“What Should Happen Next”: Doctors John Geyman, David Sundwall discuss Obamacare

John P. Geyman, MD; Author; University of Washington Emeritus Professor

John P. Geyman, MD;
Author; University of Washington Emeritus Professor

Two senior fellows of the National Conferences on Primary Health Care Access, John Geyman, MD, professor emeritus of the University of Washington and David Sundwall, MD, of the University of Utah, will discuss the continued evolution of the Patient Protection and Affordable Care Act [PPACA], nicknamed Obamacare. The discussion will take place at the 27th National Conference on April 4, at the Grand Hyatt Kaua’i.

Doctor Geyman, a noted author and advocate for a “single payer” system of financing American health care will begin the hour with the first “Thought Provocateur” session of the 27th National Conference.

A selection of Dr Geyman’s critical appraisals of the legislation may be found at “What Has NOT Changed” – A Critique of the Affordable Care Act: John P. Geyman, MD and Proceedings of the 22nd National Conference: Thought Provocateur Session #1 (John Geyman MD) – “What Will Not Work: The Fundamental Errors in PPACA”.

David N. Sundwall MD, MPH, University of Utah, Salt Lake City

David N. Sundwall MD; University of Utah, Salt Lake City

Following Dr Geyman’s Thought Provocateur session, Doctor David Sundwall of the University of Utah will provide his own analysis of Obamacare.

Doctor Sundwall has previously served as a staff member to the United States Committee on Labor and Human Resources, chaired by Utah Senator Orrin Hatch.

He also served as the Head of the United States Health and Human Services Health Resources and Services Administration under President Ronald Reagan, and more recently as the Director of the Utah Department Health under Governor Jon Huntsman and as a member of the presidentially-appointed Medicaid and CHIP Policy Advisory Commission.

Doctor Sundwall’s comments at a previous National Conference may be found at “What Has Changed?”: Health Reform in the U. S. A. – David N. Sundwall, MD.

After Doctor Sundwall’s comments, he and Doctor Geyman will engage in a conversation on the legislation’s content, legislative process, implementation and judicial review.

J. Jerry Rodos (1933-2016) to be Memorialized at 27th National Conference on Primary Health Care Access

J. Jerry Rodos, DO (1933-2016)

J. Jerry Rodos, DO

J. Jerry Rodos, DO, a co-founder of the National Conferences on Primary Health Care Access, is to be memorialized on April 4, 2016, on the first day of the 27th National Conference, to be held April 4-7, 2016 at the Grand Hyatt Kaua’i.

Doctor Rodos was a co-founder of the New England College of Osteopathic Medicine and later served as Dean of the Chicago College of Osteopathic Medicine.

He was long associated with national efforts to increase the role of primary care and family medicine in the nation’s workforce, the incorporation of the behavioral sciences into primary health care practice, and the geographic distribution of primary care resources.

In this role he served as a member of the National Advisory Council of the National Health Service Corps, then served as advisor to the Director of the Corps during the 1990s.

At the 10th National Conference on Primary Health Care Access, held in Baltimore, Maryland in 2002, he received the Surgeon General’s Medal for his contributions to the nation’s health from Acting Surgeon General Kenneth Moritsugu.

Jerry was a Senior Fellow of the National Conferences. In his honor, the National Conferences established the J. Jerry Rodos Lecture series, commencing in 1995.

At the 27th National Conference, James Herman, MD, MSPH, Dean of the University of Oklahoma School of Community Medicine in Tulsa, will present the J. Jerry Rodos Lecture.

“What Happens Next”: Doctors Norman Kahn, Hector Flores, Jimmy Hara Open 27th National Conference April 4, 2016

The opening session of the 27th National Conference on Primary Health Care Access will take place at 8:15 a.m. at the Grand Hyatt Kaua’i, in Koloa Kaua’i.

Hector Flores, MD; White Memorial Medical Center, Los Angeles

Hector Flores, MD; White Memorial Medical Center, Los Angeles

Doctor Jimmy Hara, of the Charles R. Drew University of Medicine and Science in Los Angeles, California will present the opening remarks, including a review of the 26th National Conference held in April 2015 in Orange County, California.

The keynote panel will consist of Doctor Norman Kahn, who is the Executive Director of the Council of Medical Specialty Societies in Chicago. He will be joined by Doctor Hector Flores of the White Memorial Medical Center in Los Angeles.

Doctors Kahn and Flores will review relevant events of the past year, including the continuing evolution of the Patient Protection and Affordable Care Act (ACA).

Norman B. Kahn, MD; Council of Medical Specialty Societies, Chicago

Norman B. Kahn, MD; Council of Medical Specialty Societies, Chicago

The keynote panel will also discuss national initiatives to build and stengthen a modern primary health care system, including reforms in medical education and in primary care medical practice.

For previous remarks of Doctor Flores on the subject of implementing PPACA, see: 23rd National Conference – Doctors Joshua Freeman and Hector Flores to Discuss 2011-12 Developments in Health Insurance Reform and 22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 1, Flores).

For previous keynote presentation by Doctor Kahn, see: Proceedings of the 25th National Conference; April 14, 2014 (First Plenary Session, Kahn).

The National Conference is presented by the Coastal Research Group, a 501(C)(3) corporation. For further information on the invitational National Conference, contact William H. Burnett, Conference Coordinator at whburnett@coastalresearch.org

Confirmed Plenary Faculty for 27th National Conference on Primary Health Care Access

The plenary faculty of the 27th National Conference will include the following persons (confirmed list as of January 22, 2016). The conference will be held April 4 through April 7, 2016 at the Grand Hyatt Kaua’i, Koloa, Hawai’i.

Suzanne Allen, MD; University of Washington Vice-Regent, Community Programs, Boise, Idaho

Suzanne Allen, MD; University of Washington Vice-Regent, Community Programs, Boise, Idaho

Suzanne M. Allen, MD MPH University of Washington WWAMI program, Boise, Idaho

Marc E. Babitz, MD, Utah Department of Health, Salt Lake City

Macaran Baird, MD, MS, University of Minnesota, Minneapolis

Ana Bejinez-Eastman, MD, Presbyterian Intercommunity Hospital, Whittier, California

John M. Boltri, MD, Northeast Ohio University College of Medicine, Rootstown, Ohio

J. C. Buller, MD, Touro University, Vallejo, California

Denise Crawford, CEO; Kalamazoo Family Health Center

Denise Crawford, CEO; Kalamazoo Family Health Center

William H. Burnett, MA, Coastal Research Group, Granite Bay, California

Lieutenant Colonel Lee A, Burnett, Chief Surgeon, Second Infantry, Seoul, Korea

J. Scott Christman, Office of Statewide Heatlh Planning and Development, Sacramento, California

Andrea Clarke, MD, Kaiser Permanente, Napa, California

Denise Crawford, Kalamazoo Family Health Center, Kalamazoo, Michigan

James Cruz, MD, Molina Medical Centers, Long Beach, California

Enrique Fernandez, MD, Ross University, Miami, Florida

Rick Flinders, MD, Sutter Santa Rosa, Santa Rosa, California

Hector Flores, MD, White Memorial Medical Center, Long Beach

Virginia Fowkes, Stanford University, Palo Alto, California

Joshua Freeman, MD, Kansas University Medical School, Kansas City

Donald Frey, MD, Creighton University School of Medicine, Omaha, Nebraska

John Geyman, MD, University of Washington Emeritus, Friday Harbor, Washington

Jay W. Lee, MD; UC Irvine/Long Beach Memorial Hospital, Long Beach, California

Jay W. Lee, MD; UC Irvine/Long Beach Memorial Hospital, Long Beach, California

Mark Goodman, MD, Creighton University School of Medicine, Omaha, Nebraska

Thomas Hansen, MD, Advocate Health Systems, Chicago

Jimmy Hara, MD, Charles R. Drew University, Los Angeles, California

Kevin Haughton, MD, Providence Health, Olympia, Washington

James Herman, MD, MSPH, University of Oklahoma, Tulsa, Oklahoma

Norman B. Kahn, MD, Council of Medical Specialty Societies, Chicago

Jay W. Lee, MD, Memorial Medical Center, Long Beach, California

Gary LeRoy, MD, Wright State University Boonshoft School fo Medicine, Dayton, Ohio

William A. Norcross, MD, University of California, San Diego

Thomas E. Norris, MD, University of Washington, Seattle===-

Charles Q. North, MD, University of New Mexico, Albuquerque

Jamie Osborn, MD, Loma Linda University, Loma Linda, California

Keosha Partlow, MD, MPH, Charles R. Drew University, Los Angeles, California

Judith A. Pauwels, MD, University of Washington, Seattle

Perry A. Pugno, MD, MPH, American Academy of Family Physicians Emeritus, Leawood, Kansas

Robert Ross, MD, Saint Charles Health Center, Bend, Oregon

Jill Rush-Kolodzey, MD, Louisiana State University, Shreveport, Louisiana

Devin Sawyer, MD, Providence Health Systems, Olympia, Washington

Janice Spalding, MD, Northeast Ohio University College of Medicine, Rootstown, Ohio

David Sundwall, MD, University of Utah, Salt Lake City

Daniel Webster, MD, Michigan State University, Traverse City

Allan Wilke, MD, Western Michigan University, Kalamazoo


What has NOT Changed – Reactor Session: Charles Q. North MD and Q/A Session

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference on Primary Health Care Access:

The following transcription is of the second plenary sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. 

This reactor, question and comment session follows:  “What Has NOT Changed” – A Critique of the Affordable Care Act: John P. Geyman, MD

Left: John Geyman, MD (University of Washington); Right: Charles Q. North, MD, MS (University of New Mexico)

Left: John Geyman, MD (University of Washington); Right: Charles Q. North, MD, MS (University of New Mexico)

Charles Q. North, MD, MS, University of New Mexico, Albuquerque: [Dr North is a Senior Fellow of the National Conferences]: Thanks John. It’s always uplifting to hear you criticize the American healthcare system. But the best news is that you’re getting married to Emily next month. I think that’s terrific. And that gives those of us who are just signing up for Medicare hope for the future.

I have a very strong criticism of one of the things you said and that is that I think may be taken as an insult to the civilized world that they would include the United States in that group. I think you might want to consider retracting that statement.

I say that because we have such a high rate of incarceration. We have such a high rate of childhood poverty amidst the wealth in this nation. We have such a high rate of gun violence and death from guns.

