touch of God in crystal clear water with beautiful beaches of sand from sandstone cliffs. Just another ACA writer. Good article.

  6. Pat S. –

    While I’ve had my full share of medical challenges since 1999, I’ve always been fortunate to have good health insurance through my employer. I think everyone should have access to health insurance that reimburses providers sufficiently to ensure that patients can access good medical care when they need it. So, I support the goal of the PPACA legislation to significantly reduce the number of Americans who are uninsured.

    That all said, I think it’s unfortunate that the PPACA, as well as the Massachusetts healthcare reform law, does precious little to control healthcare costs. People want benefits and providers want to sustain and even enhance their incomes. That’s understandable. However, the federal government has already made more promises than it can afford to pay for and most people seem to want more from government than they’re willing to pay for. I’m concerned that the ultimate cost of the subsidies can easily far exceed the estimates by the so-called experts at the Congressional Budget Office (CBO). There will be huge incentives to hide or underreport income to maximize the value of the subsidy that lower and middle income people qualify for. Employers in low wage industries like restaurants, retail and hospitality will also have a strong incentive to stop offering whatever health insurance they currently offer and let their employees get coverage through the exchanges starting in 2014.

    I see very little leadership from the physician community on the cost front even if we had safe harbor protection from failure to diagnose lawsuits if evidence based standards are followed where they exist. Many doctors who practice solo or in small groups treasure their independence and autonomy. They don’t like people looking over their shoulder. Many are not interested and / or can’t afford to invest in electronic medical records systems. There is resistance from the AMA to letting NP’s practice at the top of their license. Competition from outside the guild is resisted at every turn.

    I think your efforts would be even more effective if you and your fellow physicians addressed the issues related to healthcare costs even if it might pinch your own incomes somewhat. If the cost of the PPACA turns out to be significantly greater than expected, what then?

    • Barry —

      As you know, there are few people more concerned with the issue of health care costs than I. Control and even rollback of costs is critical to providing for health care for almost everyone in the US except the most wealthy.

      The ACA does in fact begin a more serious effort to control costs than has been offered by any efforts since the managed care movement of the 90’s, which of course was aborted when pushback and competition made private insurers abandon the effort. The IPAB ramps up the level of commitment to cost control and effectiveness above anything previously offered. The creation of ACO’s and of penalties to hospitals for failure to meet standards of effective and safe care are other features of the law directed at that issue. The exchanges offer incentive to potentially induce insurance companies to concern themselves seriously about cost and effectiveness of health care once again.

      Our group does in fact emphasize the issue of cost control as well as the closely related issue of effectiveness of care. Al and I recently gave a presentation to sixty members of a local service organization in which my half of the presentation was devoted almost entirely to cost control issues.

      There are two huge problems here, however.

      The first is the fact that in the absence of the continuation of the ACA there is absolutely no plan being offered by any serious political players that addresses the issue of access to care for tens of millions of Americans. The opposition to the ACA specifically is dedicated to making access worse, not better. We have seen that in the fallout concerning Medicaid following the SCOTUS decision. Access to care is worsening year by year, and consequently the threat of loss of the ACA without some workable alternative — yet to be contemplated much less proposed — is a life threatening emergency for millions of people.

      Second, the opposition to the ACA is not willing to offer any serious workable plan for control of costs while preserving adequate care and access, but rather is committed to plans that work by decreasing access even further by making larger and larger amounts of health care costs out of pocket expenses for patients, and to aggressively inhibiting serious efforts to rationally control costs. Just today, the House began action to defund and eliminate the Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Outcomes Research Institute (PCORI,) two of the most important government research agencies dedicated to evaluating effectiveness and cost effectiveness of health care.

      I do not view the ACA as a finished product. Many of the issues you raise are good ones and need to be addressed in the future, but for there to BE a future for serious health care reform in the US the law must be preserved. The choice is not between the ACA and a more carefully constructed nuanced approach, or between the ACA and any program that resembles any of the very successful programs in place in virtually every other developed country. The choice is between the ACA commitment to developing a health care system that addresses the triplet problems of access, cost, and effectiveness and a plan to abolish the 20th century and return us to the great days of the McKinley administration.

