It's about time...

It's been way too long since I have commented here; ...

We find ourselves in some new days.  All of us.  And, I guess, "It's about time."

At our Community Health Center, we've been feeling the changes.  In the late fall, one of our Behavioral Health Professionals sent out an email asking for help.  You see, she had been finding more and more patients who were seeking help because they were losing their homes.  Her plea:  does anyone know of any resources to help these people?  The answer:  No, other than to refer them to the limited shelter beds available in our communities.  The Great Recession is real, and it's touching us now.

I had a wonderful chance to hear a leader in the National Association of Community Health Centers (www.NACHC.com) speak at a regional conference in October.  Dan Hawkins is Senior Vice President at NACHC, and in those days leading up to the election, spoke of the differences in the candidates plans for healthcare reform.  (Run this google search for "Dan Hawkins" and "NACHC" and you can see some of the work Dan has done for Community Health Centers.)  The analysis of Mr. Obama's plan offered some promise.  Maybe now we could do something together to get this fixed... As I did a photowalk around Denver, I was struck by the message of hope echoed in the sign, "All Together Now".  

But, where are we now?  The country, and the world, has turned nearly all attention to the economy, blaming greed and housing and bad business practices for the onset of the Great Recession.  And, the nation and it's leaders seem to have mostly forgotten about healthcare.  

And, I think back to many discussions I've had over the past few years.  Discussions about how inhumane our current healthcare "system" is toward our less-fortunate neighbors.  Even our previous President thought that the Emergency Department was the answer to the millions of children he had denied access to healthcare by refusing to sign the State Childrens Health Insurance Plan into law.  "After all, you just go to the Emergency Room."  [Our current president sees this issue a little differently.]

And, during these discussions, I'd often hear the sentiment that, if the poor people need something else from our healthcare "system", the should just use their political power to influence our elected leaders to make it happen.  The poor, I'm afraid, don't have that power.  If they did, perhaps they wouldn't be poor!  

But, now, all of us are poor!  The list of names of those losing billions to Mr. Madoff includes many people who are smarter than the rest of us.  And, have you taken a look at your 401K lately?  So, now, maybe the "nouveau poor" will be able to speak for the "old poor".  Maybe now, we can really turn our attention to the work of creating a healthcare system for all of us.  Even the prestigious New England Journal of Medicine sees that there may be a silver lining to the recession which is causing so much suffering now - finally, healthcare reform.  

It's about time...All Together Now...

A new plan!

We had a chance to visit Old Mill Days (http://www.oldmilldays.com/) in Port Gamble, a community near our home in western Washington this past weekend. And, like lightning, I was struck with the solution to our HealthCare Meltdown!

It came to me in an unlikely place. It was listed on the bottom of a sign in front of a carnival ride. It was a beautiful day - sunny and warm. The leaves have started to turn a bit. I could hear the screams and laughter of children, of all ages, as they enjoyed the rides. And, there it was - the solution to all the problems that plague my work week!

So, that's it! "Please, no major health issues!" Simple, straightforward. I think it could garner bipartisan support.

Now, I've got to go back to work...

"The Best Healthcare System in the World"...

I'm always struck by how many of my fellow US citizens fail to see the great failings in our healthcare "system". I say "system" because we certainly do not have a cohesive, organized, orchastrated approach to providing our citizens with health care, but rather a series of niche providers, many with an entrepreneurial underpinning - we're all in it to make money! (If you've read my blog, you know that I'm a physician working as an employee of a community-owned nonprofit medical practice serving the poor, and I recognize that most physicians didn't go to med school thinking it was [only] a great way to make a living, but that we wanted to be in a helping profession. But, I would argue that the institutions of care are very much dependant upon profit, even with the best of intentions...)

I sat with a patient Monday who came in to seek care for rectal bleeding. He had met me several months ago with this problem, but couldn't find a physician willing to do a colonoscopy for less than $1400 cash. He is one of the working poor, uninsured. He has had increasing concern that something is wrong, and comes back seeking this testing again. (We are a primary care clinic, and have depended upon specialists for these sorts of tests in the past. As time has gone by, we have seen less access to specialty care for indigent patients.)

So, he tells a story that is much too common - the uninsured often delay care until disease is advanced. If, indeed, his bleeding is caused by colorectal cancer, his chances of a cure have markedly diminished by this delay.

So, do we have a great "system?" This patient clearly tells me that he doesn't think so, and wonders how his life would be different if he had access to care that other countries provide.

This report from the Commonwealth Fund shows that our "grade" as a system in the US has fallen from 67 in 2006 to 65 today, largely due to the 16% increase in the number of working-age adults who are uninsured or underinsured. That's this patient.

And, what could I say to him on Monday? Well, we'll ask our colleagues in the community and region again if they can provide this diagnostic test for you at a reduced cost to you. All we can do is ask...

Stating the obvious...

I'm always amazed at medical studies which seem to state the obvious. And, I'm always wondering, "Who didn't know that"?

The most likely to elicit a response of "Duh" are the articles like "Childhood obesity linked to eating too much and not exercising enough." Gosh, that's all it would have taken for me to get published?

But, when it comes to healthcare policy, it becomes apparent that many of my friends and neighbors don't have the same experience of the needs in our community, and frankly don't believe that things are as difficult as they really are. That might be reflected in blaming the uninsured for being "lazy", or thinking that all Medicaid recipients are just "welfare moms", who will keep having kids so that the State will pay them more money. Or simply that the elderly Medicare patient can't be underserved; after all, they have insurance.