Gun deaths are not just suffered by our military as a result of war, but even more from military suicides and guns in our neighborhoods – not rifles used for shooting animals for subsistence living – but for shooting children in schools and shooting gang members in inner cities. I mean to include us in the civilized world is a stretch in some other ways.

That brings me to my favorite topic – the role of the social determinants of health in healthcare. You know the healthcare system itself only accounts for about ten percent of the health status of a population, which you point out in your statistics that really 50% of the people in the country only account for 3% of the problems.

And that’s because they’re well off. That’s because they have access to early childhood education, and a secure home. That’s because they’re food is secure instead of insecure, so they don’t have the problems with starvation and obesity.

That’s because they have safe homes and neighborhoods; so they don’t need to use the emergency room for violence and injury. That’s because they have safe homes that aren’t full of lead, and where they can go out in the neighborhood and exercise.

That’s because there is an emergency response system in their neighborhood that works; they can get an ambulance when they need it. They have a public health infrastructure that can monitor disease and clean air and water and food. And that’s because they have a transportation system that allows them to get work and the ability to find a job.

So I really think that the ACA doesn’t address those issues at all. And those underlying social determinants of health would bring us to maybe being considered the status of civilized nation, like the nations  you referred to that have a social insurance programs that actually work and provide some kind of social opportunity – not equity, but the opportunity to work on equity – at least, in their societies.

And we know that inequity really leads to more health disparities than just poverty itself. Wealthy people are insecure because they’re afraid that poor people are going to go after them, much of the time. And we see that played out in our politics all the time.

The other thing I’d like to say is that we spend a lot of time talking about the federal deficit because of the cost of Medicare. It is really the rising cost of Medicare, not Social Security that is responsible for so much of the deficit.

We don’t talk much about the burden of private insurance premium on households, like we did in 2008 running up to Obama’s election. There was a bit of a  social movement in this country to address bankruptcy from healthcare costs – from not having enough health insurance if you will.

Brill brings that out in his Time article – that it’s people with insurance that are going broke, not just people without insurance. The private insurance premium is a huge burden for working families, and I think it’s going to drive people to Medicaid.

If there’s a choice to go on health insurance exchange and buy a “used car” of an insurance program, or you can sign up for Medicaid. Duh, it’s not much of a choice. If an employer has an opportunity to choose between having his employees getting a county integer program or Medicaid instead of private insurance; they’re going to choose the county integer program or Medicaid rather than private insurance. If they can game that system I think.

So the question becomes how many people are going to sign up for Medicaid? How many states are going to aggressively pursue signing up people for Medicaid? How many community-based organizations are going to work on signing up the members of their communities for Medicaid that are newly eligible?

Then, of course, we have to address the groups that aren’t being included in the PPACA at all. And those are the “undocumented”. Again if you get thrown in prison or you join the military you’ve got access to better healthcare than you do if you’re an undocumented immigrant who follows the rules and tries to get ahead in our society.

I never wanted to be labeled a “reactor”, because it sounds like reactionary. So I’m trying to “out-progress” you.

John Geyman, MD University of Washington Emeritus

John Geyman, MD
University of Washington Emeritus

John Geyman, MD: [Dr Geyman is a Senior Fellow of the National Conferences]:  I agree with everything you said. We certainly do lead the world in those very adverse areas that you mentioned. And we’re not talking enough about the affordability of insurance.

The latest information I saw, for a family of four it willl cost you just nearly 20,000 bucks a year now. The Commonwealth Fund has looked at affordability. They estimate that anything over five percent of your family income is starting to be considered a hardship. Median income is about $50,000 a year for families. And so $20,000 out of $50,000 for a family of four is totally untenable.

We’re getting less and less. Someone has to show me that we’re really reining in the practices of the insurance industry with the ACA. I don’t think we are. They’ll out game us at every turn.

Hector Flores, MD White Memorial Medical Center Los Angeles, California

Hector Flores, MD
White Memorial Medical Center
Los Angeles, California

Lead Question: Hector Flores, MD; Wright Memorial Medical Center in Los Angeles [Dr Flores is a Senior Fellow of the National Conferences]; Thank you for the great presentation, John, and to Chuck North for that “nuclear reaction”.

I had a chance to work with the Clinton task force from 1992 to 1994. When Hillary Clinton, who was the chair of that task force sort, was of doing the post mortem, she said that she didn’t realize how much business and politics were ingrained in our healthcare system.

It was actually humbling for me to hear her say that; and that whatever we need to do to change the system has to engage those interests. In part, she said is because America is so unique in its culture that we have a Constitution that is the greater good, but we also have an individual Bill of Rights that protects each individual’s rights. And we have a right to judicial review if we feel that our individual rights have been violated.

We apply these constitutional principles and rights to everything we do, including healthcare. We know we are willing to pay more; we have a good heart to include all Americans, but we don’t want it to mess with our individual insurance.

She added to that to advocate for “single payer”, or single anything will always be opposed by a certain powerful interest – what she called the unusual coalition of about 40% of the electorate being influenced by big business and by people who would rather die than have the government do anything for them.

If that is going to happen, it’s going to require a multigenerational change, before we can get to a new cultural thinking that says the greater good outweighs the individual rights.

In your closing comments, John, you mentioned two very salient points (among many that you did) that were wonderful. First, we need to make the business case for doing the right thing. And second, change will come from a grass roots effort. Could you comment more about that and maybe give us one thing we could do when we go home to start that process?

Left: John Geyman MD (University of Washington Emeritus); Right: Charles Q. North, MD, MS (University of New Mexico)

Left: John Geyman MD (University of Washington Emeritus); Right: Charles Q. North, MD, MS (University of New Mexico)

Dr Geyman: Now that’s interesting. Well first of all, I believe there is popular support for national health insurance.

I am aware of many studies since the 1950’s and 1960’s that show that a majority of Americans, when asked if they would support the equivalent of a national health insurance program, answer that they would.

Often that question is gamed a bit by whoever is asking the question. They add “by the government” or something like that. You know that the wording can be tricky, but there is majority support going back 40 years in this country for single payer financing. That’s the first point.

Second, we can get to thinking change will never happen, that the system is all too big to change. But there are examples where, where cultural changes can happen quite quickly. I think I might say that gay marriage is a rather recent example. That hasn’t taken 100 years. A lot can happen even in a period of ten years or so. I know it  is a big issue, but it can change and has to change.

I think we are building awareness in the business community. Ralph Nader talks about a liberal-conservative convergence. It’s history now, but if you look at General Motors’ cost of building cars, GM paid almost 1500 bucks a car for healthcare. Across the river in Toronto, Canada with its single payer system, the cost was more like $200.

I think if you’re in practice, if you’re in a teaching program, whatever you’re doing, even if you’re retired like I am from practice, you can still be an advocate in your community and inform yourself and see what you can do about it.

For example, in our own community, several of us tried to re-steer the new critical care access hospital that located on San Juan Island in a different direction. But it’s ending up as non-primary care oriented that emphasizes the ER, and emphasizes referral back to the mother hospital instead of the other hospitals where patients used to go to. We know the hospital is not going to be successful.

Over the next year, we’re going to develop a case study of the business plan of our critical access hospital. Patients are going to vote with their feet and their wallets.

We’re going to help them. We have a newspaper on the net that people read more than the weekly print edition. So even in our little community, and wherever else we can, we can lead instead of just following.

Dr North: John’s too polite to say you can join the Physicians for a National Health Program and pay your dues this year. That’s something else you can do I guess.

If you ask people that have Medicare, Medicaid or have served in the military system or in the Indian Health Service system, in the system at community health centers around the country and other examples of federal systems like the prisons (where people don’t have as much choice, of course), I just don’t think you’d find very many people that’d say “Gosh, I wish I could go out and buy private health insurance and be part of that private health system which is so great where they do CT scans and MRI scans and operate on knees nd you know god knows what other unnecessary stuff”.

People suffer from that. They don’t just get bills for trauma like David Sundwall was talking about. They suffer for their life from unnecessary tests and surgery and unnecessary costs. Those costs really keeps them from their other goals, like being able to do other things with their limited resources.

You know medical care is nice when you need it. But your life shouldn’t be centered around medical care unless you’re in the business of it. Your life should be around pursuing your self-actualization through living, loving, working, educating. Those things are more important than being in the medical care system. But we have medicalized American life to the point where money can be made off of just about anything.

Dr Geyman: Wow, well said!

Frederic Schwartz, DO ATSU School of Osteopathic Medicine in Arizona, Mesa

Frederic Schwartz, DO
ATSU School of Osteopathic Medicine in Arizona, Mesa

Fred Schwartz, A. T. Still University School of Osteopathic Medicine in Arizona, Mesa. All politics are supposed to be local, but if you look at an electoral map of the country, that shows “red” or “blue” for each county (respectively counties that voted Republican or Democrat in the last election) the red zones are all over the  country.

What I’m having difficulty understanding is not the top 1% in income, who have benefited from a system that allows them to keep all of their money.

What I’m having trouble with are the people who are between 10 and 15% – 15 times the poverty level. These are folks who vote against their own interests – you know “keep your government’s hands off my Medicare” and all of that.

This group actually is in great distress over healthcare issues, yet they elect people who promise to vote in ways that are against this group’s interests. And it happens again and again and again.

Is there anything we can do to actually reverse that trend or is it really bigger than all of us?

Dr Geyman: Well I agree with the absurdity with how that happens. I don’t have any big answers. Do you, Chuck?

Dr North: I think it’s important for us to get together and out who’s behind financing these campaigns. If you look at the NRA, they frankly don’t care about the Second Amendment at all. The Second Amendment has nothing to do with what they’re talking about. What they care about is making money for the guns and ammunition industry. They are their apologists. They’re owned by them.

And if you look at who lobbies for healthcare, you see exactly the same thing – insurance companies who profit from the position. Any good organization has people lobbying to do that or they would fire them if they didn’t, because that’s what they’re all about.

I think it’s really important to have transparency of funding. That’s something we all can participate in as citizens, regardless of our political leanings.

We can also take part in this at the local level because there are city councils, there are community meetings, there are county and state forums for us to discuss these issues. And there are more of us than there are of the people running the organizations. So we just have to do it with sheer numbers and we have the truth.

I think the Internet helps tremendously. It’s leveled the world. Look at the Arab Spring. Now who would have thought Tunisia would lead the worldwide movement for freedom and justice in Democracy a few years ago. So if Tunisia can do it, we can do it, John.

Dr Geyman: I agree with every bit of that including advocating for reversal of Citizens United, which is a big part of the “money in politics” issue.

