We gratefully acknowledge the sponsorship of Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference
The following transcription is of the first plenary session of the 26th National Conference on Primary Health Care Access, held April 13, 2015 at the Hyatt Regency Orange County. This section follows: “Time Will Tell”: the Proceedings of the 26th National Conference – The Great Debate: Obamacare has been a Great Success, Part 1 (Prislin for the Affirmative)
Charles Q. North, MD, MS, University of New Mexico [Doctor North is a Senior Fellow of the National Conferences on Primary Health Care Access]: Thanks a lot, I’m following the same rules of disclosure as Mike Prislin is this morning, but instead of a cell phone to call the President, I have my experts – Doctors John Geyman and Don McCanne – on the front row of the audience here. Sometimes, it’s a long distance call and sometimes it’s local.
I want to be fair and balanced and talk about the alternatives to the Patient Protection and Affordable Care Act. I think that the “patient protection” part of the Act’s name was to make it slide down easier. It’s like the salsa on the burrito.
So what are the alternatives? Mike went through that subject very well; RomneyCare and ObamaCare are basically the same thing. The PPACA is a Republican plan. They were just too timid to bring it forward, except in Massachusetts.
There are other alternatives. There’s the British National Health Service as well as just about everybody else’s National Health Service. and there are some other kinds of universal health coverage plan.
The United States Veterans Administration, Indian Health Service, and Armed Services Health Care.
In this country, there is the Veteran’s Administration and the Indian Health Service.
The VA is trashed regularly, because it’s so doggone popular people have to wait to get in. That tells you something about their funding.
If you look at the Indian Health Service and compare its funding to what the rest of the country costs, then the Indian Health Service is funded at 50% of the level of need,
And then there is the United States Military Healthcare System. In our audience, we have an active duty officer in the United States Army who is a physician. He does not want to go to a private sector accountable care organization for his healthcare, which would not even available for him most of the time.
Having myself used the military system as a patient most of my career, I think that system ought to be supported and expanded, and provide the servicemen and servicewomen the healthcare they need, both locally and internationally.
Universal Health in Rwanda
We have the universal access systems in Europe that we hear a lot about when we’re talking about the ACA.
I’d like to point out that Rwanda – yes, Rwanda, where genocide was occurring ten years ago – has a universal access health coverage system. They have some of the most remarkable improvements in public health measures of anywhere in the world.
I refer you to the writings of Paul Farmer of Partners in Health. It is truly remarkable in a low-resource environment that such demonstrable progress has occurred.
Then there are the “single payer” plans. We know about the Canadian plan. But there is also a single payer plan in Taiwan that has celebrated its 20th anniversary. I refer you to this the recent article in Health Affairs, reflecting on that 20th anniversary; and how the single payer system is reducing health costs in Taiwan.
Mike Prislin talked about the triple aim or the quadruple aim of health care reform. This is a concept that Doctor Don Berwick, the former director of CMS (the Center for Medicare and Medicaid Services) came up with. Parenthetically, Don Berwick became a Democratic candidate for governor of Massachusetts. I’m not a betting man, but if I were I’d always lose. I bet on Don, but he only got third place and that just in the Democratic Party, after which a Republican won the Governorship of Massachusetts. Of Massachusetts!!
At the end of his campaign, Berwick came out for a single payer system in Massachusetts, which is where Romney Care was implemented, of course.
Although Massachusetts has the lowest percentage of uninsured, it’s not zero. It’s still substantial; it’s over five percent; Hawaii and Massachusetts have comparable percentages.
Access, Quality of Care, Reasonable Cost
The triple aim is, first, about access.
It is, second, about quality of care – measured by outcomes and by patient experience. From the viewpoint of patients, did they get what they wanted and what they needed that day? Do they have a measurable outcome – not a process, but an outcome? These are questions whose responses are not often included in quality measures.
It is, third, about cost, which gets to equity, social justice, and opportunity. Is it efficient, affordable, transparent, fair and sustainable financially? I put some ethical principles into the cost element of the triple aim – equity, social justice and opportunity. This should be an ethical measure.
What do healthcare systems, delivery systems and finance systems not do? I think it’s really important to talk about what this is not about. PPACA (or Obama Care if you prefer) is just a healthcare financing reform proposal, now a law.
I quote from the satirical medical journal Onion, published just recently, which pokes fun at medical studies. “The public health report is that the majority of Earth’s potable water is trapped in Coca Cola products. Experts estimate that the average can of Coke contains nearly 12 ounces of potable, but entirely inaccessible, fresh water.” Now if you have a problem in the desert, this is where to go. We know it’s there if you can just figure out how to extract it, maybe some form of fracking would work. I’m not sure. I know it’s illegal in Southern California, but people have to be doing research.
