A Direct Primary Care Medical Home: The Qliance Experience

Why are conservative attacks on universal healthcare always so lame?

An Astoundingly Tone-Deaf Piece by Sally Pipes in Forbes Magazine.

“The pandemic has revealed the rotten core of single-payer.”

I can scarcely fathom a more obtuse sentence. Here we are, in America, currently competing to be a shit-hole nation, and Ms. Pipes is so clueless that she thinks the pandemic has exposed other nations’ healthcare problems. Wow. Just wow.

Data from the Kaiser Family Foundation showed the uninsured rate in America, thanks to the Affordable Care Act, had declined from around 17% to about 10%. So, as of 2018, about 27.9 million people in the US were uninsured. (For those of you who have not had the misfortune of reading Ms. Pipes work, these 27. 9 million people can’t even qualify for the horrific queues Ms. Pipes laments about.) Since the pandemic, these numbers have skyrocketed, as Mr. Trump might say. With the massive waves of unemployment due to the pandemic, Families USA estimated more than 5 million laid-off workers joined the ranks of the uninsured. They, too are not even eligible to get in the queues for care that Ms. Pipes laments.

Ms. Pipes points to the sad case of a man who died from kidney failure due to delayed elective surgeries in Canada. Sad, of course, but Ms. Pipes is no doubt aware of the saying attributed to Stalin, “A single death is a tragedy; a million deaths is a statistic” While Ms. Pipes is lamenting the Canadian system for this tragedy, the US healthcare system is guilty of the statistical heap of deaths due to kidney failure in the US. According to the CDC via the National Kidney Foundation:

Early referral to nephrology is associated with improved CKD outcomes, however Black or African American patients are more likely to have delayed referral or no nephrology referral at all. Communities of color are also overrepresented among patients with end-stage kidney disease. For every three non-Hispanics who develop kidney failure, four Hispanics develop kidney failure. Black or African Americans are three times more likely to suffer from kidney failure than Whites.

Pipes notes that three dozen people have died in Ontario due to cancelled heart surgeries. I hate to make light of this, because, you know, most Canadians care about each other and this bothers them. But in America, this is chump change, in terms of the cost in human lives. Again, More than 30 million Americans can’t even get into the queue for the cancelled heart surgeries. As Ms. Pipes probably knows, showing up in the Emergency Department actually having a heart attack does not turn out as well as having a primary care doctor you can afford to see and maybe try to avoid the heart attack in the first place. According to the American Heart Association (references omitted),

Americans with CVD risk factors who are underinsured or do not have access health insurance, have higher mortality rates and poorer blood pressure control than their adequately insured counterparts. Uninsured stroke patients also suffer from greater neurological impairments, longer hospital stays, and higher risk of death than similar patients with adequate coverage. Not having coverage or having inadequate coverage also impacts patients’ financial stability. More than 60% of all bankruptcies in 2007 were a result of illness and medical bills – more than a quarter of these bankruptcies were the result of CVD. Nearly 80% of those who filed for medical bankruptcy were insured. Additionally, uninsured and underinsured patients are more likely to report access issues related to cost, including not filling a prescription, forgoing needed specialist care, or even not seeking medical care during an acute heart attack. Delaying care can have huge negative consequences for both patients and for the healthcare system. To that extent, it is clear that not having access to quality, comprehensive health coverage and care is bad for patients.

Her next example is a woman from Nova Scotia who had to resort to a GoFundMe campaign to pay expenses for lung transplant surgery! Can you imagine? Oh, wait, about half of all money raised on GoFundMe is for medical expenses. The Guardian recently reported that “25% of Americans say they or a family member have delayed medical treatment for a serious illness due to the costs of care, and an additional 8% report delaying medical treatment for less serious illnesses.” BTW, the Guardian sites an anecdote about a woman who called in sick due to pneumonia and lost her job and her health insurance for exceeding her employer’s attendance requirements by one day.

And speaking of financial hardship, or the “financial toxicity” of disease, researchers reported in 2018, pre-pandemic, that, for Americans newly diagnosed with cancer between 2000-2012, at just year two, 42.4% had depleted their entire life’s assets, with average losses of $92,098. Only 7.9% of these were uninsured.

The overarching theme of this piece is that somehow citizens with universal and affordable access to care are paying a steeper price than those of us with an unreliable and expensive healthcare infrastructure. She gives examples of people with access to universal, affordable healthcare are now caught in a backlog due to the pandemic. That is awful. But, the idea that America is somehow immune to the disruptions necessitated by COVID-19 is so ludicrous that I don’t think it needs dignified with a reference. If the planet you are living on has not allowed in enough oxygen to allow you to not see what utter nonsense this is, then you stopped reading this a long time ago!

This wouldn’t be a Sally Pipes piece without a partisan attack, and she does not disappoint, attacking Joe Biden and Democrats for working towards universal healthcare. She closes with this precious line, “The pandemic has revealed the rotten core of single-payer.” I have been saying for some time now that avarice and amorality are the rotten core of American Healthcare, and the pandemic has, as possibly it’s only upside, exposed the truism that American healthcare is a mess.

Cognitive Science Lessons.