Dr Bejinez-Eastman (moderator): Just a warning. When doctors start giving you political advice, be careful!

I’ll bring everybody back at 10:14 so we can get started at 10:15 and hear about the impact of PPACA in Hawaii.



“What Has NOT Changed” – A Critique of the Affordable Care Act: John P. Geyman, MD

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference on Primary Health Care Access:

The following transcription is of the second plenary sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. 


Ana Bejinez-Eastman, MD (Moderator) [Dr Bejinez-Eastman is a Senior Fellow of the National Conferences on Primary Health Care Access]. Our next speaker is Dr. John Geyman; we’ve been anxiously awaiting, and Dr. Chuck North who will react, as usual.

John Geyman, MD University of Washington Emeritus

John Geyman, MD
University of Washington Emeritus

John Geyman, MD, University of Washington Emeritus [Dr Geyman is a Senior Fellow of the National Conferences]:  Thank you it’s great to be here. This is always a special meeting. And as Kevin Haughton indicated at the session’s start, change is all around us.

Where is primary care going? Where is the health care system going?

Change includes all of our personal lives. My wife Gene died a year and a half ago. I worked through that.

Emily Reed (front right) and part of audience for Dr Geyman's presentation

Emily Reed (front right) and part of audience for Dr Geyman’s presentation

Emily Reed, who is here in the audience, will be my new wife, starting next month. We’ve navigated that. We have a new chapter. And we need a new chapter in healthcare.

I tend to focus on basics. I tend to ask pretty basic questions. Then I tend to track them.  I’ve been out of practice now since, golly, 1997 on San Juan Island in Washington’s Puget Sound. What I do mostly is to ask the basic questions and track where we’re going.

In this talk, which I first gave at University of Missouri Columbia several weeks ago, for Dr Jack Colwill’s department, I asked the basic question of the Affordable Care Act [ACA], is it going to lead us somewhere we really want to go, or not? Well, we’ll get started!

24PHCA 360 GEYMAN 02These are the big four problems that health care reform has to address – uncontrolled health care costs, unaffordability, restricted access, and variable quality of care. Everyone here knows them.

As David Sundwall already has indicated – and I agree with him – there’s no real cost control in the ACA [“What Has Changed?”: Health Reform in the U. S. A. – David N. Sundwall, MD]. In Massachusetts, the state on which ACA was modeled, health care costs are a big problem.

24PHCA 360 GEYMAN 03ACA has a few good points. It will extend insurance. We bicker about just how many people coverage will be extended to, but maybe 32 million more by 2019. That’s a long way from now. We’ll subsidize all that.

Parents will be able to keep their kids on their insurance until 26 – that’s good!

There is expansion of Medicaid for 16 million people, but what a battleground that is. We will see underfunded Medicaid all over the country, with all kinds of variation by state as to what coverage is.

Yes, there is some new funding for community health centers and for a few – just a few – preventative services without any cost sharing imposed. There are some very limited reforms of the health insurance industry. Then there is PCORI, the Patient Centered Outcomes Research Institute, That hasn’t really gotten started yet. But these things are there on paper.

24PHCA 360 GEYMAN 04But I think we have to say, now that we are three years after the bill passed, that corporate stakeholders hijacked the whole political process to protect their markets.

That market failure wasn’t recognized as the wellspring of system problems. The essential problem is the health insurance industry is failing. It lacks enough value to justify its bailout by the federal government

We had a middle of the road approach by Democrats and the Obama Administration. There has been a total unwillingness by political leaders, including in our own medical organizations, to admit that the incrementalism of the past 30 or 40 years hasn’t worked. There was flawed framing from the start of the healthcare debate. I agree with David Sundwall that the rhetoric on both sides is just absurd.

24PHCA 360 GEYMAN 05Here’s why I think the bill won’t work; I really like Herb Stein’s Law “If something cannot go on forever, it’s going to stop.”

The health costs are what is bankrupting us. “Incrementalism” hasn’t contained costs in the past at all. Why do we expect it to do so this time?

Private insurers are on a death march without subsidies. ACA will bail them out for a little while,.

Employer-sponsored insurance continues to decline. It now accounts for less than 60% of those insured, and is trending downwards towards 50%  Many employers are looking at self-insuring, which exempts them from the provisions of the ACA, but they’ll cover less and less. They’ll cut out retirees, of course. Meanwhile, the health care “safety net” gets a little more tattered all the time.

24PHCA 360 GEYMAN 06Let’s consider the basic “20-80 rule”. Twenty percent of the population accounts for 80% of healthcare spending.

The healthier half of the population spends just three percent of total spending, and the sickest five percent account for nearly half of all spending.

Of course, the insurance industry have all kinds of games, and will continue to, including through the “accountable care organizations”. They will try to enroll the healthiest parts of the population and to offload sicker patients to the public sector.

24PHCA 360 GEYMAN 07Here’s why the ACA makes no sense to me. There are no cost or price controls,

The supposed reason for mandatory insurance is to subsidize the high users of health care services with the revenues received from persons.

However, the 20-80 rule will make it impossible to cover the costs of providing care to the highest cost 20% of the population without outsized shifts in costs to the healthy or big increases in government subsidies to the plans, or both.

As these higher costs materialize, driving insurance premiums higher, there will be Increased numbers of underinsured and uninsured.

There are studies that have demonstrated that compared with traditional Medicare, which simply reimburses providers for covered services, the “for profit” insurance plans have less efficiency and less quality. They also increase more waste and bureaucracy, both within the insurance companies and the government agencies that oversee them.

The Increasing consolidation of the insurance industry will further eliminate choice of providers and access. The total impact of Obamacare will be to further erode the safety net.

24PHCA 360 GEYMAN 08Some of the architects of the ACA and related approaches to health care reform assume and try to make us believe that information technology will fix everything.

I was at the University of Wisconsin in September, where Epic Systems Corporation, the leader in market share for electronic health records has a big campus right there in Verona, nearby Madison. Three hospitals in Madison – Children’s Hospital, University Hospital and a private hospital – all use the Epic EHR, customized to each place. If you’re a doc covering two or three hospitals, you have a different EHR for each hospital, because those three systems don’t talk to each other! That’s how it works, even in Madison, Wisconsin.

Disease management, consumer directed care, Pay for Performance, Accountable Care Organizations, managed care, risk management. Even through several of these ideas have been implemented, some in many different places, none of them have proven to contain health care costs.

24PHCA 360 GEYMAN 09We’re going to have more consolidation of the corporate stakeholders. This will lead to surging prices and profit.

Let me digress to show one of the ways that this will happen. There is a Catholic hospital in the nearby town of Bellingham, Washington; which is now the only hospital in the region. The Peace Health System, which ranges from Oregon to Southeast Alaska, now operates that hospital. Peace Health put in a rural, critical access hospital with ten beds which has been operating for six months. We probably don’t need such a service on the island, which is only 10 miles by 20 miles.

As an example of the care they have provided, a patient came into their emergency room with a little bit of abdominal distress. The doc said, “I don’t think you have anything serious here, but let’s get a CT scan to make sure.” It’s the first time we’ve had a CT scanner on the island.

After a three hours wait and a bill for $5,800, the patient has a CT scan.The patient is sent home, with the instructions to take some fluids, and is told that no follow-up appointment is necessary. I mean come on! But this is happening all over!

So inflation of healthcare costs continues. That is what is going to break our system, Inadequate access, the frayed safety net, and subsidized underinsurance will all contribute to uncontrolled costs.

24PHCA 360 GEYMAN 10Wait until we see what really is going to get covered and not covered through these exchanges. If you think we have a huge bureaucracy now, there is much more to come – all totally unaccountable and unsustainable.

We are already seeing insurance premiums going up all over.

Facility fees for hospital system services are being tacked onto medical bills – anything connected in a clinic facility, even a mile or two away, becomes part of the facility fee for the hospital system.

it chains are putting pressure on physicians to admit patients. There is both overdiagnosis, and overtreatment, especially imaging for every symptom like low back pain.

We will see a lot of “out of network prices”. There will be huge, insurer surcharges for exchanges, The exchanges are already trying to protect themselves from those charges.

24PHCA 360 GEYMAN 11So we will continue to have access problems, with 30-34 million uninsured, and an unwillingness of docs to see Medicare and Medicaid patients. That statistic will be going up.

There will be a shortfall of 30,000 primary care docs by 2015, with increasing cost sharing, decreasing affordability.

24PHCA 360 GEYMAN 12Eight million are expected to lose employer-sponsored insurance [ESI], Increasing a shift to part-time workers, because, under ACA, below a certain percentage of full-time employees, employers don’t have to provide insurance. That’s a big trend.

There are no federal subsidies when ESI is unaffordable for family members. There is also a recent trend of employers choosing to self-insure so as to be exempted from the law.

24PHCA 360 GEYMAN SLIDE 13There is an epidemic of underinsurance. Only 27 million instead of 32-34 million projected are newly insured with ACA.

There are low actuarial values in those who are newly insured. The revenues from this group are estimated to cover only 60 to 70 percent of their costs.

You watch! What will finally come out is that the actuarial values will mostly be around 60%. This will require sharply higher out-of -pocket costs for everyone, while many essential services will remain uncovered.

The health insurance exchanges and many of the employer-sponsored plans will have very skimpy networks, and these will have penalties for out of network care. Many of the plans have become high-risk pools which are running out of money. You had one in California that went bankrupt, right?

24PHCA 360 GEYMAN 14So, what is happening to the safety net? The feds have become very liberal with their waivers.

What will Medicaid really mean state by state? Governor Rick Scott in Florida has agreed to take Medicaid for two years with the federal government subsidizing it 100%, but let’s see how it goes after those two years. He has not been a big supporter of a safety net.

There will be decreased access to docs for Medicaid and Medicare patients and increased cost-sharing of up to 5% of out of pocket costs. In a number of states, denial of services to Medicaid patients is permitted. Nor has there been any fix in ACA for the gaps in coverage of long-term care and mental health.

24PHCA 360 GEYMAN 15Let’s look at the battlefield. Docs are fighting against hospital systems and insurers; insurers against hospital systems and government, employers versus federal requirements, states versus the feds; and, overall, the business “ethic” versus the service ethic.

24PHCA 360 GEYMAN 16I’ve quoted Steven Brill who authored the Time Magazine article on American healthcare costs, that I understand at 36 pages is the longest article in the magazine’s history.

I thought he was really good at identifying the problems, although he was really poor on proposing the solutions. I think in the end, he really wimped out on what should be done.

