Why I Support the Affordable Care Act

     

Watching another instant classic Jimmy Kimmel clip made me realize that we supporters of the ACA have been failing. Jimmy Kimmel went to talk with people on the street about whether they supported the Affordable Care Act versus Obamacare. The joke was that everyone supported the ACA and no one liked Obamacare, highlighting the fact that most people failed to realize they were the same thing. I want to make sure you know why I support "Obamacare", aka the Affordable Care Act. 

     At a recent town hall meeting with CA Secretary of Health and Human Services Diana Dooley, she highlighted that the Affordable Care Act has three legs to it. The “Affordable” part, aka the delivery and finance reform, the "Prevention and Wellness" leg, and the "Coverage Expansion" leg. This third leg, the expansion of coverage starts this week. Each state runs its own health insurance exchange, ours is “Covered California”, which is basically an online marketplace for health insurance. You can visit the website at https://www.coveredca.com/. From my work with creating websites in the past, I have to give major credit to Secretary Dooley and her office for the user interface and ease of use. Check it out yourself, in one of the 14 languages it's been translated into. Starting now, you can “enroll” in health insurance that will go into effect on January 1st 2014. All insurance providers who enter the exchange are required to cover 10 Essential Benefits. 

      To give you some examples of the coverage rates. If you are single, and make $27,000 a year, your health insurance will cost $175 per month, thanks to a $2460 subsidy by the federal government. Or lets say you are a nurse with a family of 4, earning $88,800 per year, your monthly health insurance will cost $700. Compared to the old individual market, where a family of 4 could cost $2k-3k a month, these are very affordable plans. The rates vary depending on the particulars of the plans you choose of course. 

    As for the other two legs of the ACA, I’ll be brief, you need to know that with the “Affordable” leg the ACA bans discrimination based on pre-existing conditions and bans insurance caps. For us healthy folks, this doesn’t mean a whole lot, but it is a really big deal. The number one cause of bankruptcy in the US is health care costs. Now, because of the ACA, less people will go bankrupt due to hitting their insurance limits while on chemotherapy treatments or living with cystic fibrosis. With regards to the “Prevention” leg, your routine health screenings, vaccines, and birth control will be free. Many of these perks have started to kick-in already. Check out https://www.healthcare.gov/prevention/ for more. 

     Is the ACA really such a big deal? A resounding yes. The insurance reform, focus on prevention, and extension of coverage, are exactly what we need in the health care sector. The ACA will make us healthier as people, communities and as a nation. There will be bumps in the road, the ACA is not perfect (has any legislation been perfect ever?), but it is definitely a big step forward. As Congresswoman Anna Eshoo recently remarked about us Americans, “we love our history once it’s been made, but we seldom embrace the fact that we are making it. As someone who was in the Senate chambers on March 23rd 2010, watching the Senators vote for the passage of the ACA like a Giants fan in game 7 of the World Series,  I knew that I was part of something historic. I will consider it an privilege to serve my country as a doctor under the Affordable Care Act. 

I hope you’ll join me in my support and spread the word yourself. 

Weekly Goods

A good book...
Hilary Rodham Clinton's Living History
Finally finished it. My favorite part of the book was learning more about her younger days, at Wellesly College especially. It was also interesting to hear her opinions on the contrast between her image as First Lady when she tried to take on legislative roles vs advocate for women's rights internationally. Her China speech as Women's Rights being Human Rights is historic, a must watch, and an excellent call to arms. "If there is one message that echoes forth from this conference, let it be that human rights are women’s rights and women’s rights are human rights once and for all". I know that in the development world so many people are advocating for women's rights as a path towards development, and I think Hilary was the one who really set that agenda in action. I'd be proud to support her in 2016 if and when she decides to run. I couldn't think of a better candidate.

A good song...
Let Her Go
By Passenger, this is a beautiful song. I want to learn the guitar so I can play it myself.

