The most recent National Conference (April 2010) examined some of the consequences of the recent legislation passed by Congress and signed by President Barack Obama.

The legislation enacted is the most comprehensive in more than a generation, and provisions of it should bring about important improvements in primary health care access. Even so, a significant percentage of the American population is skeptical that the legislation will be effective, and a large number doubt that what the legislation contained is what should have been enacted. Like Medicare and Medicaid, both enacted 45 years ago, it is quite likely that many of its consequences will be unintended and unexpected.

Over the next several months, in preparation for the 22nd National Conference on Primary Health Care Access in San Francisco (April 18-20, 2011), we will study some of the provisions that seem particularly hopeful for improving primary health care access. Likewise, we plan to propose several issues for discussion that perhaps were inadequately discussed during the recent legislative process.

The first of these inadequately addressed issues is the matter of student indebtedness (particularly the amount of loans that have been amassed by students pursuing medical degrees) and its potential impact on physician supply and the processes by which medical school graduates select their specialties.

As an introduction to the subject, we will examine a case study of the combined student debt of a married professional couple – one a physician and one a lawyer. (See Drowning in Student Debt: Young Professionals at the End of Graduate School.)

Implementation Timeline

Reflecting the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act

2010

Immediate Access to Insurance for Uninsured Individuals with a Pre-Existing Condition. Provides eligible individuals access to coverage that does not impose any coverage exclusions for pre-existing health conditions. This provision ends when Exchanges are operational. Effective 90 days after enactment.

Small Business Tax Credit. Initiates the first phase of the small business tax credit for qualified small employers for contributions to purchase health insurance for employees. The credit is up to 35 percent of the employer?s contribution to provide health insurance for employees. There is also up to a 25 percent credit for small nonprofit organizations. Effective calendar year 2010. (Later, when Exchanges are operational, tax credits will be up to 50 percent of premiums.)

Eliminating Pre-Existing Condition Exclusions for Children. Bars health insurance companies from imposing pre-existing condition exclusions on children?s coverage. Effective six months after enactment and applying to all employer plans and new plans in the individual market. (This provision will apply to all people in 2014).

Rebates for the Medicare Part D ‘Donut Hole.’ Provides a $250 rebate check for all Part D enrollees who enter the “doughnut hole”. Currently, the coverage gap falls between $2,830 and $6,440 in total drug spending. Effective calendar year 2010. (Beginning in 2011, institutes a 50 percent discount on brand-name drugs and begins generic coverage in the doughnut hole; fills the doughnut hole by 2020.)

Prohibiting Rescissions. Prohibits abusive practices whereby health insurance companies rescind existing health insurance policies when a person gets sick as a way of avoiding covering the costs of enrollees? health care needs. Effective six months after enactment and applying to all new and existing plans.

Eliminating Lifetime Limits. Prohibits insurers from imposing lifetime limits on benefits. Effective six months after enactment and applying to all plans.

Regulating Use of Annual Limits. Tightly regulates plans’ use of annual limits to ensure access to needed care in all group plans and all new individual plans. These tight restrictions will be defined by the Secretary of Health and Human Services. Effective six month after enactment and applying to new plans in the individual market and all employer plans. (When the Exchanges are operational in 2014, the use of annual limits will be banned for new plans in the individual market and all employer plans.)

Covering Preventive Health Services. All new group health plans and plans in the individual market must provide first dollar coverage for preventive services. Effective six months after enactment.

Improving Prevention Health Coverage. Requires State Medicaid programs to cover tobacco cessation services for pregnant women. Effective Fiscal Year 2011.

Extending Coverage for Young Adults. Requires any group health plan or plan in the individual market that provides dependent coverage for children to continue to make that coverage available until the child turns 26 years of age. Effective six months after enactment.

Bringing Down the Cost of Health Care Coverage. Health plans, including grandfathered plans, must annually report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios. Effective January 1, 2011

Reducing the Cost of Covering Early Retirees. Creates a new temporary reinsurance program to help companies that provide early retiree health benefits for those ages 55-64 offset the expensive cost of that coverage. Effective 90 days after enactment.

Strengthening Community Health Centers. Provides funds to build new and expand existing community health centers. Effective Fiscal Year 2011.

Strengthening the Primary Care Workforce. Expands funding for scholarships and loan repayments for primary care practitioners working in underserved areas participating in the National Health Service Corps. Effective Fiscal Year 2011.

Improving Consumer Assistance. Requires that any new group health plan or new plan in the individual market implement an effective appeals process for coverage determinations and claims. Effective six months after enactment.

Improving Consumer Information through the Web. Requires the Secretary of HHS to establish an Internet website through which residents of any State may identify affordable health insurance coverage options in that State. The website will also include information for small businesses about available coverage options, reinsurance for early retirees, small business tax credits, and other information of interest to small businesses. So-called “mini-med” or limited-benefit plans will be precluded from listing their policies on this website. Effective not later than July 1, 2010.

Improving Consumer Assistance. Requires the Secretary of Health and Human Services (HHS) to award grants to States to establish health insurance consumer assistance or ombudsman programs to receive and respond to inquiries and complaints concerning health insurance coverage. Effective upon enactment.

Cracking Down on Health Care Fraud. Requires enhanced screening procedures for health care providers to eliminate fraud and waste in the health care system. Many provisions are effective on the date of enactment.

Improving Public Health Prevention Efforts. Creates an interagency council to promote healthy policies at the federal level and establishes a prevention and public health investment fund to provide an expanded and sustained national investment in prevention and public health programs. Effective not later than July 1, 2010.

Strengthening the Quality Infrastructure. Additional resources provided to HHS to develop a national quality strategy and support quality measure development and endorsement for the Medicare, Medicaid and CHIP quality improvement programs. Strategy submitted not later than January 1, 2011.

Extending Payment Protections for Rural Providers. Extends Medicare payment protections for small rural hospitals, including hospital outpatient services, lab services, and facilities that have a low-volume of Medicare patients, but play a vital role in their communities. Effective calendar year 2010.

Establishing a Patient-Centered Outcomes Research Institute. Establish a private, non-profit institute to identify national priorities and provide for research to compare the effectiveness of health treatments and strategies. Effective date of enactment.

Ensuring Medicaid Flexibility for States. A new option allowing States to cover parents and childless adults up to 133 percent of the Federal Poverty Level (FPL) and receive current law Federal Medical Assistance Percentage (FMAP) will take effect. Effective April 1, 2010.

Non-Profit Hospitals. Establishes new requirements applicable to nonprofit hospitals beginning in 2010, including periodic community needs assessments. Effective on the date of enactment.

Expanding the Adoption Credit and Adoption Assistance Program. Increases the adoption tax credit and adoption assistance exclusion by $1,000, makes the credit refundable, and extends the credit through 2011. Effective for tax years beginning after December 31, 2009.