Brill wrote that: “unless you’re protected by Medicare, the healthcare market is not a market at all, it’s a crap shoot. People fair differently according to circumstances they can neither control nor predict. They have, they may have no insurance, they may have insurance but their employer chooses their insurance plan, and it may have a payout limit or not cover a drug or treatment they need. They may or may not be old enough to be on Medicare or given the different standards of the 50 states, be poor enough to be on Medicaid.

“If they’re not protected by Medicare or their protected only partly by private insurance with high copays, they have little visibility into pricing, let alone control of it. They have little choice of hospitals or the services they’re billed for even if they somehow know the prices before they get billed for the services.

“They have no idea what they’re bills mean. And those who maintain the charge masters couldn’t explain them to them if they wanted to. How much of the bills they may end up paying may depend on the generosity of the hospital or on whether they happen to get the help of a billing advocate. They have no choice of the drugs that they have to buy or the lab tests or scans that they have to get, and they would not know what to do if they did have a choice They are powerless buyers in a sellers’ market where the only sure thing is the profit of the sellers.”

We have a microcosm of what Brill is describing right here on San Juan Island. But we’re having an effective local grass roots response. A retired hospital administrator with 40 years’ experience is leading our effort to make our critical access hopsital and clinic more accountable to the community for access to affordable health care.

24PHCA 360 GEYMAN 17I also want to quote Paul Craig Roberts, who was Assistant Secretary of the Treasury for Economic Policy in the Reagan Administration, He was a co-founder of “Reaganomics” and a former Associate Editor of the Wall Street Journal.

Roberts writes: “What Obamacare does is to divert Medicare and Medicaid monies to the profits of private insurance companies. Instead of providing medical care to those in need, the taxpayers’ money will provide bonuses for insurance executives and profits for their shareholders. It’s the height of folly for Obama worshipers to defend a law written by the private insurance companies that uses public revenues to provide insurers with 50 million more customers and to add yet another layer of profits to the costs of American medicine.”

So, some, like Roberts, on the political right and in the business sector get what is happening.

24PHCA 360 GEYMAN 18Here is how I tie it up. We still have a market-based system. This is how markets fail patients – through predatory pricing, perverse incentives for profit, consolidation and market power, inefficiency and bureaucracy, inadequate quality control, volatility and unreliability, unethical practices and, at times, outright fraud.

24PHCA 360 GEYMAN 19We need a shift towards patients and families at the center of the system, in a service-oriented system.

We have to get rid of the multi-payer system.

Look at this chart (that has been in my books) comparing alternative financing systems and American values.

24PHCA 360 GEYMAN 20 If you look at efficiency, choice, affordability, value, fiscal responsibility, equity, accountability, integrity and sustainability; a single payer system such as national health insurance would do all that.

The United States is a real outsider in the civilized world Western Europe, Scandinavia, Canada, Australia, and many other countries around the world have some form of a single payer public financing system.

24PHCA 360 GEYMAN 21We need to organize for single payer financing by abandoning the multi-payer system, demanding that we base alternatives on credible, documented health policy science and experience; not on ideology. Obviously, what we actually practice should be based on evidence-based science and on cost effectiveness.

24PHCA 360 GEYMAN 22We need to change how docs are paid, with practicing physicians receiving a salary practice along the lines that Dr Arnold Relman has been calling for years and years.

We have to rebuild the primary care workforce, although you can’t really do that until you change the system. We’ve been going uphill for 30, 40 years. Now we are trying to build primary care, but until we can make the system more conducive to primary care practice, it will not be as effective as we want.

Emily and I were just in Buenos Aires, Argentina the last week. A colleague there translated my book Breaking Point into Spanish. There is an organization of 350,000 primary care docs in Latin American countries.

Many Latin American countries have a version of universal access. In Argentina, they have universal access and have had it for years. They still have many hierarchal subtleties in the system, but you go to medical school there, that’s free. If you become a lawyer, law school is also free. It’s amazing.

We need to get more active. As I said this morning in our breakfast breakout group, I think family docs know more about the system than anyone else in medicine, and yet our organizations wimp out on the bigger questions; like how to finance care.

24PHCA 360 GEYMAN 23This chart shows the advantages in a single risk pool. On the right side of the chart, you can see the “Fear factor” arguments that some people use against the single payer system, such as “who wants government in our medicine cabinets?”

But the best way to allocate resources for the benefit of everyone, given the 20 80 rule, would be a single risk pool.

Which the VA does, and the military does (as Dr Lee Burnett here knows from his long experience in military systems), you have a single payer system. We have a lot of studies in the VA about the quality of care in VA hospitals being better than a whole bunch of private hospitals in the country.

24PHCA 360 GEYMAN 24What are the alternative scenarios that we might see In 2020, only seven years out now?

Until we get a single payer system, the way ACA is being implemented, we’re not going to have universal access in 2020. We sure would if we could get a bill like HR 676 through one of these days – or years.

Cost containment is out of control now, and it will stay out of control with ACA, I’m quite sure. Affordability is getting worse in this multi-payer system. ACA will not provide comprehensive benefits. We will have more tiering taking place. I think most people will end up with probably 60% actuarial value in their health plan, if they have one; which is way short of what they need.

24PHCA 360 GEYMAN 25Free choice of providers is going down the tube also. Both hospitals and the networks of doctors can be changed overnight for whole groups of patients.

Quality of care will not get a whole lot better with this very complicated system.  We already have a lot of bureaucracy now, it’s going to be a lot more as ACA is fully implemented. Equity is terrible within ACA.

It may take us five to seven years to agree that ACA is unsustainable, but it’s not going to work.

24PHCA 360 GEYMAN 26If we are looking for some optimism, where can we find it?

“Stein’s Law” gives me some hope. What we’ve enacted is going to fall apart. It will stop.

We will have to see more public backlash over cost and affordability and access. Hopefully, we’ll see backlash from business one of these days. We’re not going to be able to continue all these subsidies to insurers.

I’ve cited before a survey of 2200 docs from all specialties in this country. Of that group 59% supported a single payer system. Support is out there. But we’re totally not mobilized.

24PHCA 360 GEYMAN 27We could have a liberal, conservative convergence for real reform if the system gets so out of whack on costs.

And we could have more social action from the grass roots. I think each of us, in our own situation, could be much more politically active in the interest of the patient and our community and go beyond the position of our American Academy of Family Physicians for just better reimbursement. I’ve been a member of the Academy for years and years.

But what might have been 110,000 docs in this country mobilizing for real reform along single-payer lines instead has produced a document that supports keeping the multi-payer system here and wimps on the basic questions.

Bill Moyers, a hero of mine; “This is a perilous moment. The individualist, greed driven, free market ideology that both our major parties have pursued is at odds with what most Americans really care about. Popular support for either party has struck bottom, as more and more agree that growing inequality is bad for the country; that corporations have too much power, that money and politics has corrupted our system, and that working families and poor communities need and deserve help because the free market has failed to generate shared prosperity. Its famous unseen hand has become a closed fist.” I always liked that quote.

I still like what Churchill said a whole bunch of years ago about the US. “Americans will finally figure it out to get it right, but first the exhaust all the alternatives.” And this ACA is just one more alternative. Thank you.


24PHCA “What Has Changed” – Sundwall Keynote Reactor (Wilke) and Q/A Session

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference:

The following transcription is of the opening sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. 

This section follows: “What Has Changed?”: Health Reform in the U. S. A. – David N. Sundwall, MD

Reactor Allan Wilke, MD and Question/Answer Session

Allan Wilke, MD, Western Michigan University [Dr Wilke is a Senior Fellow of the National Conferences on Primary Heatlh Care Access]: My first reaction is that I understand now why David Sundwall was asked to be the keynote speaker and not me. It was a wonderful discussion, with a very concise review of ACA and a nice review of Utah’s progress in healthcare reform, or health insurance reform. Certainly the ideas that you brought forth as to where the prognoses are, are thought provoking.

David Sundwall, MD (left) and Allan Wilke, MD (right)

David Sundwall, MD (left) and Allan Wilke, MD (right)

I think that a lot of us are feeling in limbo about where we are with ACA, health insurance reform and healthcare reform in general.

We’d like to be a little more secure in where we’re going with this. It feels to me that we’re playing the best hand with the cards that we’ve been dealt, but that we aren’t looking far enough out into the future to know how it will work out.

What kinds of plans can we put into place? What can we depend upon to occur? I guess I would look at specifics such as the part of ACA that promotes teaching health centers.

As most of you know, at the very last moment instead of funding the residency positions out of Medicare they were moved to the Department of Health and Human Services Health Resources and Services Administration [that Dr Sundwall once administered], but only for five years.

As a person that has to deal with residents and expanded residency positions, five years is nothing. Not knowing that I’m going to have a continued revenue stream after that means that I can’t plan on an expansion that is funded for certain only in the first few years. I really can’t do that kind of planning, knowing that I don’t have any alternative plans for replacing the funds in the out-years.

David Sundwall, MD [Dr Sundwall is a Senior Fellow of the National Conferences] You are absolutely right that there is not sufficient attention in ACA to long term issues. I can tell you because I worked on the United States Senate staff for five years; I helped write a lot of health law.

This process was pathetic! There was no conference committee. There was not a single Republican who voted for the bill. It’s a partisan mess. I say that because it never got a chance to iron out the kinks in it.

Some of these issues could have been attended to if they had gone to conference. It was a clever ploy based on “reconciliation rules” that the Democrat leadership use to ram the bill through. Recall the quote of Speaker Nancy Pelosi who said  “Don’t worry about it, We’ll read it after we pass it.”

Sad! Congressional legislation is a complicated process. I know how ACA happened. If you work in the Senate and you’ve got a pet project; you get them slipped into the bill. That’s what they did as a Congressional staffer. I had my pets, like Title Seven, and the Public Health Service. I was a champion of those programs in the early 80’s. I spent a lot of attention on them.

A lot of members and staffers added their provisions to this bill that never got the light of day before it was sent to the White House. We’re going to be cleaning up these complexities and addressing matters like cost containment or medical liability for long-term conditions for years to come.

Question and Answer Session

Perry A. Pugno, MD, MPH American Academy of Family Physicians Leawood, Kansas

Perry A. Pugno, MD, MPH
American Academy of Family Physicians
Leawood, Kansas

Lead Question: Perry Pugno, MD, MPH, American Academy of Family Physicians, Leawood, Kansas [Dr Pugno is a Senior Fellow of the National Conferences]This morning we started out hearing that we’ve been calling for a need for a generalist-based healthcare system since the 1930’s. In fact I recall reading in the 80’s; I think it was a treatise written by this guy named Doctor John Geyman who was articulating a conversation  Dr Osler had 100 years earlier that said the same thing.