People like Ms. Pipes have spent decades making sure that stories like the ones she has in her articles are pushed front and center in people minds. It is very effective in insuring predisposition to opposing healthcare reform for the following reasons:

Recency Effect and Availability Bias. Placing narratives, especially emotionally charged ones, as Pipes’ does expertly, is a powerful tool. It activates our mind in several ways. Because we hear stories like these repeated by conservatives over and over again (mostly the same set of stories), they are both recent and available, and thus come to mind when we are asked to think about universal healthcare. When there is a discussion of the topic, these types of anecdotes come to mind and reinforce opposition, if that is our predisposition, to change. The obvious counter to this is to make the “American Horror Stories” that physicians, nurses and really anyone who has had an interaction with the healthcare system, know so well, and tell those thousands and millions of stories! Even for someone who has run the gauntlet and gotten the crowning jewels of medicine, like a transplant or interventional procedures or survived sepsis in the ICU, it is rare to not have numerous tales of the hassles of prior authorization and “explanation of benefits” forms and bills and checks and everything that makes the business of medicine such a horror show.
Loss or Risk or Dread Aversion. Knowing or hearing stories of dreadful outcomes creates powerful aversion in us. If we hear stories of people not receiving care and dying, that arouses significant emotions and colors our assessment of a problem. Thus, when stories are recent, available to our minds readily and scary, they are impactful. And as with the former effects, those who know the benefits of universal healthcare that we see around the world, and the horror show we see here in America, this should be our wheelhouse. We have the stories of the heartlessness and cruel rationing of care in front of us every day. We need to collect them and use them. Recency, availability and dread aversion need to become the friends of advocates for universal healthcare.
I was going to add a third point here about the pro-business, pro-corporate brainwashing that has occurred in the US over the past half century or so, but rather, I’ll just ask you to read Anand Giridharadas’ Winners Take All, or at least get a taste of it here in this Guardian review. And for those who think private corporations always handle things better than government or other public agencies, I’ll just ask you to recall the last time you called your a) cable company b) health insurance company or c) well, almost any large corporation.

In Texas Hospitals, You Don’t Get to Decide to End Care | Houston Press

In Texas Hospitals, You Don’t Get to Decide to End Care | Houston Press: 2016

[Full disclosure – I don’t know if this has been changed at this time.]

“In Texas it doesn’t matter what instructions you’ve previously given or what your relatives say: If you’re in critical condition, you’re dependent on machines to survive and hospital officials decide it’s time to pull the plug, you will die. And it’s completely legal.”

‘via Blog this’

Fertile ground for Medicaid pitch- The Washington Post

Remote Area Medical back in western Virginia, as the battle to expand Medicaid rolls on…

The three-day clinic, which relies on more than 1,000 volunteers, will serve as many as 3,000 people before it ends Sunday. The vast majority of patients — more than 70 percent — come for dental care, Brock said.

Every year, hundreds of people have every one of their teeth pulled there. Then they put their names into a denture lottery, with the hope of being picked to get a set of false teeth made for them at the next year’s event. Forty-six people were picked from a list of 700 to get dentures this year.

“They pull thousands of teeth here. At the end, they’ll have buckets of teeth,” said volunteer Jennifer Lee, Virginia’s deputy secretary of health and human resources and an emergency room doctor.

Medicaid expansion would not fully alleviate the dental situation. Medicaid does not cover routine dental care for adults or dentures. But Medicaid does pay for emergency tooth extractions, so patients would not have to wait a year to have a bad one pulled.

“I just had an 18-year-old have a full mouth extraction because she’s never had dental care,” said Beth Bortz, who runs the Virginia Center for Health Innovation. “It’s not unusual.”

She said patients often want their good teeth removed, too, because they associate teeth with pain. She said health-care providers counsel them to keep them.

– The Washington Post

Cost of Treatment May Influence Doctors – NYTimes.com

Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.

The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.

“We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room,” said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.

Cost of Treatment May Influence Doctors – NYTimes.com

Cabbies Hail For Health Insurance | NBC 10 Philadelphia

Getting health insurance in spite of Gov. Corbett!

About 80 percent of the nearly 5,000 taxi drivers in the city did not have insurance prior to the Affordable Care Act going into effect, said Ronald Blount, president of the Unified Taxi Workers Alliance of Pennsylvania.

"They were pretty much on their own," he said. "If a driver was hit by a drunk driver, the taxi auto insurance doesn’t cover the driver.”

"They’d be stuck with big medical bills,” added Blount, who said many drivers are plagued by “silent killers” like diabetes, high blood pressure and high cholesterol since many eat while on the go and are sitting for most of the day.

In an effort to enroll as many cabbies as possible, the TWA teamed up with two nonprofits focused on health care, Healthy Philadelphia and Get Covered America, to hold regular enrollment and information sessions.

Cabbies Hail For Health Insurance | NBC 10 Philadelphia

Pennsylvania isn’t serious about expanding Medicaid. How do we know? – latimes.com

Pennsylvania Gov. Tom Corbett has lately been getting credit in the political press for being one of those Republican governors coming around on the expansion of Medicaid under the Affordable Care Act. Advocates for the underprivileged can’t understand why.