Encouraging Investment in New Therapies. A two-year temporary credit subject to an overall cap of $1 billion to encourage investments in new therapies to prevent, diagnose, and treat acute and chronic diseases. Available for qualifying investments made in 2009 and 2010.

Tax Relief for Health Professionals with State Loan Repayment. Excludes from gross income payments made under any State loan repayment or loan forgiveness program that is intended to provide for the increased availability of health care services in underserved or health professional shortage areas. Effective for amounts received by an individual in taxable years beginning after December 31, 2008.

Excluding from Income Health Benefits Provided by Indian Tribal Governments. Excludes from gross income the value of specified Indian tribal health benefits. Effective for benefits and coverage provided after the date of enactment.

Establishing a National Health Care Workforce Commission. Establishes an independent National Commission to provide comprehensive, nonbiased information and recommendations to Congress and the Administration for aligning federal health care workforce resources with national needs. Effective not later than September 30, 2010.

Strengthening the Health Care Workforce. Expands and improves low-interest student loan programs, scholarships, and loan repayments for health students and professionals to increase and enhance the capacity of the workforce to meet the range of patients? health care needs. Effective calendar year 2010.

Special Deduction for Blue Cross Blue Shield (BCBS). Requires that non-profit BCBS organizations have a medical loss ratio of 85 percent or higher in order to take advantage of the special tax benefits provided to them under Internal Revenue Code (IRC) Section 833, including the deduction for 25 percent of claims and expenses and the 100 percent deduction for unearned premium reserves. Effective for tax years beginning after December 31, 2009.

Indoor Tanning Services Tax. Imposes a ten percent tax on amounts paid for indoor tanning services. Indoor tanning services are services that use an electronic product with one or more ultraviolet lamps to induce skin tanning. Effective for services on or after July 1, 2010.

2011

Discounts in the Part D ‘Doughnut Hole.’ Provides a 50 percent discount on all brand-name drugs and biologics in the donut hole and begins phasing in additional discounts on brand-name and generic drugs to completely fill the donut hole by 2020 for all Part D enrollees. Effective January 1, 2011.

Improving Preventive Health Coverage. Provides a free, annual wellness visit and personalized prevention plan services for Medicare beneficiaries and eliminates cost-sharing for preventive services. Effective January 1, 2011.

Increasing Reimbursement for Primary Care. Provides a 10 percent Medicare bonus payment for primary care physicians and general surgeons. Effective January 1, 2011.

Improving Health Care Quality and Efficiency. Establishes a new Center for Medicare & Medicaid Innovation to test innovative payment and service delivery models to reduce health care costs and enhance the quality of care provided to individuals. Effective January 1, 2011.

Providing New, Voluntary Options for Long-Term Care Insurance. Creates a long-term care insurance programs to be financed by voluntary payroll deductions to provide benefits to adults who become disabled. Effective January 1, 2011.

Improving Transitional Care for Medicare Beneficiaries. Establishes the Community Care Transitions Program to provide transition services to high-risk Medicare beneficiaries. Effective January 1, 2011

Transitioning to Reformed Payments in Medicare Advantage. Freezes 2011 Medicare Advantage payment benchmarks at 2010 levels to begin transition. Continues to reduce Medicare Advantage benchmarks in subsequent years relative to current levels. Benchmarks will vary from 95 percent of Medicare spending in high-cost areas to 115 percent of Medicare spending in low-cost areas with higher benchmarks for high-quality plans. Changes are phased-in over three, five or seven years, depending on the level of payment reductions. Effective January 1, 2011.

Increasing Training Support for Primary Care. Establishes a Graduate Medical Education policy allowing unused training slots to be re-distributed for purposes of increasing primary care training at other sites. Effective July 1, 2011.

Expanding Primary Care, Nursing, and Public Health Workforce. Increases access to primary care by adjusting the Medicare Graduate Medical Education program. Primary care and nurse training programs are also expanded to increase the size of the primary care and nursing workforce. Ensures that public health challenges are adequately addressed. Effective July 2011.

Increasing Access to Home and Community Based Services. The new Community First Choice Option, which allows States to offer home and community based services to disabled individuals through Medicaid rather than institutional care. Effective October 1, 2011.

Reporting Health Coverage Costs on Form W-2: Requires employers to disclose the value of the benefit provided by the employer for each employee?s health insurance coverage on the employee?s annual Form W-2. Effective for tax years beginning after December 31, 2010.

Standardizing the Definition of Qualified Medical Expenses. Conforms the definition of qualified medical expenses for HSAs, FSAs, and HRAs to the definition used for the itemized deduction. An exception to this rule is included so that amounts paid for over-the-counter medicine with a prescription still qualify as medical expenses. Effective for tax years beginning after December 31, 2010.

Increased Additional Tax for Withdrawals from Health Savings Accounts and Archer Medical Savings Account Funds for Non-Qualified Medical Expenses. Increases the additional tax for HSA withdrawals prior to age 65 that are not used for qualified medical expenses from 10 to 20 percent. The additional tax for Archer MSA withdrawals not used for qualified medical expenses would increase from 15 to 20 percent. Effective for tax years beginning after December 31, 2010.

Cafeteria Plan Changes. Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax?free benefits to their employees. This would ease the small employer?s administrative burden of sponsoring a cafeteria plan. The provision also exempts employers who make contributions for employees under a simple cafeteria plan from pension plan nondiscrimination requirements applicable to highly compensated and key employees. Effective for tax years beginning after December 31, 2010.

Pharmaceutical Manufacturers Fee. Imposes an annual, non-deductible fee on the pharmaceutical manufacturing industry allocated according to market share and not applying to companies with sales of branded pharmaceuticals of $5 million or less. Effective for tax years beginning after December 31, 2010.

2012

Encouraging Integrated Health Systems. Implements physician payment reforms that enhance payment for primary care services and encourage physicians to join together to form “accountable care organizations” to gain efficiencies and improve quality.

Linking Payment to Quality Outcomes. Establishes a hospital value-based purchasing program to incentivize enhanced quality outcomes for acute care hospitals. Also, requires the Secretary to submit a plan to Congress by 2012 on how to move home health and nursing home providers into a value-based purchasing payment system.

Reducing Avoidable Hospital Readmissions. Directs CMS to track hospital readmission rates for certain high-cost conditions and implements a payment penalty for hospitals with the highest readmission rates.

2013

Improving Preventive Health Coverage. Creates incentives for State Medicaid programs to cover evidence-based preventive services with no cost-sharing.

Administrative Simplification. Health plans must adopt and implement uniform standards and business rules for the electronic exchange of health information to reduce paperwork and administrative burdens and costs.