We’ve come to realize this, that this need, we’ve got, we’re drowning in data that proves that a generalist healthcare system is what we need. We acknowledge this growing importance of the interface between generalist care and public health – that the social determinants of health are more and more important along the way.

You acknowledged this morning that there’s very little cost containment material in the ACA. I’d really, really, really like to hear something optimistic that’s going to tell me that something’s going to happen with time.

But my diagnosis our country with pernicious partisan politics; and so I’m worried that the feds are not going to make it happen and I have, I’m seeing bits and pieces of evidence; and you just articulated some of it from Utah, that the states are going to grab hold of what few resources they can pull from the feds and that maybe the solution to some of this stuff will come from the states rather than the feds. I’d like your reaction to that.

David N. Sundwall, MD University of Utah

David N. Sundwall, MD
University of Utah

Dr Sundwall: I thought I was kind of optimistic. I was trying to tell you we’ve moved down the road. We just have gone about, you know a few miles; we’re not far on our journey. But we are getting there.

I do sincerely appreciate that more people having insurance is a good thing. That’s good for public health, good for personal health; but as far as the prognosis, I think we’ll get over this bad patch.

I think that the Tea Party folks’ antigovernment rhetoric is wearing so thin and there just are many of us who are just appalled by the kind of obstructionist kinds of things. So I’m hopeful that we’re going to see some change. I’m not sure it’s going to happen soon.

But I think like this Time Magazine article the economic imperative is so strong that we do something about healthcare that I think we’ll get there. And I’m a proud American I think we can work this out.

In the next 100 years?

Probably, in our lifetime, Who knows Perry? You never know!

Kevin Haughton, MD Providence Health Systems Olympia, Washington

Kevin Haughton, MD
Providence Health Systems
Olympia, Washington

Kevin Houghton, MD, Providence Health Systems, Olympia, Washington. [Dr Haughton is a Fellow of the National Conferences.] David, thanks for your work!

In Washington State we hold out Utah as the model because their per capita healthcare costs are dramatically lower than Washington State. Can you tell me two or three reasons why you think that might be true?

Dr Sundwall: I can tell you in a nutshell. When I was Commissioner of Health I used to acknowledge to the legislature and other people that my job was much easier when you live in a state where half the people are afraid they’ll go to hell if they drink or smoke. (Go to hell if you drink. Boy am I going to get it!)

I’m being a little facetious, but the Mormon culture, that has its own health code against those smoking, alcohol and the like, is helpful. Aside from that, I think there is a culture of health that isn’t religious-based. We’re an outdoorsy folk. We’re kind of like Colorado! We enjoy relatively low obesity rates, although the statistical difference between states is not great. We’re fat too!

Donald Frey, MD Creighton University Omaha, Nebraska

Donald Frey, MD
Creighton University
Omaha, Nebraska

Donald Frey, Creighton University, Omaha, Nebraska: David, you’ve shown once again why you’re the nicest Republican I know! As you recall, I said that before to David a few years ago at a breakfast session, and one of our colleagues from the University of Washington said “David you’re the only Republican I know.”

My question is this. You’ve articulated a very, very well structured system to help give people choices with regards to the health insurance market.

From my view, one of the most difficult issues we contend with is that there’s a fundamental difference between a health insurance market and a health care market. The two are not synonymous. Often, they can be at odds with one another.

To what extent do you think the system you’ve set up in Utah that in fact provides information that helps consumers make health insurance choices is really effective in terms of helping them make healthcare choices in the healthcare market?

Dr Sundwall: Well, that’s a hard question. I do think there’s an enormous amount of unhealthy behaviors for people to choose to you know, read or ignore. I honestly,

Here’s where I get skeptical, I don’t think that information drives insurance choices. I think it’s cost. When push comes to shove you buy the policy you can afford. If you are a young family that needs OB coverage, you buy a policy includes OB. You search out what you need at the best price.

Based on my own experience as a federal employee, when the annual open enrollment came around, I always looked at what had the lleast out of pocket cost for me. So I’m not sure that having a lot of information about healthcare options will cause people to make a choice related to health over a choice related to cost. I think they vote with their pocket book primarily.

David Sundwall, MD (left) Allan Wilke, MD (right)

David Sundwall, MD (left)
Allan Wilke, MD (right)

Allan Wilke, MD, Western Michigan University School of Medicine: Arkansas’ state responses, as I understand it, is to purchase insurance for their poorest citizens. To me, that sounds like a good idea, but isn’t that what the health exchanges are supposed to do? As I understand the Arkansas plan, it will offer even less choice because someone will go out go out and purchase it for you.

It also sounds to me like Arkansas’ Republican administration has taken a good idea and putting lipstick on it and called it something else, so they didn’t have to say that they supported Obamacare.

Dr Sundwall: What you’re referring to is the waiver that Arkansas applied to CMS for. Although it has not actually been finalized, Secretary Sebelius has said good things about granting a waiver that would allow states to use their Medicaid money to purchase private health insurance for their citizens under the 138% poverty level. It would not be just a subsidy to buy private insurance, but to buy a policy for them in the private sector.

That of course appeals to Republicans. Your concern about what kind of policy are they going to get is a good one. If the plan that Arkansas purchases has to meet the minimum benefit standards that are in the law, it probably will be pretty good. So I think that it’s an experiment that’s worth playing out.

I can tell you in Utah the reason why I predicted they might go for the expansion is based on the fact that they might allow use of those public dollars to buy private insurance. So it’s an interesting twist and I think an attempt to diffuse some of the Republican criticism of Obamacare.

Marc E. Babitz, MD Utah Department of Health

Marc E. Babitz, MD
Utah Department of Health

Marc Babitz, MD, Utah Department of Health [Dr Babitz is a Senior Fellow of the National Conferences]: I had the pleasure of working for David twice in my life – once at the federal level in HRSA, once at the State of Utah’s Department of Health.

Actually, he did my physical exam last week and he said I passed. I was so happy. I had to make sure he was certified for billing insurance.

Those of us in the audience know David as having been a very good and supportive Republican, but when it comes to Utah they actually thought he might be a Democrat.

I have a comment and a question. If 50% of our current providers were in primary care medicine/healthcare, I think the ACA would have a good chance of being successful. My fear is that with our current problem in primary care that the ACA is going to rapidly become bankrupt – just as we saw in Massachusetts. All those people who have insurance will need some place to go. There won’t be enough primary care providers to see them, so they’ll go to the emergency rooms and they’ll go to the subspecialist. They’ll have lots of procedures done, and the costs will skyrocket. What are your thoughts on my comment?

Dr Sundwall: I believe that your worries are justified.. Massachusetts bragged about their 99% coverage, their almost universal coverage in their state. But what has it done to cost containment? Nothing.

They now have a tiger by the tail with more people having insurance. By the way, a little prediction that I heard from a reliable source is; when the mandate kicks in and everybody has to go to insurance that if you are in an employer-based insurance plan your rates will state relatively the same, but for all those people who haven’t had insurance, there will be many of them who are going to be “poor risk”, so it is predicted that the rates of private insurance will go up double digits. Not only is ACA not a way to get cost containment, it might prove to be cost inflationary. That will be a problem.

If ACA were primary care based it would be helpful, but the workforce issues are unbelievably daunting. The primary care provisions that are currently in the ACA, if they do anything, it will be seven years down the road. ACA didn’t enact more training support for primary care. By 2014 we will have to have to have a lot more primary care docs to meet the act’s requirements, but it’s going to be years down the road before we do, so we’ve got a real workforce problem.

This will be our last question.

Robert Bowman A. T. Still University Mesa, Arizona

Robert Bowman
A. T. Still University
Mesa, Arizona

Robert Bowman, A. T. Still University School of Osteopathic Medicine, Mesa, Arizona; One quick comment. You have made reference to the link between better healthcare outcomes from health insurance in states like Utah, Colorado and Minnesota with favorable social determinants of health. So until you deal with those social determinants in less healthy communities, the emphasis on health insurance makes little sense.

My question relates to the corruption of processes intended to reform healthcare. Between the enactment of Medicare and Medicaid in 1965 and 1980 the emphasis on health access in those acts was so diluted as to no longer be a priority. It took about five years to defeat managed care; often because we didn’t have the primary care workforce to operate it.

It seems that even before the 2010 PPACA reforms were enacted, they were defeated. Do we have a chance against a very powerful corporate, multi-corporate lobby that gets more and more hundreds of billions of dollars design a healthcare system from which they directly profit?

Dr Sundwall: I’m not sure what the question is, but there’s no question that the Washington’s run by money and the poor and the needy don’t have a voice that’s anywhere comparable to the self-interest group. So that’s another thing in our society that’s troubling; even to some of us Republicans!

“What Has Changed?”: Health Reform in the U. S. A. – David N. Sundwall, MD

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference:

The following transcription is of the opening sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. 

Dr Bejinez-Eastman, Moderator: [Doctor Bejinez-Eastman is a Senior Fellow of the National Conferences on Primary Health Care Access].

I’d like to introduce our next speaker on policy basis and politics, Dr. David Sundwall. And Dr Allan Wilke will be the reactor.

David N. Sundwall, MD; University of Utah

David N. Sundwall, MD; University of Utah

David N. Sundwall, MD, University of Utah [Dr Sundwall is a Senior Fellow of the National Conferences on Primary Health Care Access]:

Good morning! What an honor it is for me to be the keynote of this conference!

I’m going to get myself in trouble. I don’t come for the speakers or the content. I just love to see you guys. It has been so many years since I’ve been coming to these things. It’s not that I don’t learn something every time, and tjat it’s always provocative and fun. I’m delighted to be here.

SUNDWALL 2013 01 360I’m going to give you my take or my presentation on the Patient Protection and Affordable Care Act (PPACA) – what I will call Obamacare, because President Obama embraced the term, which was wise.

It was a pejorative initially when the Republicans were trying to disparage the effort and demonize it as a takeover of medicine by the government and socialized care.

But I think it’s fair to call it Obamacare, it’s a nice term actually. So whether, whatever your politics are I’ll call it Obamacare, meaning not to be for or against.