      The ACA gives us a starting point for beginning to work toward a just and effective US health care system. There is no workable alternative in play to address that. Although you are correct that many doctors do not want to think about all these issues and would resist serious efforts to deal with them, many other doctors have been and will be in the front lines of this fight, since doctors know more than almost anyone else what is at stake because they see the suffering, waste, and ineffectiveness that characterize our current system. That is what the Friends of Al are doing and will continue to do.

    • Yes cost controls. But Obamacare is already the “biggest government takeover in US History”, whatever that means. Imagine if there were actual significant cost controls? Do you like being called comrade? Because real cost controls sound like communism to me!

      Also, don’t people already have “huge incentives to hide or underreport income”? Those incentives are called “taxes”. Luckily the threat of jail time somehow provides proper counter-incentive to the average American to correctly report income to the IRS.

      Sorry for all the sarcasm, but ACA is the best bill that could possibly pass given our dysfunctional government. It’s a significant improvement over the status quo. Instead of complaining about progress, get out there and make more!

  7. Pat S. –

    Thanks for the detailed response as always. Just to be clear, I do NOT support trying to repeal the ACA. I want to see the number of people without health insurance decline as much as possible. I do worry about the cost of the subsidies, though, as I noted last time.

    The ACA puts significant limits on what the IPAB can do to control healthcare costs so its effectiveness is likely to be limited, at least in the near term. I think there is also a significant risk that Congress will attempt to defund it or even kill it altogether. I was also disappointed to hear that Congress is again going after the AHRQ.

    I think ACO’s have significant potential to deliver care more efficiently and cost-effectively. We certainly need to move away from the fee for service payment model in favor or some combination of bundled and capitated payments. I’m concerned, though, that ACO’s with outsized local or regional market power might be able to extract a capitated price high enough to drive healthcare costs even higher than they would have been under fee for service. As I understand it, something similar has already happened in Boston with the BCBSMA Alternative Quality Contracts.

    I continue to be troubled by what I perceive to be an attitude among most doctors that their job is primarily to diagnose and treat patients. It’s not their job to know or to care about costs except on a case by case basis when patients indicate that they are either uninsured or face potentially high coinsurance payments. Moreover, as I noted in my last comment, the AMA has a long history of trying to stifle and thwart competition from outside the guild. Since doctors’ decisions to order tests, prescribe drugs, admit patients to the hospital, refer them to specialists, consult with patients and perform procedures themselves drive almost all healthcare spending, they need to take a leadership position in bending the cost curve. I think it’s going to be an uphill battle to put it mildly.

    In Germany and Switzerland, insurers negotiate with providers as a group in each region or canton (Switzerland) to maximize their bargaining power. Insurers in the U.S. would need an anti-trust exemption before they could attempt a similar approach. I suspect that both hospitals and doctors would be staunchly opposed to that idea. Costs weren’t dealt with in Massachusetts or in the ACA because the provider groups were perceived (correctly) as too powerful to take on. When I see doctors and hospitals taking a leadership role in bending the medical cost growth curve, I’ll be a lot more optimistic about the sustainability of our system.

    • Just two quick points:

      “I think it’s going to be an uphill battle to put it mildly.”

      I agree totally. That is why the impetus for this is going to have to come from outside the normal day to day medical practice. No one has succeeded in cutting costs by saying “let’s be sensible.”

      The impetus is going to have to come from payers — and in the US for now that means Medicare, since private insurers are reluctant to engage in effectiveness based cost control since the managed care debacle, preferring to control their own costs by using higher co-pays and deductibles. Medicare will need to expand their already existing efforts to make health care payments contingent on effectiveness.

      Second, someone — and again this basically means Medicare — will need to push providers and hospitals to be more accountable for the effectiveness of their care, including pushing for discharge follow-up and for prevention of patient injuries.

      Third, someone — ditto — will need to push providers and hospitals to form organizations that will offer care systems that take responsibility for the patient as a whole, modeled on programs like Mayo, Intermountain, Kaiser, etc. There is emerging data suggesting that the key factor in providing more effective care for less money is well integrated systems with clear cut models for management.