Encouraging Provider Collaboration. Establishes a national pilot program on payment bundling to encourage hospitals, doctors, and post-acute care providers to work together to achieve savings for Medicare through increased collaboration and improved coordination of patient care.

Increasing Medicaid Payment for Primary Care. Requires states to pay primary care physicians the same rate Medicare pays, and fully federally funds any additional state costs.

Limiting Health Flexible Savings Account Contributions. Limits the amount of contributions to health FSAs to $2,500 per year, indexed by CPI for subsequent years.

Eliminating Deduction for Employer Part D Subsidy. Eliminates the deduction for the subsidy for employers who maintain prescription drug plans for their Medicare Part D eligible retirees.

Increased Threshold for Claiming Itemized Deduction for Medical Expenses. Increases the income threshold for claiming the itemized deduction for medical expenses from 7.5 to 10 percent. Individuals over 65 would be able to claim the itemized deduction for medical expenses at 7.5 percent of adjusted gross income through 2016.

Additional Hospital Insurance Tax for High Wage Workers. Increases the hospital insurance tax rate by 0.9 percentage points on wages over $200,000 for an individual ($250,000 for married couples filing jointly). Expands the tax to include a 3.8 percent tax on net investment income in the case of taxpayers earning over $200,000 ($250,000 for joint returns).

Medical Device Excise Tax. Establishes a 2.3 percent excise tax on the first sale for use of a medical device. Excepted from the tax are eye glasses, contact lenses, hearing aids, and any device of a type that is generally purchased by the public at retail for individual use.

Limiting Executive Compensation. Limits the deductibility of executive compensation under Section 162(m) for insurance providers if at least 25 percent of the insurance provider?s gross premium income from health business is derived from health insurance plans that meet the minimum creditable coverage requirements. The deduction is limited to $500,000 per taxable year and applies to all officers, employees, directors, and other workers or service providers performing services, for or on behalf of, a covered health insurance provider. This provision is effective beginning in 2013 with respect to services performed after 2009.

Fee for patient-centered outcomes research. Annual fee becomes effective on insured and self- insured plans to fund the patient centered outcomes research trust fund.

2014

Reforming Health Insurance Regulations. Implements strong health insurance reforms that prohibit insurance companies from engaging in discriminatory practices that enable them to refuse to sell or renew policies due to an individual?s health status. Insurers can no longer exclude coverage for treatments based on pre-existing health conditions. It also limits the ability of insurance companies to charge higher rates due to heath status, gender, or other factors. Premiums can vary only on age (no more than 3:1), geography, family size, and tobacco use.

Eliminating Annual Limits. Prohibits insurers from imposing annual limits on the amount of coverage an individual may receive.

Ensuring Coverage for Individuals Participating in Clinical Trials. Prohibits insurers from dropping coverage because an individual chooses to participate in a clinical trial and from denying coverage for routine care that they would otherwise provide just because an individual is enrolled in a clinical trial. Applies to all clinical trials that treat cancer or other life-threatening diseases.

Establishing Health Insurance Exchanges. Opens health insurance Exchanges in each State to the individual and small group markets. This new venue will enable people to comparison shop for standardized health packages. It facilitates enrollment and administers tax credits so that people of all incomes can obtain affordable coverage.

Ensuring Choice through a Multi-State Option. Provides a choice of coverage through a multi- State plan, available nationwide, and offered by private insurance carriers under the supervision of the Office of Personnel Management.

Providing Health Care Tax Credits. Makes premium tax credits available through the Exchange to ensure people can obtain affordable coverage. Credits are available for people with incomes above Medicaid eligibility and below 400 percent of poverty who are not eligible for or offered other acceptable coverage. They apply to both premiums and cost-sharing to ensure that no family faces bankruptcy due to medical expenses again.

Ensuring Choice through Free Choice Vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an Exchange plan.

Promoting Individual Responsibility. Requires most individuals to obtain acceptable health insurance coverage or pay a penalty of $95 for 2014, $325 for 2015, $695 for 2016 (or, up to 2.5 percent of income in 2016), up to a cap of the national average bronze plan premium. Families will pay half the amount for children, up to a cap of up to a cap of $2,250 per family. After 2016, dollar amounts are indexed. If affordable coverage is not available to an individual, they will not be penalized.

Promoting Employer Responsibility. Requires employers with 50 or more employees who do not offer coverage to their employees to pay $2,000 annually for each full-time employee over the first 30 as long as one of their employees receives a tax credit. Precludes waiting periods over 90 days. Requires employers who offer coverage but whose employees receive tax credits to pay $3,000 for each worker receiving a tax credit up to an aggregate cap of $2,000 per full-time employee.

Increasing Access to Medicaid. Medicaid eligibility will increase to 133 percent of poverty for all non-elderly individuals to ensure that people obtain affordable health care in the most efficient and appropriate manner. States will receive 100 percent federal funding for the first three years of this coverage expansion.

Small Business Tax Credit. Implements the second phase of the small business tax credit for qualified small employers.

Quality Reporting for Certain Providers. Places certain providers – including ambulatory surgical centers, long-term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, PPS-exempt cancer hospitals and hospice providers – on a path toward value-based purchasing by requiring the Secretary to implement quality measure reporting programs in these areas and also pilot test value-based purchasing for each of these providers in subsequent years.

Health Insurance Provider Fee. Imposes an annual, non-deductible fee on the health insurance sector allocated across the industry according to market share. The fee does not apply to companies whose net premiums written are $25 million or less.

2015

Continuing Innovation and Lower Health Costs. Establishes an Independent Payment Advisory Board to develop and submit proposals to Congress and the private sector aimed at extending the solvency of Medicare, lowering health care costs, improving health outcomes for patients, promoting quality and efficiency, and expanding access to evidence-based care.

Paying Physicians Based on Value Not Volume. Creates a physician value-based payment program to promote increased quality of care for Medicare beneficiaries.

2018

High-Cost Plan Excise Tax. Imposes an excise tax of 40 percent on insurance companies and plan administrators for any health insurance plan that is above the threshold of $10,200 for self-only coverage and $27,500 for family plans. The tax would apply to the amount of the premium in excess of the threshold. The threshold would be indexed at CPI-U plus one percentage point for 2019 and CPI for years thereafter. An additional threshold amount of $1,650 for singles and $3,450 for families is available for retired individuals over the age of 55 and for plans that cover employees engaged in high risk professions. Employers with higher costs on account of the age or gender demographics of their employees when compared to the age and gender demographics nationally my adjust their thresholds even higher.

This interview was conducted by William H. Burnett and first appeared 30 August, 2009.

Students may not be aware of the variety of opportunities available within the Indian Health Service (IHS).

To learn more about IHS and the volunteer, scholarship, and employment opportunities available, the Student Doctor Network recently spoke with Dr. Charles North, retired Chief Medical Clinical Officer for Indian Health Services.