A good film...
Miss Representation
A few facts I learned from this film... Cuba, Iraq, China, and Afghanistan have more women in politics than the U.S.... Did you know domestic abuse was acceptable denial of insurance as a "pre-existing condition?" (Thank goodness for Obamacare)...I also didn't know that the US is the only industrialized nation without paid family leave. Jennifer Newsom did a great job.

A good talk...
Stanford Population Health Symposium 
I attended Stanford's kick off conference debuting the new department of Population Health.  The best part was my lunch table conversation with Dr. Jack Rowe, former CEO of Aetna, and Dr. Mads Melbye, head of the Danish National BioBank -to say it was an interesting conversation is an understatement.

A good youtube..
Hitting the Wall
Paula Newby Frasier, one of the epic ironman triathletes in 1995 pushed herself beyond her limits. This is a heartbreaking and inspiring video illustrating her limits. "Totally surreal". It shows how dangerous athletics can be when we are strong enough to push ourselves beyond our limits. You get knocked down, but you get up again. That's the best 4th place finish I've ever seen.

Another good week in the books.

Weekly Goods

Attempting to get back in the blogging groove, here are a few highlights of last week.

A good movie...
La Misma Luna
A wonderful movie directed by Patricia Riggen about a boy and his mother.  An enticing summary can be found here. Spanish with english subtitles, so a great movie for improving your spanish language skills as well. It's also called Under the Same Sun. Watch the movie trailer for yourself.

A good song...
Pure Imagination
A hauntingly beautiful song remade by Fiona Apple. This is the song behind Chipotle's latest advertisement, The Scarecrow.

A good book...
The Thoughtful Dresser
A novel by Linda Grant taking a closer, and more serious look into our love of fashion. She intertwines many wonderful bits of fashion history, from Chanel to Christian Dior's New Look, while telling moving stories of the power of fashion and style in the face of of atrocities against humanity. Makes me like fashion even more then I did before. Quick and easy read, if you like fashion at all, this book is for you.

A good eat...
Boulevard
After making a reservation 3 weeks ago, we finally had dinner at Boulevard. If you are up for a gourmet meal, wonderful ambience and the best halibut I've ever tasted, Boulevard is where you should eat. Chef Nancy Oakes lives up to expectations, now I want to check out her other restaurant in town, Prospect.

A good talk...
ACA Town Hall Meeting 
I attended Stanford's Affordable Care Act Town Hall Meeting today. The guest speakers were Congresswoman Anna Eshoo, California Secretary of Health & Human Services Diana Dooley, and Stanford Pediatrician Paul Wise. Enrollment in "Covered California", our health insurance exchange begins next week. Thus why House Republicans are all in a fit this week. Diana Dooley did an excellent job breaking down the 3 legs of the ACA, the delivery and finance reform, prevention and wellness aspects, and expansion of coverage. My favorite quote from the event was via Anna Eshoo, "We love our history once it's been made, but we seldom embrace the fact that we're making it". Let's hope that with the bans on lifetime insurance caps and discrimination based on pre-existing conditions that health care stops being the number one cause of bankruptcy in the US.

A good run...
Palo Alto Moonlight Run
Stanford Med came out in full force, fundraising over $6k for our free clinics in honor of former Dean Phil Pizzo, aka Marathon Man and one of my idols. I entered the 5k race, and wasn't going to push myself, because I strained my calf earlier in the week (yes injuries still mar my existence). But, when the gun went off, I couldn't help myself and I went for it. The sheer joy of racing was felt in every ounce of my being. I was grinning from ear to ear for at least the first half of the run (don't worry shortly after I started to feel like I was going to die from lactic acid). Seriously though, such a joy to be out there with everyone. Racing is a spectacular feeling! Even though I was about 200 people back and took a solid 5 minutes before we were going faster than 10 min/mile pace, I somehow managed to win my age division? I didn't even know this until my advisor emailed me saying she picked up my medal for me. Sure enough, I am now in possession of a blue ribbon medal! A surprising highlight. I think I can run a pretty good 5k in the upcoming year. So here goes nothing...