So what I’m going to try to talk about today is give you a historical perspective on health reform, a brief one. I’ll talk a bit about the Act. I’m going to share with you kind of a different view of health reform that we have in the state of Utah, which is of course a federalist view where the states have more responsibility. and more, some ideas that merit being tested.

Donald A. Barr, MD, Ph.D. Stanford University

Donald A. Barr, MD, Ph.D.
Stanford University

I’m sure many of you know the history of health care reform, I use a text book for a class I teach on health policy by Doctor Donald Barr at Stanford. In this textbook he nicely illustrates the previous efforts that were significant in health reform, as long ago as the presidency of Herbert Hoover, who had a committee on cost containment and care.

Some argue that there were early efforts in the early part of the century, but actually it was just the Veterans Administration that was created in 1921, after World War I.

By the way my great, my grandfather’s brother, John Sundwall was the first professor of public health at the University of Michigan.

SUNDWALL 2013 03 (360)He was on the Hoover committee. Interestingly if you read any of the Hoover committee transcripts, they talk about the need to train more generalist physicians, as long ago as the 1930s. So there’s nothing new under the sun there.

Notice the opposed on the column, whether we talk about Franklin Roosevelt’s effort, Harry Truman, Lyndon Johnson, Bill Clinton; the arguments that were most vocal in opposition were the American Medical Association and the National Medical Association interestingly enough.

We all remember when President Clinton tried to get his health care reform proposals enacted. Remember the Harry and Louise ads; remember them? This was opposed by the Health Association of America, who are primarily the health insurers. They were very vigorous in opposing it and succeeded.

SUNDWALL 2013 04 (360)President Barack Obama’s efforts were eventually successful, with the Congressional Republicans clearly the big detractors.

So what I’m going to try to do briefly in my time is talk about the PPACAs, policies, politics and prognosis.

This is a busy but an important chart from the American Public Health Association. This is a very nice, informative illustration of the elements that are in the bill.

SUNDWALL 2013 05 (360)The attention to the ACA has been primarily on insurance expansion. That is significant. On the left of the chart are the insurance reforms, and they are significant. The primary goal is to expand health insurance coverage and they do it through a variety of ways.

But the other important things that don’t get as much attention are the health system reforms, improving quality and efficiency, stronger work force, infrastructure, greater focus on public health prevention.

I can tell you as someone who’s a family doctor who “backdoored” into public health and became the Commissioner of Health in Utah for six years. We welcomed many of these changes on public health. They are a bit cumbersome and complex, and somewhat difficult to navigate. But they are certainly helping build the infrastructure of public health that, for a long time, has not been attended to as well as it should have been.

SUNDWALL (360) 2013 06Let’s talk about policies a bit. The number one priority was to expand health insurance coverage.

It was estimated that as many as 32 million more people might have insurance when the mandate kicks in in 2014. It does not strive for universal coverage.

I’m looking forward to hearing John Geyman’s comments on that. I’m sure he’ll have a lot to say, because, in the opinion of many, it falls short of what should have been. But still, 95% of legal US residents would have coverage, theoretically, if these expansions were to be phased in as they’re intended to be.

The primary way to do that is to expand Medicaid up to 138% of the poverty level, subsidized to lower income individuals and families pay for health insurance. Health insurance exchanges are there to keep track of all of those expansions, whether they be in public or private insurance, making it easier for people to buy health insurance.

And while many have misgivings about our present health insurance model, lots of studies have been done to show that having insurance, insurance is healthy. And simply every measure suggests, that, if you have insurance, you’re healthier. Notwithstanding the flaws, or copayments, or problems, it’s a public health factor that’s important.

SUNDWALL (360) 2013 07The next policy is the “mandate” starting in 2014. Almost every American – there are a few exceptions, will need to carry insurance or pay a fine.

The insurance regulations are really important.

I’m not sure if you’re all familiar with the term rescission, but I find that a particularly repugnant practice of private insurance companies where you could, in fact, when someone becomes ill, when it’s time for them to re-up on their insurance they say sorry we don’t cover that anymore. That is ridiculous, it’s just an absurd policy that everybody, Republican and Democrat alike agree couldn’t be sustained, or shouldn’t be.

As soon as the bill was signed into law, it was illegal for children to be denied coverage because of a pre-existing condition and it will no longer be possible after 2014 for adults. Nor can you impose limits on lifetime benefits paid out.

All of these are insurance regulations. I heard a presentation by an insurance lawyer in Utah recently. I hadn’t appreciated how important these changes are to the insurance companies. They apparently are going to change the way they do business in rather profound ways.

Those changes are more significant than I appreciated, When you hear it from their prospective it’s a big deal. But again, all intended to make insurance more affordable and more effective coverage.

SUNDWALL (360) 2013 08The public health provisions in here I want to emphasize are important and I think welcome in most respects.

There’s a focus for spending on chronic illnesses the top killers.

I like that they actually took the things that both the CDC and CMS are working on and wove them into the bill, trying to focus on reducing heart disease, cancer, stroke, respiratory disease, and diabetes.

SUNDWALL (360) 2013 09How are they going to do this? It sounds good to say it, but they did put their money where their mouth is so to speak, with a new Prevention and Public Health Fund.

Its funding increases dramatically. It would be up to $2 billion by 2015; in fact I think they project up to 2.5 billion.

All the years I was the health officer in Utah we scrambled for our share of $100 million block grant in prevention. They were precious dollars and we used them for a variety of programs in chronic disease management, or health education and they are really critical to health departments. To have this real infusion of more dollars is significant.

Now mind you the “sequestration” that was mentioned by Dr Haughton this morning is already affecting that. So, it won’t be as much but it’s still significantly more than it was previously. And that was all administered by my old agency the Health Resources and Services Administration [HRSA].

School based health centers have been given a shot in the arm, something like 180 million. I can’t remember the figure. This is important and something I think needs to be strengthened. I’m not proud of the fact that Utah has the lowest school-nurse ratio to student in the nation. Schools should have some onsite healthcare for kids.

The CDC is trying to build healthier communities through Community transformation grants. They are dealing a lot with the obesity epidemic.

There is increased funding for immunizations, improved capacity and technology for public health labs. That, I believe, is the foundation of public health. I’m a big fan of the public clinical laboratories – the ones responsible for doing the disease surveillance and identifying risks to the public. That line of funding is really important.

Last on the list is a $1.5 billion dollar home visit program added to the $635 million dollar a year Maternal and Child Health (MCH) block grant. This, I think, is an example of rather careless funding. In the enthusiasm to get this bill passed, some things were slipped in it without regard to cost or benefit.

I’m not saying for a minute arguing that home visiting is not wonderful. It’s probably what really put nursing and public health on the map in the 1800s. One of the fair criticisms of the ACA is that there is too little cost containment, if there is any at all. In their enthusiasm to get this bill passed some things were slipped in it, without regard much to cost or benefit.

But I just find it too little attention to ACA’s impact on the federal deficit. I think it’s fair to say that one of the fair criticisms in the ACA there’s little in there to do cost containment; notwithstanding their promise that it would save money.


SUNDWALL (360) 2013 10We will be hearing about the policies relating to the health care workforce later in this conference.

There is an attempt is to increase the number and geographic distribution of health workforce, not just doctors but nurses, dentists and others.

How? Increased payments for primary care services. You know that the Medicaid rate will go up to Medicare rates, for primary care physicians, for two years only.

This is another point I’ll make about the carelessness in the act. One of the hats I currently wear is the Vice Chairman of the Medicaid Commission in Washington, the MACPAC, Medicaid and CHIP, Payment and Access Commission. Our analysis of that is the complexity of implementing it and tracking it then terminating it is going to probably cost more than the bump doctors will get.

It was a careless, yet well intended, effort, of course, to make primary care more attractive. But we think that it was a rather silly thing to do. If they were going to do it they should have done it, not make it temporary and then make it so difficult to define who would be getting it.

There are also some other good things. They are strengthening the National Service Corps. That’s always good, in my opinion. There is a pilot project related to medical homes for pediatrics, special needs and more.

There are lots and lots of things in there on the other side of that busy slide I showed you that aren’t just related to insurance that I think are positive.

SUNDWALL (360) 2013 11

Utah’s version of health reform would be less government, but none-the-less not indifferent to the problems of the poor and the needy. We always have to acknowledge that if someone is against a federal program, it’s not that they’re against healthcare services or caring for the poor, but that they have a different view on how that might be achieved. They prefer to rely on the private health insurance market, promote personal responsibility, and ensure transparency in value.

That is something that I think is a positive in our state – that you can go online and get quality and cost data for many things that you can’t get in other places. Wee have one of the all payer databases that includes not only what was charged by the hospital or doctor but what was actually paid. Closing that loop is important, because we all know the gap between charges and what’s paid is extraordinary.

Now I’m going to digress for a minute because some of you know me well enough that you’d want to know that, this personal thing. My wife was in a serious car accident on February 9th. She, coming back from California after a week in Disneyland, she was following our son and his five children, and his wife and family.

She hit an ice patch north of Cedar City, the truck rolled off the rolled, and she sustained seven rib fractures and a very badly broken arm, but no head injury, no leg injuries. She’s well on her road to recovery, which is going to be long with physical therapy. I say this because I’m now learning about costs. I’m blessed in that I personally have enjoyed great health.

I’ve never been hospitalized for heaven’s sakes. I don’t have any chronic illness that I’m aware of, other than chronic obesity. but that’s not been a handicap. In fact I’m going to go hiking with Charles this afternoon, I’ll see if I can handle it.

But the point is the bills that we’ve been getting, the EOBs are now up to 129,000 for her shock, trauma and her care. Of course, we’re grateful for the high quality care and the attention she got, but it’s been an interesting thing for me to see the ka-ching, ka-ching, ka-ching every week as these things come in – a real time lesson in healthcare costs.

We need to know what these costs. I love that Time article [“What Has Changed?”: the 24th National Conference Welcoming Remarks (Haughton)] that Kevin referred to andI agreed with his point that if we get enough public anxiety about this that things will change.

Another thing in Utah that I think is impressive is they’ve maximized the tax advantage so that even if you’re an individual buying health insurance you can do that with pretax dollars. That’s something that used to be reserved for just employers. But individuals can take advantage of that.

When they talk about in Utah about optimizing Medicaid, what that means is they finally, like many other states did some time ago, Utah has gone to risk-based managed care. They’ve actually capitated Medicaid payments to hospitals and individuals. We’ll see how that works out. That’s a popular effort all over the country. Well over half of our state Medicaid plans have capitated managed care.