Charles North attended medical school at the University of Pittsburgh and completed his residency at the University of Minnesota. Currently, he serves as Professor of Family and Community Medicine at the University of New Mexico School of Medicin

[Below: Charles Q. North, MD]

Would you explain what the Indian Health Service is?

Gladly. The Indian Health Service (www.ihs.gov) is an agency within the United States Department of Health and Human Services (HHS). Since IHS is designated as an agency or “Operating Division” within HHS, it is a parallel organization to the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the Food and Drug Administration (FDA) and several others.

The IHS was created in 1955 when Congress transferred responsibility for health of American Indians and Alaskan Natives from the Bureau of Indian Affairs to the federal department that preceded HHS. The IHS is the principal federal health care provider and health advocate for Indian people.

The mission of the IHS, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

The goal is to ensure that comprehensive, culturally acceptable, personal and public health services are available and accessible to all American Indian and Alaska Native people.

The foundation of the Indian Health Service is to uphold the Federal Government’s obligation to promote healthy Indian people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes. It is charged with providing direct medical care in the broadest sense, elevating their health status to highest level possible.

Congress passed the Indian Self-Determination and Education Assistance Act in 1975 to provide Tribes the option of assuming from the IHS the administration and operation of health services and programs in their communities, or to remain within the IHS-administered direct health system.

The IHS has around 15,000 employees and Tribes probably employ about an equal number of tribal employees. Over 70% are Indian or Alaska Natives. There are about 1,000 physician positions in the system, about half of whom are primary care physicians.  As of July 2009, 21% of the physician positions were vacant.

There are 35 states that have significant Indian populations and/or reservations, mostly in the western United States and Alaska. About half of the health care for Indians and Alaska native populations is administered by the tribes and reservations themselves and half by the “feds” (i.e., directly by the federal IHS).

The Indian Health Service might be an appropriate career path for certain health professional students. Is this mainly a program for students who are from Native American Indian communities, or is it open to any qualified health professional?

The IHS’ first priority is indeed to the Native students themselves. We have a scholarship program for Native students and Indian preference for all federal positions.

But there is a shortage of qualified Native students, with not enough people in training to meet the projected need of the rapidly growing population. Even though there has been a steady increase in numbers, we do not expect that Native students will be able to meet the human resource needs of either the IHS or tribal programs in the foreseeable future.

What type of background do you look for in the IHS and whom do you think would find this an appealing career?

The most successful students are those oriented towards working with service to underserved populations, who enjoy cross-cultural and “transcultural” experiences, who have a special appreciation for an American Indian or Alaskan Native community or who want to work with indigenous people.

If you have a background working in the Peace Corps, or AmeriCorps or have done missionary work, you may be attracted to the populations and communities that the IHS serves.

Say you are a college student interested in pre-med or in one of the health professions.  How would you get information about eligibility for the scholarship programs?

There is a national IHS office in Rockville, Maryland that helps anyone interested in scholarships. However, the criteria for scholarships are quite rigorous. Most of these opportunities would be for enrolled members of tribes. If you are in this category, ones’ tribal administration or the Rockville office can guide you through the application processes.

The Native Health Initiative funds summer health and justice internships. The IHS does provide some opportunities nationally in the Commissioned Officer Student Training and Extern Program (COSTEP) that lead to early commissioning in the United States Public Health Service (USPHS) Officer Corps and provide exposure to health professionals in federal agencies, including the Indian Health Service Commissioned Officer Corps.

Are there experiences for baccalaureate students on Indian reservations and other places?

Several reservations and tribal clinics have developed programs, such as the “health and justice” initiatives mentioned above. An interested person should contact a local site. There may be a volunteer program that would suit your interests and background. I am aware that anthropology majors, linguistics majors – even persons interested in law enforcement – have found things to do on some reservations. Undoubtedly, an experience of this kind early in one’s education might reinforce an early interest in this kind of service.

I would expect that there are more opportunities for students who are already enrolled in health professions schools?

Yes, such students have several options. The summer COSTEP program mentioned above requires that one signs up for the commissioned corps. We get a lot of students. Most of the interest is from pharmacy and engineering programs, but other health professionals are eligible.

Many of the schools in the 35 states with federally recognized Tribes have relationships with IHS and Tribal sites. Some programs in Alaska will pay room and board and airfare to get students to remote Alaskan communities.

Other programs will cover transportation and room and board for fourth year medical school elective rotations. You should check with your school and see if there are options for you to work in Indian Health facilities.

In Albuquerque, the IHS has a formal affiliation with the University of New Mexico. One of its Tribal sites takes students from all over the country. The Navajo, Tucson and Phoenix IHS Areas in the Southwestern United States also take students from throughout the nation.

Oklahoma has many local affiliations, so there are many opportunities there. The Northern Plains, Montana, Minnesota, North Carolina and Washington State regions all have some active and dynamic relationships. Check with your school.

How did you personally decide on a career in the Indian Health Service?

I was interested in service to needy populations even when before I was a medical student at the University of Pittsburgh. After taking a senior year elective in preventive medicine on the Navajo reservation, I entered a residency at the University of Minnesota and took an “outstate” (rural) rotation in Cass Lake, Minnesota, home of the Leech Lake Ojibway.

At that time, having a residency rotation at a remote Indian Health Service site was considered so different an experience that my University of Minnesota department chair and several professors flew up to Cass Lake to see it.

If you are a student or resident and want to do something like this, check with your school. Most likely you have faculty that are IHS veterans. The school may work something out with you.

Are there particular lifestyle interests that you find make a good match?

Generally, people who like to live in rural areas may find this is a good fit. Those people who love riding horses, rodeos, backpacking into “frontier” areas, mountain biking, long distance running, skiing, fishing, hunting, and so on often find the rural and frontier IHS settings attractive.

But for those who are oriented to urban life, you could live in a city and work at an Indian Health urban or rural site.  It is a fact that over 50% of the Indian population lives in urban areas. Urban Indian programs exist in some of the largest cities in the US. For some specialties, the only positions that exist are at the urban sites.

Beside the scholarship program for Indian students, do you have “loan repayment for service” programs?

The IHS has a loan repayment program, similar to the federal Health Resources and Services Administration (HRSA) National Health Service Corps program for community health centers. It has been funded at a lower level than the need, but it is quite possible that there may well be more money allocated to this program in the future.

It currently is set at $20,000 a year covering all the health professions, not just physicians. Because of the financial resources of some of the tribal sites, such as the Navajo, there are supplemental funds for loan repayment. One should check with local sites.

In the IHS, to date, loan repayment has been used mainly for retention, rather than recruitment. Stay tuned on on loan repayment, as this may be augmented in this era where health care reform is a legislative priority.