Ok, first post in two months, have to start somewhere. This was certainly a good week, hopefully I"ll have something worthy of posting soon. Pass along any "goods" from your week.

Affordable Care Act

Quite a few folks have asked my opinion on the Affordable Care Act. My bottom line on health care: providing health care for citizens is a fundamental component of a fair and just society. On a daily basis I am horrified at the disparities in care and outcomes I witness.

The details of how we provide universal health care for citizens of the United States are just that, details.  I agree 100% with Ted Kennedy's philosophy:

"...Quality care shouldn’t depend on your financial resources, or the type of job you have, or the medical condition you face. Every American should be able to get the same treatment that U.S. senators are entitled to." 

Ted Kennedy

The most difficult specialty in medicine

Family Medicine.

Are you surprised at my answer? Here are my 5 top reasons, see if you disagree by the end.

1. Breadth of knowledge. 
General practitioners like to say they care for patients from "womb to tomb". It's impressive. Knowing pediatrics, preventive medicine, all specialties, geriatrics, end of life care. On any given day in the clinic I would see cases that spanned the entire first two years of medical school.

2. Early infancy of disease processes.
It's easy for the specialist to look back and say, how did the PCP miss this? The tough part of primary care is that you see disease in it's early phases, often before the easy hallmarks become apparent. It's really difficult to diagnose some diseases in their early phases.

3. Behavior change.
We all know how to stay healthy: diet, exercise, sleep, joy in our life, avoid stress, good relationships, no evils like smoking, alcohol or drugs. Easy eh? These are the things that GPs deal with every day, they are in the trenches trying to improve health care in the U.S.

4. Keeping pace with changes across medicine.
How many studies and policy changes occur every year? How do you decide which ones to follow, to change your management of patient care? Keeping up with the NY Times controversies, from cancer screening to statin side effects to HPV vaccines and contraception -a frontline doc needs to stay on top of the headlines and have a critical take to inform their patients.

5. Current structure of healthcare delivery.
GPs bare the brunt of the disaster that is currently known as American health care delivery. They're also going to be the area of medicine most transformed in my life time, no doubt about it. Change is hard.

PS. Family medicine, general practitioner, primary care provider, pediatrician, general internist are all generalists, first line doctors who help keep America healthy.

PPACA -Health Care Reform

Did you know that the new health care reform doesn't have limits on insurance premium prices? The reform may be better than nothing, but it is seriously lacking...

Asha Medical Foundation

This evening I had the good fortune to listen to a talk by Dr. Kiran Martin, the Director of the Asha Medical Foundation, which is an organization that delivers health care to slum communities in India. Dr. Martin is a remarkable woman, she speaks with passion, has a clear understanding how to get results, and is motivated to make the most impact possible. She challenged all of us in audience (as we enjoyed the delicious Indian food), to do more to improve situations of those less fortunate than us. She spoke quickly, so I'll have to paraphrase her challenge:

"You can be the people with the inspiring vision, the credible vision, the moral authority. You can use your gifts to see that the shame of child poverty will not have the last word. This is my challenge to you"

In the last 21 years, Asha has been successful in creating a sustainable model that is not expensive, but gets results. They train community health workers (selected by those in the slum community) to do the majority of the medical work, health prevention, promotion, mid-wifery roles. They connect the communities to excellent referral systems to meet with medical specialists when needed, and focus efforts on education folks to take an active role in getting clean water, electricity, housing rights, sanitation for their community.

You can learn more about ASHA here.

VideoMD

Learned about this website tonight, VideoMD.com. I think it's a really good idea to use short videos to give health information to patients, and this is a starting point. Take a look and let me know what you think.

Shout out to Jay for passing along this info!

Cartoons about the US HealthCare System

These are pretty much right on. Comedy is the best medicine. I particularly like the one about intelligent design...SO TRUE.

3 Totally Unrelated Notes

1. This Simpsons clip about St. Patrick's Day is awesome. My mom used to sing that song to me when I was little!

2. Learn something every day: In medical/legal speak CMO means Comfort Measures Only. As I learned from this NYT blog This is differs from DNR/DNIs in that CMO means "stop doing tests, stop giving antibiotics, and start giving enough intravenous narcotics that she wouldn’t have to live in pain."