They’re right to wonder. Corbett’s "Healthy Pennsylvania" plan, which was released for public comment this week, is a sham. It would reduce health benefits for many of his neediest citizens and impose punitive conditions on their coverage. It requires waiver approval from the federal government that’s almost certain to be refused, because some of its provisions are in flagrant violation of federal law. And even if it were approved, Corbett waited so long to put his plan together that it probably couldn’t be implemented until 2015. In the meantime, 500,000 of his citizens will be medically uncovered.

"He’s being very disingenuous," says Joan Alker, executive director of the Center for Children and Families at Georgetown University. "He knows a lot of this proposal is not approvable" under federal law.

Corbett’s proposal shows that many Republicans still aren’t done posturing with their citizens’ lives, even as some have done the right thing–among them Gov. John Kasich of Ohio and Jan Brewer of Arizona. Some GOP governors, like Rick Perry of Texas and Bobby Jindal of Louisiana, seem determined to take their neediest citizens all the way down–they’re not budging on their refusal to expand Medicaid coverage.

Corbett wants to have it both ways. He intends to masquerade as a feeling governor intent on bringing healthcare to the masses at practical cost. But beneath the fancy dress lies a cynical politician who knows his plan isn’t practical. If it gets rejected he’ll blame the Obama administration. "We tried," he’ll say. "But they blocked us." Don’t be taken in.

Pennsylvania isn’t serious about expanding Medicaid. How do we know? – latimes.com

I Watched My Patients Die of Treatable Diseases Because They Were Poor | Alternet

There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.

My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.

One night, a friend called to say that my patient was in the hospital. He’d finally gotten so anemic that he couldn’t catch his breath, and the University of Texas Medical Branch (UTMB), where I am a student, took him in. My friend emailed me the results of his CT scans: There was cancer in his kidney, his liver and his lungs. It must have been spreading over the weeks that he’d been coming into St. Vincent’s.

I went to visit him that night. “There’s my doctor!” he called out when he saw me. I sat next to him, and he explained that he was waiting to call his sister until they told him whether or not the cancer was “bad.”

“It might be one of those real treatable kinds of cancers,” he said. I nodded uncomfortably. We talked for a while, and when I left he said, “Well now you know where I am, so you can come visit me.”

I never came back. I was too ashamed, and too early in my training to even recognize why I felt that way. After all, I had done everything I could—what did I have to feel ashamed of?

UTMB sent him to hospice, and he died at home a few months later. I read his obituary in the Galveston County Daily News.

I Watched My Patients Die of Treatable Diseases Because They Were Poor | Alternet

Opinion: Cancer survivor: Obamacare got me covered – CNN.com

In January, for the first time since my diagnosis 36 years ago, I will have an individual health plan that offers quality coverage for me and my family. I will save $628 every month on premiums. Best of all — I wasn’t even asked if I’ve ever had cancer.

Opinion: Cancer survivor: Obamacare got me covered – CNN.com

Uninsured in Pennsylvania reaches record high – Pittsburgh Post-Gazette

Overall the number of uninsured Pennsylvanians increased by 11 percent from 2011 to 2012, while nationally the number decreased by 1.4 percent.

The numbers, based on data from the U.S. Census Bureau and the Centers for Medicare and Medicaid Services, reflect a troubling trend in health care insurance, which people traditionally received through their employer.

"We continue to see a dangerous erosion of employer-based coverage," said Andy Carter, president and CEO of the Hospital and Healthsystem Association that represents the interests of nearly 240 health facilities.

"The number of Pennsylvanians covered by private, employer-based plans hit an all-time low of 59.5 percent in 2012," he said.

And that’s not solely because people are out of work, he added.

"Three out of every 4 uninsured Pennsylvanians live in a household with at least one working adult, and nearly 4 out of 5 live in Pennsylvania’s suburban and rural regions," Mr. Carter said.

The association has advocated for the expansion of Medicaid as outlined under the Patient Protection and Affordable Care Act.

Uninsured in Pennsylvania reaches record high – Pittsburgh Post-Gazette

Who Will be Uninsured After Health Insurance Reform? – Robert Wood Johnson Foundation

The ACA would reduce the number of nonelderly people without health insurance by 28 million—from 18.9 to 8.7 percent.

Of the 23 million still uninsured, 40 percent would be eligible for, but not enrolled in, Medicaid or the Children’s Health Insurance Program (CHIP). A further 22 percent would be undocumented immigrants.

The majority of those uninsured—19 of the 23 million—would be nonelderly adults:

Thirty-seven percent—mostly young singles without dependents—would be eligible for Medicaid, but not enrolled.

Twenty-five percent would be undocumented immigrants.

Sixteen percent would be exempt from the individual mandate because they would not have an affordable insurance option.

Eight percent would be eligible for affordable subsidized coverage in the health benefit exchanges.

The remaining 15 percent—most higher-income families with dependents—would likely be subject to the mandate, having an affordable private insurance option despite not qualifying for a subsidy.

Who Will be Uninsured After Health Insurance Reform? – Robert Wood Johnson Foundation