SUNDWALL (360) 2013 12The “defined contribution market” concept is important. We keep all payments pretax. Employees cannot be penalized for their health status. We don’t support plans that won’t cover preexisting conditions.

We’re a conservative state, but that isn’t a partisan issue. “Guaranteed issue” or community rating is something that the insurance companies hate, but that we think it is important to require. You can’t go “cherry picking” any more.

Companies will not be forced to pay for health insurance, but they are required – if they are going to participate –  to give a certain amount of money to a employee to let them buy coverage. That’s the company’s contribution – not a benefit per say. The employee can choose to add or subtract or get more or less – depending on what they want to pay.

SUNDWALL (360) 2013 13Utah’s health insurance exchange was one of the first exchanges in the country. Massachusetts had what they called the Connector. We had our Utah Health Insurance Exchange, which by the way, has recently been re-named Avenue H. I don’t know why. I guess they thought it’d help with marketing. It’s kind of like Travelocity where you can go online and choose insurance based, tailored to your family needs.

Avenue H connects consumers with information so that they have a single shopping point and can make some personal decisions, all online. I’ve looked at the website. It’s really quite user friendly, and it does take some of the mystery out of health insurance shopping.

These are the policies. You can see a contrast between the federal government’s and that of Utah’s. The state is more personal-based and assumes consumers are going to use data to make informed choices themselves about the costs and benefits of the health care policy they are choosing.

Let’s talk about the politics. That is far and away the most dramatic thing about the ACA.

I will tell you that the ACA is not as it has been portrayed by either party. The Democrats make it sound like it’s the most sweeping, social, legislation for the betterment of mankind since Medicare and Medicaid. Not!

The Republicans would say it’s the end of the world, that the government’s taking over, and that you better watch your wallets – that it’s socialized medicine. Not!

The rhetoric on both sides has just been ridiculous. That’s not a good thing.

I asked at the outset of my presentation, whether we are we on the road to a more fair and affordable healthcare system. I’m anxious to hear Dr. John Geyman.

I don’t think we’re very far, but that we are a little further down the road. Basically, I think ACA IS positive in that if people have insurance. That’s a good thing. If we do some strengthening of public health, that’s a good thing. But it hardly solves the major problems.

Although there are a lot of demonstrations going on in finance reform, there were no requirements in ACA for such. We’ve done demonstrations on this before, and I’m not sure what we’ll learn, but I’m hopeful that maybe Dr Hector Flores and others at this meeting can enlighten me that there’s some light at the end of the tunnel on these payment reforms.

SUNDWALL (360) 2013 14This is a quote “We are in the process of an intense national debate related to healthcare in the United States. What should be divided, and how to pay for it. The outcome will redefine the rolls of governments, federal and state and the private sector in our healthcare enterprise.”

That was my quote. I read it printed somewhere and I thought “That’s cool. I’m going to quote myself”. I really do think the best thing about the ACA is that it has raised the level of debate. We’re not very far down the road. We’ve got miles to go before we rest. And as Betty Davis said “Fasten your seatbelts – it’s going to be a real bumpy road, bumpy ride.”

A few more points: In the recent Supreme Court decision, most of the ACA was upheld. It is the law of the land. I got to go to a wonderful, invitational conference at Princeton in November; just about a week after the election. This conference included all the fanciest folks in health policy that you can imagine, all the economists that you’ve all heard about like Doctors Uwe E. Reinhardt and Mark Pauly; the head of the CBO in Washington; and other very influential people.

SUNDWALL (360) 2013 15What I came away with from the meeting was, “Get over it; it’s the law of the land”.

We have misgivings on both sides about it, but it is the law. As complex and costly as it is, we need to implement it and make it work for the betterment of the people.

Of course, the monkey wrench that they through in was making the Medicaid expansions optional. And that is a fascinating drama being played out now. Utah’s one of the few states where we’re still in a wait and see mode.

Utah has commissioned a study that’s due now. We’ve got a group representing both the Governor’s office and the Congress to look at where the effort is. We should decide by September if we’re going to expand.

Some governors, like Bobby Jindal in Louisiana, have said “Hell no, we won’t go. We’re not going to go with this big federal program.” Others have said we can’t afford not to because of all the money that you can get. You understand that the feds have promised to pay 100% of the expansion for three years and then down to 90% for seven.

SUNDWALL (360) 2013 16Let me close with the current challenges facing us. Regarding Medicaid: to cover, to expand or not to cover, that is the question.

I will give you a prediction on Utah. They will go for it because they’re fundamentally pragmatic.

They are conservative and there’s a lot of the “Tea Party” rhetoric, but in fact my impression of our legislature over time is that they’re very practical and they’ll probably go with the expansion.

We’ve already, by the way, caved in on the exchange and we’re going to go with using the federal exchange to deal with the subsidies. In other words we’ll help individuals buy their market, but we don’t care. We don’t want to get into the business of the subsidy determination.

There is another flaw in the bill that I’ll just throw out for your consideration. I learned this in my work with the Medicaid Commission. The subsidies are to be available to people between 138% and 400% of the federal poverty limit. In Utah a family making about $80,000 a year would still entitled to the subsidy to help them purchase health insurance in the private sector.

Do you know what the ten-year projections for the cost of that subsidy alone? One trillion dollars.

So this sounds fine, it rolls of the tongue. Oh, we’re going to help people buy insurance if they’re not poor enough to get Medicaid, but are still struggling to buy it. Well I don’t think the money will be there. That’s my prediction.

My prognosis of PPACA’s future is guarded. It’s certainly the law of the land, but it will inevitably be modified. People are very afraid in Congress to open it up for amendments before the next election. It is already become a partisan issue again. Whether they amend it in this Congress before the next election in 2014 remains to be seen. It will have to be modified, because there’s a lot of bipartisan feeling that there are parts of it that are just too troublesome.

SUNDWALL (360) 2013 13For healthcare I think it’s good, you know we do wring our hands a lot in this group and we have a lot of compassion for poor and about things that aren’t being done for them, and about cost and complexity.

But I think that I still will stand by my statement – understanding completely that the U. S.’s health status is not good compared to other countries – that most of us get good care in this country and will continue to do so in our current system when we need it.

But we need to revisit how we care for the most vulnerable among us and how do we afford it in the long run?

I will note that Social Security Medicaid trustees voiced doubt that the federal government could maintain its financial commitments to pay for the bulk of the Medicaid expansions as well as the, as well as the subsidy.

We just had the third anniversary of the ACA on March 23rd. The American Public Health Association put out this happy anniversary celebration with all the statistics about how marvelous it is and its great accomplishments. You know about 71 million more people have health insurance and on and on.

The Republicans are already carping and complaining and saying, my gosh, you haven’t taken into account the costs. It’s absolutely flawed in every respect. So it’s still a very much a partisan issue and will be the forefront of our policy debate for years to come.

Thank you very much.


“What Has Changed?”: the 24th National Conference Welcoming Remarks (Haughton)

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference:

The following transcription is of the opening sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. The


Ana Bejinez-Eastman, MD, Presbyterian Intercommunity Hospital, Whittier, California: [Doctor Bejinez-Eastman is a Senior Fellow of the National Conferences on Primary Health Care Access].

Welcome everybody, I’m moderating today. I’m here to deliver the wedgie, pull the hook, – whatever needs to be done to try and stay on time.

A view of the Kalalua Trail on Kaua'i North Shore

A view of the Kalalua Trail on Kaua’i North Shore

I have one announcement to make. If anyone is interested in doing a hike this afternoon with Doctor Charles North on Kauai’s North Shore, there he is, the hiker extraordinaire.

The hike will go the beautiful Hanakapi’ai Falls, right, on the North Shore, partway through the Kalalua trail, so it should be beautiful. There will be free transportation. Who can pass that up? Anyone interested, please see him.

All right, without further ado I would like to introduce Dr. Kevin Haughton, who is going to review our last session.


Kevin Haughton, MD; Providence Health Systems; Olympia, Washington

Kevin Haughton, MD

Kevin Haughton, MD, Providence Health Systems, Olympia, Washington:    [Doctor Haughton is a Fellow of the National Conferences on Primary Health Care Access] 

Good morning! Welcome to the 24th National Conference. I recognize many faces from here from last year.

The tradition is that the person who does the closing comments at the end of the national conferences does the opening introduction of the succeeding conference.

The conference theme for this year is “What Has Changed?”

This is where we were last year, at the Park Aviara resort near Carlsbad, California.


And this is much more what it looks like this year.


So that’s, this is one thing that’s been a dramatic change.


Dr. James Herman gave us a talk last year where he talked about change, and I think it was mostly about a change machine that required dialogue in order to get change back out of it. So that’s been a theme even starting from last year.


Well, one thing that’s changed is that the general population has had enough. At our breakfast breakout meeting [see Discussion Question, Breakout Groups Announced for 24th National Conference First Day, April 8, 2013], we started talking what I’m hearing in my practice.

Patients come to me complaining about their specific items in their medical bills that sound completely outrageous; $1400 for some routine minor lab work. Tens of thousands of dollars for some hospitalization visit.

These medical bill items have hit the pop literature journalism pretty big time. A Time Magazine article about health care costs referred to a 10,000 percent markup for Tylenol, resulting in an image of a “bitter pill” on the cover of Time Magazine.


There are a number of things happening on these same lines. Here are three books published by the ABIM Foundation: Over-Diagnosed, Over-Treated and Epidemic of Care. There’s a theme I think that is emerging here. Some patients would have been better off if they had never sought care. There are a lot of things that we’re doing with our current system that’s motivating us to do a lot than we need to.


The Centers for Medicare and Medicaid Services (CMS) are involved with this. They are trying to fix primary care.


There are a lot of ideas up here that look familiar to you, like patient centered medical home and accountable care organizations.


There are some ideas about payment redesign that CMS has been supporting. Some of these are leaking out into the public.


But CMS also included a 2% cut in Medicare reimbursement as of April 1, 2013. I haven’t heard as much crying about that as I would have expected, but I’m anticipating this is expected to continue and I’m not sure anyone’s going to stop it. That will have a big impact on what we’re doing in our system.

I am in a hospital system that wants to become an integrated delivery system on the West Coast. In my particular office we have a deal where with a couple of different payers where we get paid our usual fee for service. In addition, we get a very small per member per month payment in order to build some extra infrastructure to monitor our patients more closely – our chronic disease patients primarily.

Then the actuaries figure out how much money that population of patients was expected to spend on hospitalization and emergency room visits. If we spend less than that amount, then we share that money with the insurance company. Some of what we are paid is dependent on meeting some specified quality targets.