My favorite example of an unbelievable situation is that of the GAU system in our state. (If "favorite" is the right word ...) In our state, we have a public program to provide support for those who are disabled, referred to as "General Assistance for the Unemployable ". Well, that makes sense - if we have citizens who are unable to provide an income for themselves, I would argue that our rich society has an obligation to help them in meeting their daily needs.

But, listen to these words that one of my patients read on the letter which announces her enrollment:

We have decided that you are unable to work at this time based on Mental Health Disorder. ... You do not qualify for medical that covers mental health treatment and so, you must find a primary care doctor to help you explore possible medications for your mental health disability.

So, did you catch that? You are disabled. So, you deserve medical insurance coverage. But, we're providing you with insurance coverage which does not have the benefit of coverage for care for the condition which causes your disability. (And, then, goes on to suggest that your PCP just give it a whirl and see if he/she can help you, without benefit of specialty consultation, if indicated.) Incredible. But, true.

"A Moral Imperative"

In the August 4 edition of American Medical News, a publication of the American Medical Association, I find some hope...

The headline reads: Ethics panel may back universal coverage, ponders access as a "moral imperative".

The article reviews the ponderings of a panel of ethicists appointed by President Bush, and "appears set to endorse some sort of societal obligation to provide health care access to all."

Gosh, isn't that what we've been saying?!?! http://www.savehealthcareinwa.org/stories/index.php, http://healthcaremeltdown.blogspot.com/2008/01/advocacy-101-workshop.html, http://kpbj.com/headlines/articles/2003-05-02-HED-16.html.

As I read the article a bit further, I must admit that this cynical old guy is disappointed that "A report is likely to be issued after the November election." And, the article goes on to talk about the panel having exceeded its expertise to attempt an analysis of our healthcare policy from this ethics viewpoint.

This is exactly the place to start a review of our healthcare "system". It really is a simple analysis. Do you agree that access to health care is a fundamental human right? If so, then society has an obligation to ensure that this right is made real to all of its citizens. The mechanism for making that right real certainly is complicated by many competing interests - political, social, economic, etc.

But, if we start at the beginning, we can figure out the rest!

Power for change?

As I look over my microwave lunch today, I'm glancing at the headlines on the American Medical News for July 21, 2008.  The headline says: "Health Care Access Problems Surge Among Insured Americans."  

So, my first reaction was - "Duh".   Just ask my partners - we are seeing more and more insured patients in our practice, particularly Medicaid, Medicare and Tricare.  Tricare is the public insurance program to support our retired military and dependants.  And, they are our community's newest "underserved" population.  These fine Americans carry an insurance card with a great slogan - "The Best Health Care in the World".  That's certainly the topic for another entry...

But, after reading the story a bit more closely, I see that the article is not about the insured among us.  Rather, it reviews access for all of us - insured or uninsured.  The article reviews the report from the Center for Studying Health Systems Change, which has been tracking access for the past ten years.  And the report shows a marked increase in delaying and deferring care due to growing access barriers.

But, why the emphasis in the headline on the insured?  Ah, that might just be the power for change... Larry Seaquist noted that 97% of voters have medical insurance.  The uninsured, therefore, have little political clout.  Why would they?  They are typically poor or young or immigrant.  But, when the headlines start talking about the "Haves" rather than just the "Have-Nots", maybe that will lead to enough power to effect true change. 

At least, we can hope so.  And, soon.  It would be immoral for us to watch even more people die during this crisis:  Uninsured People Ages 50 to 64 Have 43% Higher Death Risk Than Insured, Study Finds

Community Comment...

Earlier this week, I had a wonderful opportunity to sit with a group of people in my community to discuss the state of health care.

It was an evening hosted by Gail Ross, co-founder of America in Solidarity. And, I was asked to join Larry Sequist, a State Representative for the 26th District, in talking about the state of our current system, and how we might consider moving forward. Foremost in our discussion was the enhancement of the "medical home" model, and reducing administrative costs of our disjointed "system".

The stories around the table included many who currently had healthcare insurance, but were afraid that the future would see them unable to find adequate coverage for healthcare costs. That is actually a common finding, it turns out - many Americans have seen the trend, and are concerned that employee-sponsored health insurance will become unaffordable, and that they will not be able to find coverage for their family. In fact, the coverage offered by my own employer has premiums of over $20,000/year to cover my family.

I'm encouraged that more people are becoming concerned about our failing system.

And, I would certainly agree with the editorial piece in the Seattle Post Intelligencer, co-authored by someone I'm proud to consider a colleague in this work. Teresita Batayola is the Executive Director of International Community Health Services, the nonprofit agency serving the healthcare needs of the many of the residents of the International District in Seattle. The theme of this editorial is that our priority would be to ensure that all Washington's citizens have access to affordable healthcare coverage.

For me, it always comes back to the basic question - do you believe that access to health care (not health care insurance, by the way), is a basic human right? Do you agree with the World Health Organization that health care is a fundamental human right? Do you agree with the motto literally etched in stone at the Harvard School of Public Health - "The highest attainable level of health is one of the fundamental rights of every human being"?

If you do, then all the other issues seem to fall into place...http://kpbj.com/headlines/articles/2003-05-02-HED-16.html