The Impact of Sugar on Obesity and Diabetes
Our food supply here and around the world is infused with sugar. The big change in the last 40 years is that processed food has more and more sugar. We talk about the salt a lot, but if you look at diabetes, obesity and processed food infused with sugar, they are very highly related. This is a public health problem that requires regulation at an appropriate level. The Affordable Care Act doesn’t address this,
The Impact of Public Campaings Against Smoking
Look at this graph of smoking, starting out in 1900. We didn’t smoke much in 1900, because there weren’t cigarettes. You had to make them. You had to roll your own back here.
About the time Medicare and Medicaid were started, we decided cigarettes were bad for your health and that they caused cancer. Who would have guessed back during World War II that they caused cancer? We thought it was a great way to win the war, fueled on nicotine.
The smoking rate has fallen since then, but it doesn’t really matter if you have an Affordable Care Act, a single payer system, or no healthcare financing system at all.
You can have a public campaign to regulate cigarette smoking and to counter advertising about cigarettes, whether or not you finance the healthcare system.
Child Poverty and Income Inequality as Social Determinants of Health
Completely separate from the ACA is child poverty in America. We’re right behind Turkey and ahead of Mexico in child poverty. 21.7% of children in this country are poor. That is one of the key social determinants of health.
The Affordable Care Act does not really address this. We’re talking about expanding the Medicaid child health program (CHIP) for another two or four years. But why aren’t all children eligible for healthcare in this country? Why isn’t it universal?
Why is it that if you have an undocumented child – who is probably the most needy child you’re going to see – that they can only be covered through their state health department where they might services without people asking about their immigration status. That’s the way we presently cover them.
Linked to childhood poverty is income inequality, which is a major determinant of health, and which has increased in this country. The Affordable Care Act really doesn’t address income inequality.
Actual Causes of Death in the United States
Most of what we do in healthcare financing delivery does not affect the health status of the population. Many of you will remember that Doctors J. Michael McGinnis and William Foege published the article “Actual Cause of Death in the United States” in 1993. That article showed that – when you look at the actual statistics (from death certificates) relating to premature death – healthcare delivery system and how that system is financed only accounts for about 10% of the health status of a population.
Your risk factors for the likes of heart disease and Alzheimer’s are little affected by health care delivery.
Most of the determinants of health status are the result of behavioral patterns, genetic predisposition and social circumstances. These determinants are related to addictions to cigarettes, sugar, obesity, alcohol, genetic predisposition and bad behavior (such as criminal activity).
Large Numbers of Uninsured Continue
In New Mexico we looked at our 2014 and 2015 Medicaid populations and our 2020 projections. We have a total Medicaid population of 741,000. It looks like it’s going to go up by another 90,000 in 2020. Our uninsured rates have decreased from 339,000 in 2014 to 235,000 in 2015 to a projected 167,996 in 2020.
There still will be a lot of uninsured people in 2020. That uninsured group is bigger than the population of many of the cities in the Los Angeles metropolitan area. They’re not just undocumented people. Most people who come here across the border from Mexico realize that there are jobs in Texas and California and skip comimg to New Mexico. The undocumented population is a small part of New Mexico.
The ACA reduction of the uninsured in this time period in 2014, and it’s not too much different in 2015. It still leaves New Mexico and California with 15% of the population uninsured. 15% is a lot of people, even in New Mexico, which is 1/14th the size of California, and 1/7th the size of Los Angeles county. There are about 2 million people in New Mexico and about 14 million in the LA basin here. 15% leaves a lot of people out in the cold.
Replacing the Uninsured with the Underinsured
Most of the newly insured are underinsured with health insurance exchange products or Medicaid. A team of us at University of New Mexico wrote a paper recently on underinsurance in our international district clinic in Albuquerque. Underinsurance really does prevent people from getting healthcare.
Medicaid is a form of underinsurance. Most of the health insurance exchange products are too. We’ll look at that in a minute and see why.
The undocumented, of course, aren’t covered under the ACA. Because of this, public hospitals and other safety net programs are being overwhelmed. Yes, they are getting paying customers now, but they’re being overwhelmed in terms of the delivery system because those vanguard ACOs don’t want Medicaid patients.
They don’t want them just like they didn’t want uninsured patients because they know those patients are underinsured and have complex medical problems that are based on the social determinants of their health – their poverty mostly, and, in many cases, their addictions.