3. Information Therapy -a new area of medicine and health care that helps patients sort through medical information, be better informed and hopefully help them to feel better. Harvard Pilgrim has an awesome Interactive Conversation feature about low pack pain that I think is really cutting-edge and awesome. Found this in a WSJ article that talks about some cool stuff Kaiser is doing to help all of us understand our health, see how it changes overtime and generally be healthier because of it!

Update:
4. Kyrgyzstan is the one country in Central Asia that I could not name. It's official languages are Kyrgyz and Russian and the majority of the population is Muslim and it's supposedly an incredibly beautiful place!

Check out Medpedia

I wrote about this Medpedia a while back when it was in Beta, well now it's launched so you should check it out.

It has 3 main objectives:
1. Be the go-to website for accurate medical information (Edited by physicians only)
2. Social networking site for medical professionals (View my roommate's profile here)
3. Create online disease/illness/health interest communities

Pretty awesome idea, I definitely joined and I encourage you to do so as well.

8 Ways the Stimulus Bill Will Improve America's Health

From Division A, Title IX

• $600 million for the training of nurses, primary care physicians and dentists and to boost funding for the Health Service Corps
• $1 billion to renovate and rebuild health centers and health IT
• $1.5 billion to the NIH specifically for funding more scientific and clinical research
• $700 million to fund comparative effectiveness and evidence-based research (Ie the beginnings of a Federal Health Board made up of physicians in federal agencies that will examine current clinical patterns vs. the evidence-base and will create an annual report to the president and congress
• $2.1 billion to expand the Head Start program
• $2.5 billion for immunization and disease prevention programs

From Division B, Title III

• Extending COBRA benefits for those left unemployed

Division B, Title IV: Health Information Technology (HITECH Act)

• Policy and Requirements for national health IT standards and implementation

You can read the whole bill for yourself here

The Health Care Crisis

Health Care can be dwindled down into 3 basic parts: Cost, Quality, and Access. It is almost impossible to improve all three parts at the same time.

So far the media has focused on Cost and Access. Republicans yell about cost, Democrats rant about access. I think they are both important to the average American. My question is, what can we do now to improve our health care system for the long term? So we can improve all 3 aspects over time?

It's a tough question, no easy answers. Can focusing on quality and access to care lead to reduced costs in the long term? Will focusing on cost and quality lead to improved access in the end? How will technology play a factor in this triangle? Right now most assume that technology is increasing costs, but what if our innovations in the future lead to reduced costs? We have MRIs now, like the mega-computers of the 80s. Who is to say we won't have improved imaging technology in 15 years at much lower costs? This I believe, we are destined for. So, with this belief in mind, that technology will lead to lower costs of care in the future, I saw we don't worry about increased costs for now. I say that all these projections of the Health Care Sector taking up 40% of the GDP are wrong. Yes we do have some startling problems with an aging population and a fattening population, but I am seeing technology being the key to this, reducing physician visits, ER visits, making care accessible and affordable.

With this in mind, the government should own up, and take more of the costs off American's back. But we shouldn't worry about cost in the big scheme of things. Right now we need to focus on improving quality of care and access to quality of care first and foremost. This means we need a larger physician and health care provider pool and we need to really tackle quality. I don't have the time to go into quality of care right now. But lets just say that continuity of care would make for so much less duplicate and extra care that I think that would be a good place to start.

Medical Interpreters

I've had the fortune of working with several different medical interpreters at my job. Russian, Japenese, Cantonese and Mandarin speakers. I've come to respect their role for patients who do not speak english, it can be a tricky one. I wish I spoke a different language because I've very interested in learning what exactly changes through translation. I see the role of the medical interpreter to be one of complete translation, word for word, what the physician says to the patient. But given the variation in language this can't be true 100% of the time. My other respect for medical interpreters is derived from the fact that they work in all different types of health care settings, disease areas and spectrums. They must know so much medical terminology! This cross-work in different areas of medicine must give medical interpreters a very unique perspective on the health care system. I wonder if anyone has taken the time to ask them what they thought of how care is given in these different settings? What they thought could be done better?