This is very much a baby step. This is the “in-betweener”. There is the accountable care concept, which is as far as we’re hoping to go. Then there is this in the middle. Also there is our usual, old fashioned fee for service preferred provider organization , in which free range patients pay for random acts of healthcare – which is the way we’ve been doing it for the last 50 years.

To give a little history of where we’re going with the ACOs, we should go back to the HMOs of the 1970’s. They were really cranking; I was in Minnesota in the early 1990’s and it was kind of exciting times with managed care.

Then, you know we had a lot of backlash, and slid back to the sort of same old fee for service for a while. So we’re going to have to do it different now. I think th type of capitation we are going to face is much more complicated. Hopefully, it will make us develop a better system as opposed to just withholding care.

We are in a world where we have one foot on a boat and one foot on a dock, and the boat is leaving.

We’ve got to keep people out of the hospital, out of the cath lab and out of the operating room. That’s the boat that we want to get on.

In the meantime, we’re making all our money in those places and that’s what’s keeping the health system going.


Somehow, we have to transform the way we pay for this at the same time we’re transforming the way we do it. That’s tricky but we’re up for it!

 I will cite three geniuses here in a row.

First, Michael E. Porter gets a lot of credit for his 2006 book pushing value-based payment for healthcare. He’s really got us going. He really brought us a long way.

Porter just came out with an article in Health Affairs discussing an idea for redesigning primary care.

His idea is basically to break it up into subpopulations. People who are high-end users, high needs patients like those in the Program of All-inclusive Care for the Elderly (PACE). He’s going to put them on one pathway.

He would create another subpopulation of people who are in their middle age, but who have one chronic disease at the most to make sure they’re getting their mammograms and their colonoscopies.

Putting them in a category of their own with their own systems that manage them as they come through fragments the population. This has been hard for me to take, because I’m an “everybody comes to see me” kind of primary care doctor. That’s what I think of myself.

But Porter is a pretty smart guy. He’s figured out a lot of stuff, so I’m paying attention to what he says and to where he’s going.

That’s another genius we talked about last year, somebody has to do something, it’s just pathetic that it has to be us.


24PHCA 360H HAUGHTON 17Clay Christianson is another pretty brilliant guy. He is a “disruptive innovation guy” and pretty much gets credit for that term.

His model looks something like this: You have your established businesses, such as IBM in computers, who developed mainframes where there are very high margins. That is their main business.

IBM wouldn’t have come up with personal computers, which really disrupted their business, because personal computers couldn’t do all of the stuff that mainframes did when they first started, and the margins for personal computers would be very low.

The really disruptive innovations are people that open up new markets of people that have less money. Those new markets are cut out of the high end markets where the high margins are.

These new markets have low margins. Cars would be examples of this. So you have your Model T’s and then all of the Detroit stuff, and then they start making Cadillacs and fancy cars.


Then in the late 80’s and early 90’s Japan was making these little Datsuns and Hondas that were barely switched over from motorcycles. They disrupted the whole thing, then Japan kind of took off.

Now Japan sort of has been replaced by Korea that came in with inexpensive cars on the lower end of the market. And now there’s $2,000 cars being made in India and China that might do the same thing.

This model of disruptive innovation is pretty widely accepted now.


My question is what is the disruptive innovation for primary health care? What might there be that’s going to replace us? At the high end of the diagram (sustaining innovations) for health care, it is probably DiVinci robots, and MRI machines and hospitals and it’s everything high tech. We’re probably down on the lower end (disruptive innovations).

So you know there’s home urgent care visits by this company in Seattle, near where I’m from, offering webcam visits and phone visits,


Walgreens has two branches of Take Care clinics. One is like an instant care where you walk in and your seen by a nurse practitioner. Walgreen’s also offers employer-based primary care clinics.


This is, actually an effort by my old group health partners in Minnesota. They have virtual well, where they have 24/7 access to nurse practitioner for 40 diagnoses, similar to the walk-in clinics. There is lots of patient satisfaction for this really easy access, so innovation is out there.


There is lots of other nontraditional stuff that you can think about; lots of new ideas, direct primary care and concierge practices. We’re experimenting with telemedicine.

This is Second Life. It’s an avatar.  It’s where you can make an avatar of yourself, and then go visit some made up doctor and meet him on a fake world on the internet. It’s pretty clever, but apparently people can talk about things through their avatar online that they can’t talk about with a physician in person.


Last year, we talked about PPACA. At that meeting we were expecting a decision from the Supreme Court and Dr. Wilke predicted that the vote would be five to four.


We’re going to hear a lot about PPACA today. Here’s two guys we’re going to hear from.


So let’s get started on today’s adventure. Welcome! Let the Games Begin!



“What Happens Next?” An Overview of Strategic Initiatives Combating the Misallocation of Health Care Resources

The National Home for Disabled Volunteer Soldiers; Dayton, Ohio, established 1867

The National Home for Disabled Volunteer Soldiers; Dayton, Ohio, established 1867

Up until a half century ago, the federal presence in the direct financing of health care was limited to such special populations as the armed forces and their dependents, Indian tribes and the merchant marine.

A federal Public Health Service existed with a principal mission to deal with contagious diseases.

An indirect subsidy providing tax deductions for employers providing health insurance was enacted in the mid-1940s. Part of a series of early post World War II legislative actions intended to prevent hyperinflation, its unintended consequences would be far-reaching.

The enactment of Medicare and Medicaid 50 years ago transformed American health care. It settled the question of whether the funding of health care in the United States would be a governmental responsibility.

President Lyndon Johnson signs Social Security Act amendments creating Medicare as former President Harry Truman observes

President Lyndon Johnson signs Social Security Act amendments creating Medicare as former President Harry Truman observes

The Medicare program’s emphasis on citizens 65 and older proved to be highly successful in improving the health of the nation’s elders, was politically popular, and soon became the major force in the funding of American health care.

The Medicaid program, whose mission was to assure basic health care for the most economically disadvantaged Americans, was impacted by variations from state to state in structure, eligibility and financing.

A feature common to both Medicare and Medicaid was the political decision (arguably an imperative to secure enough votes for passage) that the legislation not take on the mission of re-organizing the health care system. Such issues as who would provide health care service and at what cost were hardly addressed.

The consequences of infusing massive amounts of funds into the healthcare system as it existed in 1965, without appropriate structural reforms in that system, proved to be significant.

Among those consequences were the further encouragement of long-term trends towards the sub-specialization of medicine, in medical schools and in practice, and the encouragement of a disproportionate percentage of physicians and health care institutions to locate in high income areas, to the disadvantage of rural and lower socioeconomic urban areas.

The Kalamazoo Family Health Center, Kalamazoo, Michigan

The Kalamazoo Family Health Center, Kalamazoo, Michigan

There were countervailing movements with the objective of creating “primary care systems” that are community-oriented and appropriately designed for universal access to health care.

New approaches to training generalist physicians, community-oriented health centers, medical homes, primary care teams are important components of strategies to increase access to primary health care.

Those countervailing movements are the subject of the National Conferences on Primary Health Care Access, whose 27th conference will be held April 4-7, 2016 at the Grand Hyatt on the Island of Kaua’i.

27th National Conference: A Century of Change in Primary Health Care

The 27th National Conference on Primary Health Care Access will be held April 4 through 7, 2016 at the Grand Hyatt, Koloa, Kaua’i, Hawai’i.

An evening view of the Grand Hyatt Kaua'i

An evening view of
the Grand Hyatt Kaua’i

The conference theme “What Happens Next?” will address such issues as the implementation of national health care legislation a half-decade ago, designed to reform the system, which is having a transformational effect. It will also look at the current state of long-term efforts to promote community-based health care, family-oriented primary care, medical homes and health team practice.

The theme sessions will be integrated into plenary discussion panels which will focus on reform efforts that were in the process of implementation a century and half-century ago.

Perry A. Pugno, MD, MPH; Vice President Emeritus, American Academy of Family Physicians

Perry A. Pugno, MD, MPH; Vice President Emeritus, American Academy of Family Physicians

In 1916, a major emphasis was implementing ideas such as the Carnegie Commission’s Flexner Report and initiatives of the Rockefeller Foundation promoting research-based academic medical centers integrated with teaching hospitals.

In 1966, Medicare and Medicaid, along with health-oriented Great Society programs, had been enacted and were in the process of being implemented.

In addition several key national “citizen’s commissions”, named after their chairs, Folsom, Millis and Willard, had proposed major changes in reforming undergraduate and post-graduate medical education and in providing health care to communities.

William H. Burnett, MA; Coastal Research Group

William H. Burnett, MA; Coastal Research Group

Over the next few years, such innovations as the family medicine specialty, the federally funded community health center, and the National Health Service Corps were established.

Each of these events of a century and half-century ago achieved much of what was intended and yet had unintended consequences, many of which came to be recognized as problems that must be addressed.

These historical discussions are designed to bring insights into where we as a nation have been and what our feature might bring.

Panel members currently announced include Doctor Perry A. Pugno, Vice-President Emeritus of the American Academy of Family Physicians and William H. Burnett, MA, Program Coordinator of the National Conferences. Further announcements of panel participants are forthcoming.

Perry Pugno, MD to Lead Discussion on Medical Student Career Interest in Primary Care Careers at 27th National Conference

Perry A. Pugno, MD, MPH, Executive Vice President Emeritus, American Academy of Family Physicians; Leawood, Kansas

Perry A. Pugno, MD, MPH, Vice President Emeritus, American Academy of Family Physicians; Leawood, Kansas

The 27th National Conference on Primary Health Care Access will be held April 4 through 7, 2016 at the Grand Hyatt Kaua’i.

Among the subjects to be addressed as part of this 27th National Conference Theme “What Happens Next” will be student interest in primary care medicine and primary care medical education, especially the innovations in practice that have been embraced by the specialty of family medicine over the past decades.

Doctor Perry A. Pugno, who until last year held the position of Vice President for Education within the American Academy of Family Physicians, will present the lead off theme discussion.

Dr Pugno observes: “While our family medicine residency programs struggle with new curriculum requirements, data collection demands, and escalating financial challenges, many program directors have been reporting increasing applicant numbers and “quality” for nearly a decade.

” other trends in student interest and residency education are impacting our training programs?  And, in light of those trends, why have the number of US senior matches remained essentially flat?

“A review of trends in family medicine education will provide participants the opportunity to consider some possible answers to those questions and perhaps reveal some potential strategies to favorably impact those trends.”