This is why you don’t see people scrambling to get the Veteran’s Administration population. They can’t take care of veterans with TBI, PTSD, addiction to heroin, alcohol, and cigarettes. They don’t do that very well. It’s very expensive for them to do that. So they’re not going out there and recruiting those patients.
The private health system is narrowing their networks, and trying to get rid of their uninsured and Medicaid patients, and developing very narrow networks so that patients have to stay in that system if they get that insurance. That’s been an unintended consequence of the ACA. It’s a real problem if you’re working in a metropolitan area, but if you’re not in a metropolitan area it maybe even a larger problem depending on how many options rural communities have.
The expanded Medicaid program, of course, doesn’t even exist in many states and the benefits vary extremely widely between states. The confidence intervals around the average Medicaid benefit are huge.
It’s not the same program everywhere like Medicare is. Medicare is a much more standardized program. Medicaid will pay or not pay for a variety of different things. And expanded Medicaid has copays and deductibles in some cases.
Case Studies of My Patients: #1
I have a continuity practice, in which I see patients regularly.
One of them is a 53 year old, Hispanic woman who is a security guard. She was told that she is “self-pay”. These patient notes are from a conversation that I had with her, that I documented in our email system and in her electronic health record and shared with her social worker.
She works 12 hour shifts, makes $8.50 an hour, so it it looked to me like she’d meet poverty guidelines, especially if it’s 400% of the poverty level, which is where Medicaid is at. She’s been to the financial assistance office at our hospital three times.
We have an electronic health record. Any time one of my patients enters the system anywhere, I get a message and I look what is occurring. My patient, whom I hadn’t seen for awhile, was in the Emergency Department. I didn’t know what happened to her. I found out that she was actually enrolled in Medicaid family planning.
We have a lot of 53-year old males who are enrolled in Medicaid family planning too and we were wondering what kind of family they were planning. I found out that it was a gimmick to get people onto Medicaid, because we didn’t hire enough people in our state to enroll people on Medicaid. Because they couldn’t process all the claims, they put them in this “category 29” – family planning. It really confused people. It confused us. The patients would ask, what is that? We don’t need condoms, you know.
I learned that my patient made too much money for Food Stamps, but didn’t need family planning. She sounded unwell and overwhelmed. She was beyond frustrated. She previously had been on the Bernalillo County indigent program, which is sponsored by our hospital, before she was enrolled into Medicaid. She understood the indigent program. It worked very well for her. She had regular primary care visits and several specialty evaluations before that.
Case Studies of My Patients: #2
There’s another patient of mine, another Hispanic woman who’s in her 40s – hardworking, employed by a small business. She has fairly controlled Type 2 Diabetes. She’s got an insurance exchange product and had been on the county indigent program. She can’t see her primary care pharmacy clinician; who I defer to, to do Diabetes medication modifications and titrations. That is the pharmacy practitioner wasn’t on her plan, nor could we get the practitioner on her plan. I talked to our pharmacy faculty about this and they’re working on it, it but the practitioner is still not listed.
Because of this, my patient had disruption in her care. She wasn’t able to get into see the practitioner, so as to adjust her insulin, which she needed to do because the formulary was narrowed. The health insurance exchange plan had a very narrow formulary and instead of Lantus and Humalog, which I’ve used for the last ten or 15 years. She’s back on NPH and regular insulin, which I used back in the previous millennium, but I don’t have anybody else on NPH and regular insulin.
The patient’s sugars were all over the place, because she had to take her insulin – her regular insulin – much sooner than she would have Humalog, which you can take right before the meal. So she wouldn’t know how much she was going to be eating, and then she’d miss the mark. Her A1C rose substantially.
This lady is very adherent and very careful, very bright, very hardworking, and doesn’t expect a dime from anybody. She took this on as her responsibility to work her way through this unwieldy system.
So I spent a lot of time on this, just as I’ve spent another few minutes talking to you about. My time is valuable, so its seems a misallocation of resources that I spend it coordinating her care, trying to get her on the right medication, trying to figure out how to get her pharmacy clinician on the provider list.
This was a consequence of the Affordable Care Act. It was not affordable for her. It was very expensive. And it wasn’t affordable for me. It did not protect these two patients I just showed you.
The Bernalillo County/UNM (University of New Mexico) Health System
Let’s consider the UNM Health System’s county indigent program. It’s basically a single-payer system for the Bernalillo County for people that are below the poverty level. We had very small deductible and a reasonable maximum amount for out of pocket charges for, emergency room visits, the prescription formulary, etc. And we had a pretty broad formulary, including the new Hepatitis C drugs, because we did some of us at the university the research on them. No charge was over $75 and that $75 was for non-formulary prescription drug.