Insurance coverage for medical procedures

I have some questions about insurance coverage that I thought I'd throw into the blogosphere.
Who determines whether a certain medical procedure that reduces risk will be covered financially by the insurance company?

My question comes from issues surrounding prophylactic mastectomies (removing a breast even though it does not have cancer). Given the improvements in cosmetic outcomes of breast reconstrcution, many more women who have breast cancer in one breast are interested in having the opposite breast removed as well. In general, there is about a 10% chance of developing breast cancer in the opposite breast when you are diagnosed with breast cancer. Is this procedure paid for under this particular situation?

Another example: a 30 year old woman with a family history of breast cancer, her mother had it, her older sister had it, has recently tested positive for the BRCA1 gene, meaning that she has about an 85% chance of developing breast cancer in her life time. This woman wants bilateral prophylactic mastectomies. Will this be covered by insurance?

The core of my uncertainty with these two situations is that in neither case does the medical procedure "treat" a disease, it only reduces risk. My question is, at what risk reduction is this procedure considered appropriate? What if the risk of developing breast cancer is 5%? 15? 50? 90? And who has the authority to deem the "medical appropriateness" of this procedure? Let's say that one doctor deems that a particular woman has a 20% risk of breast cancer and this risk warrants a prophylactic mastectomy. What about financial coverage of this procedure? Will insurance companies listen to this physician's logic? Do insurance companies have their own formulas for what risks they are willing to take on (ie deny coverage) compared to what is "too risky" (ie they will pay to reduce the risk)?

In terms of what I think, I think that if a doctor has evidence in the medical literature to reduce risk by doing the procedure, and if the patient is highly risk averse, then the procedure should be covered--assuming that the risks of the procedure are minor compared to the risk potentially reduced.

This is also a situation where the grayness between evidence-based medicine and consumer-based medicine come into play. Let's say the doctor does not feel that the procedure would be a good decision, but the patient really wants the surgery. She doesn't care if the medical literature states that the mastectomy would minimally reduce her risk. Psychologically, she "wants the breast off", "doesn't want to lay awake in bed every night worry about it" etc. What's the role of the physician in this situation? To be consumer-based, to do the surgery because of the patient's desire. Or to be evidence-based and not perform the procedure? How does costs play into this decision? What would most doctors do in this situation? What ought doctors do? What would insurance companies do in this situation What ought insurance companies do?

Why Hillary Clinton's health care plan won't work

I was too young to remember the 1992 attempt to reform health care made by Hillary Clinton so I can't be a primary source on the matter. But, I have taken several classes on health care and done a ton of reading on why it failed.
Health care is NOT a partisan issue, we all want everyone to have health care, Most people that are Republicans do not like the idea of universal health care for two reasons:
1. Cost (the dirty T word)
2. Choice

Number 2 is a BIG number 2, this is the reason that Mrs. Clinton's 1992 policy failed, and this is the reason why her 2008 plan would also fail. It's like putting fresh kill in front of a lion, the Republicans will shoot down her proposal so fast it is not even funny. NOT FUNNY. NO NOT FUNNY. It's not funny because we really do have a serious problem, our health care costs per capita are so exorbitant that even if we mandated people to pay, they would not be able to! There is not a shot in hell that this proposal will get past Congress, and there will be such negative ad campaigns on our television airwaves that even the American public will be against it. American people are capitalists, they like CHOICE, conservatives (read: insurance companies) will conjour up images of day-long waiting lines, poor quality care, and all those other horrible things that apparently happen when you don't have choice in your health care insurance...