There are a number of IHS Indian health Health centers sites that get HRSA “Section 330” funding – a principal program for funding community health centers. They may be eligible for HRSA loan repayment program for either an urban Indian or Tribal site.

Not every person who went through the University of Pittsburgh medical school chose careers in the Indian Health Service. How did you get interested in this field?

I grew up in Seattle and observed that Native people there had both lower health status and lower socioeconomic status. I was interested in civil rights and social justice. I met Native students in in college and found we had many interests in common.

When I went to medical school in Pittsburgh, they had an elective on the Navajo reservation rotation for fourth year medical students. I went to a preceptorship at Fort Defiance, Arizona, where I worked in the hospital, clinic, and community health program and did some epidemiological research.

Personally, I love the Southwest, and liked working with tribal people, feeling that I was responding to a tremendous demand for health services. I found that the IHS healthcare services were extremely well organized into a rational system, unlike most of the rest of the country.

The IHS integrates public health and primary health care in such a way that one could make a difference quickly in meeting healthcare needs. I found this system of community oriented primary care very satisfying compared to private practice. Then I did a third year residency rotation in Minnesota and found that the system there was very similar and comfortable for me.

I loved the IHS system that existed in both Fort Defiance and Cass Lake. The population needs far exceed our ability to meet them, but I felt that I was fighting the right battle, that the organization’s core values were congruent with my core values. So after residency that is all I wanted to do.

I went to the Hopi Reservation in Keams Canyon, Arizona and served as a family physician, director of community health services and eventually became the chief executive officer of the health system there.

The integration of public health and medicine in team programs made great sense . The health care team is much better developed in Indian health.

This interview was conducted by Laura Turner and first appeared 26 July, 2009

[Below: Doctor David N. Sundwall.]

What do you think are the greatest issues facing the U.S. healthcare system today?

“Cost” control, i.e. restraining the rate of growth of spending for health-care services.  This is not unique to the U.S., but is a global challenge in that our capacity and technology have outstripped our ability to pay for them.

The U.S. is the only industrialized/Western nation without single-payer health care.  Why do you think that is?

It is a historical fluke, in some respects, in that the passage of Medicare/Medicaid in 1965 was made possible by compromising to use existing private health insurance to administer the programs, even though paid for by federal (and federal/state ) taxes.  The general skepticism of “government” has long been a significant factor in the various health policies we have enacted, and avoided.

What concerns do you have with the single-payer model?

Few, but we all need to acknowledge that if we eventually embrace a “ single payer” system it will likely result in delays, inconvenience, and frustration with coverage policies that will be based on the “public good,” not necessarily the best new technologies.

What impacts would you anticipate to physician income and quality of life if a single payer model were to be implemented?

There will likely be a more fair, i.e. “narrower” distribution of compensation among physicians, regardless of specialty.  Primary care physicians would be paid more, sub-specialists less but still more.  I do not necessarily think income is closely related to quality of life, but most strive for high incomes and associate this with “success”.

What do you think the best solution is for the U.S.?

Eventually we will have a single payer system, not because it is necessarily “the best” but because it will be more fair, and enable restraint of spending.  It will be a difficult but necessary transition in that we are accustomed to getting what we perceive we need and want and when we want it.  This is simply too expensive to sustain, so we must acknowledge that “he who pays the piper gets to call the tune,” and to the extent we pay for health care with public funds the “government” could and should determine what services are covered and at what level.

The health reform bills currently under discussion in the House and Senate all require that every U.S. citizen carry health insurance (“individual mandate”) – do you think this is a necessary element of any solution?

Short of a “single payer” system, this is an essential component of health reform.  If it is not an entitlement, it should be required.

Proponents of nationalized health care often cite information that U.S. health care lags other industrialized countries, including the U.S. being 42^nd in life expectancy and 41^st in infant mortality.  How do you respond to such criticisms?

When you compare health status of Americans with health insurance coverage with other countries we compare favorably (better than most aggregate data from other countries).  This is pretty good evidence that having health insurance coverage is important to improve health.  However, there are other important factors that are not necessarily related to coverage, e.g. economic status, race, access, etc.

What are the incentives a for-profit health care model to focus on preventative medicine and keeping people healthy versus having them consume as much care and incur as much cost as possible?

Not many – though there is little hard evidence that “preventive” health services pay off over time.  We still don’t have consensus on what constitute best practices for preventive care and what will improve health status and reduce costs over time.

Critics claim that pharmaceutical and medical device companies make egregious profits.  Do you agree or disagree, and what reforms, if any, would you like to see in this area?

In a free market economy, I believe there should be opportunities for medical device and drug companies to compete and charge what the market will bear.  However, there may be justification for imposing regulatory restraints when “public” health insurance programs (financed with tax dollars) are purchasing such.

What solution would you propose address the criticism that overseas businesses have an advantage on costs because they don’t have to provide private health care?

I haven’t proposed a “solution,” but I believe our country’s ability to reduce health care expenditures will improve our ability to compete, whether it is accomplished by private or public-based health reforms.

What will be the impacts on physician income and quality of life of the proposed reforms?

See the answer I gave to the fourth question.  “Quality of life” and income are not necessarily related.  Physicians motivated primarily by income will be disappointed and possibly seek other ways to make a living. Those of us who value the rewards of patient care, service, and life-long learning of new biomedical science will still find being a doctor very rewarding.

Selected Interviews from the Coastal Research Group’s Studentdoctor.net website.

This interview was conducted by William H. Burnett and first appeared 7 May, 2008.

SDN readers have responded favorably to our series of “20 Questions” asked of various health care professionals. With this interview of Dr. Gary LeRoy we launch a new series called “Health Care Policy and the Student Doctor”.

SDN: Gary, your resume is pretty awesome. You currently hold the position of Medical Director of the East Dayton Health Center, a community health center with federally qualified health center status; and you are simultaneously Associate Dean for Student Affairs and Admissions at Wright State University’s Boonshoft School of Medicine in Dayton, Ohio.

Yours is a unique postion, with major responsibilities in a community health center serving the disadvantaged, and as the dean of students for a medical school, which will include lots of students from more privileged backgrounds.

From the perspective of these two different worlds, what do you see as the major health care issues that medical students should be considering?

GL: Sometimes students look at the world from the perspective that they are familiar with and grew up in; and get some degree of culture shock when they come across patients who do not think like they think nor share their world-view. Most students do not know what it is like to live in poverty and see health care as a luxury of life instead of a commodity that is always available to their household.

I see three issues of major importance – all inter-related. The first is that we are approaching a majority of persons in this country that simply cannot afford health care – at least with its current cost structure. Second, the aging of the population will place far more demands on the health care system than anyone seems to planning for. Third, we as a society are under-investing in primary and preventive care. A lot of people believe that the answer is political – simply elect the right people to run the government, have them mandate universal insurance coverage for everybody and the problem will go away. I think that is an illusion.