If you look at the silver plan for an individual and the silver plan for a family; they’ve got $2000 and $4,000 out of pocket maximums and deductibles of $400 and $800. How are people going to afford that? Then there are percentages, such as 15% of an outpatient surgery that cost $5,000. That’s a lot of money. People make decisions based on this, once they figure it out.
The county indigent program was much better and much more affordable; than the Affordable Care Act. I would claim that the Patient Protection and Affordable Care Act it doesn’t protect patients and is not affordable.
The Downside of PPACA to Lower Income Patients in New Mexico
If we summarize these patients’ experiences, they’re paying higher premiums. They can’t afford the family coverage. They pay higher deductibles. They pay higher co-pays. When they are billed for higher co-pays they miss visits once they find out what the co-pays are. Patients say “I can’t come in and see you. I’ve got to pay 50 bucks up front.” Before it was $5, $10, or nothing.
I worked in the Indian Health Service for 30 some years, with no co-pays, no deductibles, no premiums, no barriers to care. It made a huge difference. We’re seeing higher no show rates all the time. We have 14% average no show rates in our system. Some of our better clinics it’s about 7-8%. One of my jobs is to drive down those no show rates. Tell me that doesn’t waste the doctor’s time. It wastes a lot of time.
Higher drug costs, even the generic drugs are costing more because the Affordable Care Act isn’t affordable for individuals, but it makes money for Big Pharma. They were able to raise their prices.
We don’t have diabetes nutrition education covered under all of the plans in the Affordable Care Act. What happens is patients are uncertain about what is in their plan. They doubt that they really understand it. They’re confused about it, so what they do is to avoid care, basically.
They don’t know about the hidden costs and when they find out about them we get more complaints. Patient satisfaction goes down.
PPACA’s Chief Benefit is Expansion of Medicaid That Could Have Expanded Without PPACA
Most of the benefit of this program is from the expansion of Medicaid. When looking at PPACA as a whole I would say that in most cases states have benefited the most from expanded Medicaid. But expanding Medicaid didn’t require having a Patient Protection and Affordable Care Act. It just required changing the criteria for Medicaid.
So, who benefits?
Stephen Hemsley the CEO of United Healthcare’s salary is $106 million. That’s just a little bit more than the $100 million income in revenue that we got at the entire University of New Mexico Hospital system in one year. The University of New Mexico benefited. We can give raises to the staff and faculty. The positive impact on Big Pharma we’ve talked about. Medical device companies, physician executives and ACO owners I would say have benefited. A number of us are in physician executive positions that didn’t use to exist. And the Heritage Foundation who came up with this whole thing has benefited.
But let’s talk about value-based healthcare.
Americans aren’t getting a good value for the amount of money they put into healthcare compared to all these other countries in the world. You can’t have value-based healthcare if the whole system isn’t very valuable. Right? We don’t know how to measure quality so it comes out that value equals cost most of the time.
PPACA Fails on Access, Quality and Cost
I would submit that the PPACA fails on the criteria of the triple aim – access, quality and cost. It’s not a public health program. It doesn’t address public health for the most part, except for some prevention.
It’s not social progress, it doesn’t lead us to wealth equity. Instead I would recommend that we look at this quote from Senator Edward Kennedy’s 1972 book In Critical Condition: The Crisis in America’s Heath Care:
He talks about the triple aim, the entire nation, universal access, high quality, reasonable cost healthcare. I read it in medical school. And Senator Tom Dashell used it as the basis of his book that was published right before the Affordable Care Act was debated.
Here’s a better solution, How ObamaCare is Unsustainable by Doctor John Geyman. I would read this. You might recognize the guy on the right.
If you want the Cliff’s Notes version for Dummy’s, John published this in the International Journal of Health Services in 2015. You don’t have to read the whole book, but I’d recommend you buy it at least cause I’m sure some of the proceeds will go for a good cause.
What we want is high quality healthcare services at an affordable price for all. It’s not a very difficult concept. It doesn’t require a very difficult law. What it requires is an incredible amount of political will. I think it’s up to us, those of us who understand this, to advocate for a universal coverage program, preferably a single payer or national health program of some kind, of which there are many examples.
We’ll come up with our own, but everybody would benefit from that. American industry would much more competitive. So I think the people who pay for campaigns, pay for politicians will get on board and see the light and advocate for a system that makes more sense so they can be more competitive. Thank you.