Hidden inside reason number 2 is the idea of accountability. If we are going to mandate health insurance, how are we going to enforce this? Will there be a penalty? If you don't enforce it, then what's the use, and if there's a penalty, doesn't that strike you as unfair? Penalizing the very people that need our support and fair policy the most? This particular point really urks me -any reasonable person who knows anything about health care policy knows that enforcement and accountability are BIG deals. Again, feeding the lions.

I would love love LOVE it if someday we have completely equitable, cost-effective health care in this country. If it could happen overnight, that would be like a dream come true. I think we can make some excellent strides towards a single-payer system (which, if planned right, would also be a dream come true), but you have to have evidence to prove it can work! Starting with an opt-in policy like Obama's is reasonable: we prove to the American people that the government as a single-payer is feasible, and through our ability to show results, we can draw more and more people towards this system. At a certain point, the large bargaining power will result in huge price drops for the American public, and like signal transduction, we'll recruit even more citizens to be a part of the single-payer system! This is reasonable, feasible, and thought out by none other then David Cutler, Professor at Harvard, Barack Obama's health care lead.

I would like to point out that the founders of Medicare and Medicaid, also think that this program is the most politically feasible and pragmatic way to reform health care. Their names are escaping me right now, but I can always look them up if you are interested.

Why are health insurance companies for profit?

This revelation struck me this morning as I was reading an article on the front page of sfgate that I have a personal connection to.
(http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/12/15/MNQETTOVL.DTL)

Kaiser profited over $2.9 BILLION dollars in a 9 month period this year. (http://www.bizjournals.com/sanfrancisco/stories/2007/11/05/daily36.html)

Kaiser also forked over $96.1 million dollars to the consulting company McKinsey, in 1995. (http://www.kaiserpapershawaii.org/kaiserwatch.htm)

But Kaiser can't afford $250,000 to pay for one person's experimental therapy when it's their fault their "prevention and early detection" strategies didn't work? A simple biopsy could have prevented their need to pay this money, instead, IT'S TIME TO FORK IT OVER KAISER.

this makes me really peeved.

My HMO vent.

We pay so so so much for health care. $700 per month in my case, but of course, I "only" pay $17 a month, the rest is taken out of my wages. So, when I hurt me knee (or hip, or back...) I expect to be able to see a Doctor, not any doctor, but a doctor who knows a lot about Orthopedics, you know, because I have history in this area and I'm pretty sure that's what I need!

Instead, scenario A happens: I call up my PCP (read: was put on hold for 5-7 minutes), and to then, to my surprise, my PCP isn't accepting any new patients! Even though she's supposed to be my doctor!!! So I have to call another office, oh GUESS WHAT? Not a single primary care physician at UCSF is accepting new patients, WOW. Unbelievable. So, I call some other random PCP, oh wait, no, not that easy, I find out that first my insurance company must approve the switch! So, I call my insurance company (read: was put on hold for 10-15 minutes this time), and I was finally able to make the change, but of course, it will take 3-4 business days to process.

So basically, I can go to the Emergency Clinic, wait about 2 hours and have some snide doctor think that he has seen my case before and I don't really need an MRI, because, you know, we're trying to cut medical costs in this country and frankly my knee/hip/back just isn't worth it.

BAH.

The Future

I've been impressed with a variety of individuals as of late, and I think one thing they all have in common is their ability to look towards THE FUTURE. Innovation is a very exciting part of life, we are are all born innovators, child development is like programmed human innovation, we're always reacting, learning and adjusting. However, I think the ability to look way ahead in the future, see what could be, or what is necessary at the end produce if you will, and then have the capability to break down that version into smaller attainable steps over a timeline is a TREMENDOUS talent, and I think that this quality is extremely impressive in people. To be able to grasp a concept, create it, play with it your mind, fully understand it, and then convince others to believe and invest in your idea and your time line, is so impressive. I think the health care industry needs to be looking to the future more, and as of yet, we don't have a leader that is able to innovate and get other people to invest effectively. I think my current example of someone who I think has a keen ability to understand the future of their industry is Steve Jobs, and I wish I could see in his head and understand what he thinks out communication, music, and video technology will look like in 20 years.