SDN: How so? Why wouldn’t universal health coverage work?

GL: It might work with fundamental system reform, and some of the proponents of universal health coverage include the idea of a single payor system of a kind that might wipe out whole industries. I personally don’t think our political structure will produce THAT type of change. But I do think some kinds of changes will come, and perhaps quite rapidly.

Even if you give people full access to care with our current system, it has be appropriate access. It is inappropriate for emergency rooms to be dealing with most primary care problems, and it would inappropriate access to care for a person with a stomach ache to show up at the office of a gastroenterologist as the first point of contact. What we have to address as a nation is a bottom up approach where primary care is the anchor of a health care system dedicated to providing quality health care for all.

SDN: What kind of changes do you foresee, and what should medical students be thinking about?

GL: I think there are parts of the health care cost structure one can think of as a bubble. We have the example of what happened to the technology sector at the beginning of this decade. Students were in computer sciences curricula dreaming of their high incomes. A lot of computer science graduates ended up bitterly disappointed. This isn’t to say there is not a lot of money in technology, but those who made it often had to work much harder than they thought they would, and some found the high salaries were not the cinch they thought they would be.

Students have to aware that modern medicine is constantly changed by innovations in technology, pharmaceuticals, and evidence-based changes in standards of care. Students could choose a specialty that is technologically lucrative and relevant at this time, but changes in community standards of care may limit the numbers of subspecialists needed in that field.

SDN: You advise medical students. How do you suggest that they prepare for the kind of systemic change that you see?

GL: First, to be very suspicious of the idea that you make specialty choices on the basis of perceived income or “lifestyle” of the specialty. Of course, if a specialty attracts you because you really like doing what that specialty does, you should pursue it. But, if you are thinking that this is a good specialty for you, because you will have a high income for a 40 hour work week or less, and can pay off your student loans rapidly, you could find out this is as much a bubble as the dot.com industry experienced (and more recently mortgage banking and investment banking) and that neither that super-high income nor the easy lifestyle will materialize for you.

If medical students know that a specialty gets high remuneration for not that much work, everyone else knows it too, and that can be perilous when everyone in a society is trying to figure out how to rein in health care costs.

SDN: But aren’t physician salaries determined by the marketplace?

GL: Not the kind of marketplace you learned about in economic classes. Our system is neither a planned system, nor a market-based system. Basically, it is a group of arbitrary pronouncements that prices will be set a particular level, and more often than not it is simply a group of physicians that has recommended what those price levels should be to some government entity that can agree with them, or do something else entirely.

If your income is based to a large extent on an arbitrary policy that can be changed more or less at will, I think that should give you pause. Probably, the most important health care financing agency is Medicare. When it sets a pricing policy, the rest of the system follows, often very rapidly. As an example, when it developed “diagnostic related groups” in the 1980s, it completely changed the ways that hospitals were reimbursed, and created great pain for many institutions.

SDN: Do you think Medicare might impact the incomes of sub-specialists?

GL: All projections of Medicare is that there is not enough money in the future to handle the aging of the population without significant change in the budget, either through increased revenues, decreased benefits or decreased costs in the current system. I don’t see much change in the benefit structure, nor a vast increase in revenues. These changes would require a consensus in our national politics. I do see Medicare changing rules of how it reimburses physicians and hospitals, and I would not be surprised to see a Congressional mandate that it do so. It will have to find a lot of cuts to keep the budgets reasonably balanced. The low-hanging fruit of those could well be those physician services where medical students see high incomes for comparatively little work.

The deepest cuts are very unlikely to occur with the primary care specialties, in part because that’s not where the money is, and because Medicare and other health agencies are understanding that the primary care infrastructure needs attention and infusion of more resources. The major studies of the cost-effectivenss of health care expenditures, all tend to highlight the value of preventive services, early treatment of acute illness, and comprehensive and continuous approaches to chronic disease. All of that is the arena of primary care.

SDN: What do you advise medical students to do?

GL: One of the lessons of economics is that if there is manifest need, and previous underinvestment in resources, that could very well be an area in which to expect rising incomes and other positive changes. I think there are several things that favor choices in the primary care specialties right now – especially family medicine, but also general pediatrics and general internal medicine as well.

SDN: The primary care specialties in the United States have had lower remuneration that such specialties as, say, radiology, orthopedics, anesthesiology, dermatology and surgery. Why should your student advisees consider primary care?

GL: If you think in terms of lifetime instead of annual earnings, even in our current system primary care does better than when you compare the average annual remuneration of physicians in established practices by specialty.

Remember, you still can become board-certified in family medicine after three years of residency, and can negotiate a pretty decent beginning income in a group practice. General internists and pediatricians also can be in established practices while their sub-specialty colleagues that entered residency at the same time still have years of residency ahead of them. Opportunities exist for primary care physicians throughout the nation, some enhancing the income with loan repayment.

What is more, some of the specialties that you might have several extra years to be able to enter, may turn out to be vulnerable to revenue decreases through technological innovations (since pharmaceutical and medical equipment manufacturers are always seeking to develop products that change the way care is provided), changes in reimbursement policies of such third payers as governments and insurance companies, or simply because too many of a given specialist are being produced not to affect the marketplace for that kind of a physician..

SDN: But isn’t the knowledge base required for primary care pretty bewildering, if someone wants to do it well?

GL: Primary care is intellectually challenging, but that is why it always has attracted a portion of the brightest medical students. I find family medicine very rewarding, and always have. However, this is an especially wonderful time to choose primary care, because the technology of being a primary care physician is advancing along with the rest of medicine. The electronic medical record permits the effective incorporation of chronic disease management and quality assurance guidelines into primary care practice. Practices are being transformed in other ways, to enhance the relationship between physician and the persons for whom he or she cares.

In quite a few medical schools and teaching hospitals, the faculties seem to believe the world revolves around the practices of the referral specialists. But that simply is not how the world works. Primary care practices tend to be one of the most important businesses in any neighborhood. When you are in medical school or in residency at an academic medical center, there may be little understanding of how much respect you have as one of your community’s local primary care physicians and how professionally satisfying are the long term relationships you develop with your patients. When you leave the teaching hospital and academic medical center, you find that in most communities there is a great respect and comfortable working relationship between the community’s primary care physicians and the subspecialty colleagues to whom they refer and with whom they collaborate.

For several years, a majority of medical students have chosen to enter the referral specialties. As a result, if you are a medical student with good clinical skills, you may find that some of the most prestigious of the primary care residency programs may be willing to interview you.

SDN: What is it like to be a family physician in an Internet age?