      In the end, if Medicare will carry these efforts to begin with, private insurers will be given cover to be more aggressive themselves and will begin these efforts as well, a pattern that we have seen repeatedly.

      Finally, I think that most progressives would be eager to adopt programs like Germany and Switzerland, where government entities, providers, and very well regulated usually non-profit insurers join together to set both pricing systems and practice patterns based on effectiveness.

  8. Pat S. –

    When I think about the aggressive pushback that occurred after CMS tried (successfully) to save money by opening durable medical equipment to competitive bidding, it’s discouraging to think that it will be allowed by the Congress to drive waste out of the healthcare system by pursuing some of the strategies that you outlined. On the other hand, as the need to do something substantive about the federal fiscal imbalance comes to a head, presumably after the election, maybe it will be easier for CMS to withstand pressure from the physician and hospital lobbies to maintain the status quo. I note encouragingly that even the ethanol lobby finally lost its subsidy though it took over 30 years. In theory, it should be possible to reduce federal spending on healthcare without cutting benefits to enrollees or raising beneficiary premiums further on higher income people or anyone else for that matter.

    On the private insurance side, they have multiple product offerings from broad network insurance policies to narrow network HMO’s to tiered networks. The tiered networks are comparatively new and seem to be gaining some traction as employers are increasingly interested in controlling healthcare costs and employees suffer stagnation in wages along with higher co-pays and deductibles. There should be room for further experimentation here regardless of what CMS does or doesn’t do especially as the industry continues to consolidate into fewer but larger entities. To paraphrase the economist, Herbert Stein, if a trend can’t continue, it will stop.

    As for the likes of Mayo and Kaiser, it’s been quite difficult for them to fully replicate both their model and their culture outside of their home markets. For Kaiser, even in Northern CA where its market acceptance is greatest, its premiums don’t seem to be much if any lower than its competitors. I’m not sure why that is since the insurer and providers are on the same team, they offer integrated care and they make extensive use of electronic records.

  9. I am whlstling the Star Spangled Banner as I read about what is happening to my profession on the other side of the Atlantic. May I offer a little insight from a country with a National Health Service that absorbs most of our GDP? Don’t worry, we can still afford to help you with your wars! Everyone loves the NHS here even though patients often need to be very patient and wait for a long time for elective surgery.

    I am watching what happens across the pond with some interest and have an insight for you: All will become clear when you stop calling sick people ‘patients’. This is a serious error. These people are CUSTOMERS not patients. Once you assimilate this knowledge, an obfuscating fog will lift from over this issue. Do you think BIG PHARMA, BIG INSURA and BIG MD CLOSED SHOP’s actions are aimed at customers or patients?

    What happens to a ‘customer’ with no money and no credit card who strolls into the Ferrari showroom and asks to test drive the latest model? Try it and find out. All businesses seek out customers who can pay. Medicine became big business in America in 1776 when your founding fathers promised liberty the pursuit of happiness and JUSTICE but NOT universal healthcare for all.

    I do understand that making amendments to the Constitution are prohibitively expensive so accept that that ain’t gonna happen.

    Thus customers who cannot afford healthcare must be content to watch top medicine on TV in the USA. Only there will they find it absolutely confirmed that indeed it is the USA that provides the BEST MEDICINE MONEY CAN BUY.

    • “the USA that provides the BEST MEDICINE MONEY CAN BUY.”

      Would that it were so.

      In the US, the highest income quintile actually has worse health care results than the lowest income quintile in your country.

      US health care tends to spend way too much money and attention on heroic intervention in catastrophic situations and way too little on dealing with the more mundane things that are more important for most patients’ — excuse me, customers’ — health.

      We are the Navy Seals, you are the local constabulary. We stand ready with assault helicopters, rocket launchers, and smart bombs while you are puttering about in squad cars and foot patrols armed with a nightstick and a radio. However, all that does us very little good in dealing with traffic violations, domestic abuse, rowdy drinkers, and misbehaving youth — we are waiting around for a terrorist assault that we will handle with great skill, but you are much better in dealing with the other 99.9% of problems.