GL: Well, it’s fun. It helps in relating to people. Of course, some of my patients are not as Internet-savvy as others and some just want me to do something to make them feel better. Other patients have self-analyzed their symptoms, surfed the Internet, and come to me as their coordinator of care with pages of information.

There is a consensus emerging that people need a “medical home”. In my view, the primary care physician’s office has been the gold standard for the medical home in every part of the world., and the past 40 years we have seen an extraordinary enrichment of the primary care infrastructure, principals and practices in this country. I see these primary care improvements as becoming increasingly valued over the next few years.

Many of the primary care practices are already set up to use Internet extensively, including assymetrical communications such as e-mail, and even are set up for patients scheduling their appointments by computer. This can help keep patients out of emergency rooms, when they should not be there, which is good for the whole society. For Internet-savvy patients collaborating with a primary care physician, it can help in the patient receiving comprehensive and continuous health care.

SDN: Is the Internet not a mixed blessing?

GL: The downside I see is one that is analogous to pharmaceutical advertising on TV.

SDN: How so?

GL: Most patients who need any kind of physician intervention have conditions that are appropriately managed at the primary care levels, and, except in a true emergency situation, those that need sub-specialty consultation or treatment are best identified by a primary care specialist. Television (and Internet) advertising helps promote the idea of the general public working directly with referral specialists. There is a current advertisement that suggests that you “consult your rheumatologist”. In fact, if the referral specialists had to handle any significant part of the primary care workload, it would erode their effectiveness as referral specialists. It is in the referral specialists’ interest also to promote the re-invigoration of the primary care system.

In fact, almost everyone, whether they are rich or poor, working class, professional or retired, should have a personal physician to help them navigate the health care system and to provide them or assist them in getting whatever services they need to meet their health care needs. It is very heartening for me to be the personal physician for whole families, as well as individuals. It is a great career choice in medicine, and one that will be ever more relevant, regardless of what changes occur in medicine.

Dr. Al Berg

Selected Interviews from the Coastal Research Group’s Studentdoctor.net website.

This interview was conducted by William H. Burnett and first appeared 27 September, 2009.

Alfred O. Berg, MD, MPH, is a professor at the Department of Family Medicine at the University of Washington in Seattle.  He is board certified in Family Medicine and General Preventive Medicine and Public Health.

Dr. Berg’s research has focused on clinical epidemiology in primary care settings.  He has served as chairman of the United States Preventive Services Task Force, co-chair of the otitis media panel convened by the Agency for Health Care Policy and Research, chair of the CDC STD Treatment Guidelines panel, member of the AMA/CDC panel producing Guidelines for Adolescent Preventive Services, member of the Institute of Medicine’s Immunization Safety Review Committee, and chair of the Institute of Medicine’s Committee on the Treatment of Post-traumatic Stress Disorder.

He currently chairs the CDC’s panel on Evaluation of Genomic Applications in Practice and Prevention.

He recently spoke with the Student Doctor Network about evidence-based medicine and health care reform.

You have been associated with the concept of “evidence-based medicine [EBM]”. Would you explain the term, and its relevance to the current debate on health care and health insurance reform?

The average person imagines that medicine has always been “evidence-based”, but there is quite a difference between the older ways of thinking about evidence and the systematic approach to evidence that is now considered the state of the art.

In the past, if you were a medical student, resident, or practicing physician trying to find answers to a specific problem, and your attending or your consulting physician said “this is your answer” you assumed it to be true.

What has changed is that we now ask who or what is the authority for the evidence. We are now more systematic about deciding when something is authoritative.

The most important characteristic about the new approach is that the evidence is scrutinized in standard ways, leading to more accountable and transparent clinical recommendations.

Unfortunately much of current medical practice still uses the “it’s true if I say so” approach, so a lot of medical practice is not evidence-based by current standards.

EBM is one of the “under the radar” features of the current health care reform debate. Would you see it as a major change, if it ends up in any form of the final legislation?

EBM could have a huge impact on reform. It could lead to more transparent and accountable practice, and would change the ways things are done now.

One of the likely outcomes of health care reform, in whatever final form the legislation takes, is that clinical practices and outcomes will be monitored and behaviors that depart from evidence-based standards of care will not be acceptable.

Over time, evidence-based practice has potential to reduce the huge variations in procedures and interventions we have now when there are no medical reasons for the differences.

You have been a member of and chaired advisory bodies on EBM for both the Institute of Medicine [IOM] and the U.S. Department of Health and Human Services [DHHS] over the past two decades.  How did you come to be involved with these advisory bodies?

My interest began as a fellow in the Robert Wood Johnson Clinical Scholars Program where I first learned basic epidemiology, health services, and biostatistics.  I made some connections with one of the DHHS committees that existed in the late 1980s, in which I had expressed skepticism whether a guideline released for treating asthma was supported by the published evidence – there was too much expert opinion.

In 1989 I was appointed to the Preventive Services Task Force, my first real assignment in this area. I was then asked to chair the Centers for Disease Control committee that published the 1993 Sexually Transmitted Disease guidelines, and co-chaired a committee for the Agency for Health Care Policy and Research on otitis media with effusion.  I have gone on to other committees on vaccine safety, genetic testing, post-traumatic stress disorder, and genetic tests, sponsored by various agencies.

What qualifications led to your appointments to such a diverse group of committees?

Being a generalist on clinical topics and a specialist in critical appraisal and systematic review has led me to be involved in a variety of clinical questions. As a non-specialist on any given clinical topic, I do not come into the process with preconceptions about what our conclusions should be.

And, because of the experience in reviewing the basis of evidence in dissimilar clinical areas, I have developed some general expertise at managing the committee processes that are designed to reach clinical and research conclusions.

You are a member of the Institute of Medicine.  What does it do?

It is an organization of around 1,700 elected members, part of the National Academy of Sciences which was chartered by Congress during President Lincoln’s administration, although the IOM formally began just in 1970. It receives no direct federal appropriation, but does accept contracts from federal agencies when an agency wants answers that are unbiased and evidence-based.

For example, the VA commissioned the IOM to do a study to advise them what interventions work in treating PSTD — a controversial topic where some might have questioned the conclusions if the VA had done the study on their own.  The agency negotiates the contract with the IOM, but once the project begins the IOM works independently. The IOM accepts broad input but its internal processes are confidential. The IOM also takes extraordinary steps to limit conflict of interest on its committees so that the conclusions are not tainted.

How does one determine what kinds of medical interventions are “evidence-based” and what kinds are not?

Medical students, residents, and physicians need to be moving towards asking that question more often. I have become wary of what I call the “journal club approach” to medicine where a single article is discussed hoping that it might be a “silver bullet” that will change practice. From where did the article come? What were the clinical questions asked? Are the questions relevant to my own practice?  Where does this fit in the body of evidence already available?

Medical schools are beginning to do a good job of teaching how to evaluate individual studies, but there is a parallel list of questions on how to evaluate evidence-based clinical practice guidelines. I believe this skill is as important as being able to evaluate a single research article.

How much of a problem are health care disparities in your opinion?

The folks at Dartmouth have shown how the same condition is managed in different ways at different costs in different parts of the country, when there is no apparent reason for difference.  If we were following evidence-based practice more uniformly, a patient with the same characteristics would be managed the same way in rural Texas as in New York City.

A New Yorker article (”The Cost Conundrum“) looking at the highest Medicare costs in the U.S. showed that over-treating and over-diagnosing have negative consequences. If one wants to maximize health, the “sweet spot” is when you use only as much health care as you need. When you use more medical services than you need it can lead to poorer outcomes.

If we have high standards for evidence-based practice, we could decrease costs and make health care more rational, regardless of who you are, who your doctor is, or where you are.

How do you assess President Obama’s health care reform efforts?

I believe his heart is in the right place. What I think he is finding is that EBM is important. He is also finding thatscience is not what is driving the system, but rather the economic benefits enjoyed by lots of people in the healthcare industry. EBM threatens the profits of some very powerful special interests. I believe that all the special interests are willing to bend on some issues, but their second best position tends to be keeping the status quo.

I hope the public will figure out that they are getting neither good value nor good health from its money, and we’ll finally be able to move ahead.  EBM has potential to help in that process.

Are there models in other countries of how EBM would work?

Much of the rest of the developed world is ahead of us on EBM. In many countries, there is a process for deciding when there is enough evidence about an intervention’s efficacy to make a product or intervention available to the public at public expense. Interventions considered experimental or not achieving a level of confidence in the outcome are generally not paid for with public funds. The U.S. is quite unique in that evidence of an intervention’s proven effects can take a back seat to other concerns.

Can you employ EBM techniques to determine if less invasive therapies work, such as those advanced by, for example, holistic health practitioners?

Of course. We should move toward a single standard of evidence that is blind to the kind of therapy being promoted.  We should be able to objectively assess the balance of benefits and harms of any test or intervention, whether performed by an MD or a naturopath.

How do you see the future widespread use of the Electronic Health Record (EHR) interfacing with the idea of EBM and federal funding of evidence based preventive care?

That is something I’m working on at the moment. One of the issues of EHRs is the proliferation of products that cannot talk with each other. The business incentives are not aligned to make this easy. The feds have been trying to come up with a list of common data elements, but EHR vendors are dragging their feet. At the University of Washington, we would like to develop ways to use EHRs across practices for disease management and prevention within the practice and for collaborative research regardless of the particular EHR being employed.

What are things do you believe have a chance of going right?

President Obama has made it clear that he is interested in science and objectivity. I have faith that in the long run being open and transparent about evidence supporting medical practice will result in desirable change. There are many examples of where the EBM approach has made a difference in the outcomes of patients and where it has nudged the funded research agenda. People like me continue to hope that focusing on the evidence will eventually improve the public’s health.

[Below, from left: Peter V. Lee, Jr, JD; Philip R. Lee, MD; Peter V. Lee, MD; Hewlett Lee, MD.]

The following podcast, the first in a planned series of historically important speeches that have taken place at the first twenty National Conferences, is of Dr Phil Lee speaking about the unintended consequences of the last great federal health care reform intitiatives – the passage of the Medicare and Medicaid laws. Dr Lee served both President Johnson and President Clinton during the two periods in which health reform was attempted – succeeding in 1965 and failing in 1993.

Dr Lee’s comments are especially relevant in this period in which dramatic changes in the health care system are expected. The Twenty First National Conference’s theme “Consequences” directly relates to Dr Lee’s comments.

Joshua Freeman, MD, University of Kansas

Even as the United States Senate debates health care reform legislation, two Fellows of the Coastal Research Group’s National Consortium on Community-Based Medical Education, joined by a former official of the United States Department of Health and Human Services’ Health Resources and Services Administration, are preparing the lead-off roundtable discussion for the 21st National Conference on Primary Health Care Access, which begins April 12, 2010 at the Grand Hyatt Kaua’i. Doctors Joshua Freeman, Perry A. Pugno and Enrique Fernandez will be the panel participants.

One of the consequences that will surely have implications for the long term is that “health care reform” has been politicized in a way that possibly no other major issue before Congress has been in our lifetimes.

One political party had committed to passing a comprehensive reform package that has been designed to get 60 votes in the Senate. The other political party has committed to opposing that package. No deviations from party lines (or traditional voting patterns of independent senators) were expected.

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

Political strategists for both parties have calculated what they believe this may mean for the short and intermediate term – specifically, Congressional and Senatorial elections of 2010 and the presidential election of 2012. What this will mean for the long term is unpredictable, but likely will impact policy decisions, large and small, that affect the many elements that constitute the health care system.

See Doctor Joshua Freeman’s accompanying essay, posted on this website October 28, 2009. Dr Freeman’s essay reflects his obvious preference between these two political positions, even though it is clear he would have constructed and financed the legislation in an entirely different way. Dr Freeman is a Fellow of the National Consortium.

Enrique Fernandez, MD, MScEd, Ross University

Dr Freeman is a member of the faculty of University of Kansas’ medical school in Kansas City. Dr Pugno, a Senior Fellow of the National Consortium, directs the education division of the American Academy of Family Physicians.

Dr Fernandez headed the Health Resources and Services Administration’s Division of Medicine during the 1990s and is currently affiliated with the Ross University, a Caribbean-based medical school.

He will speak to the process of implementation of legislation, and some of the expected consequences, and some possible unexpected ones, that will become evident as the implementation process begins.

__________

xxx.

The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the “best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 blue states and 7 of the 17 purple states.

From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is the blue(Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.

Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.

But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red, blue, and purple, we see:

The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.

Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington Times “Insurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)

So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…

…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.

So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.

With profound thanks to Robert Ferrer, MD, MPH

Josh spoke eloquently, and then posted his remarks on his weblog devoted to medicine and social justice. Another conferee Doctor Don McCanne, highlighted Dr Freeman’s thoughts on the website of the Physicians for a National Health Program. Dr Freeman’s weblog entry and Dr McCanne’s response follows:

Posted by Don McCanne MD on Friday, Apr 10, 2009

This entry is from Dr. McCanne’s Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP’s website.

By Josh Freeman
Medicine and Social Justice
April 10, 2009

At a recent conference, I was asked to be a “thought provocateur” (!!) on the topic “The nation needs a clear policy on the basic right to health care”.

This is an interesting question, since my first reaction is: “Of course, we need a clear policy on the basic right to health care! I mean, I have a pretty clear idea of what that policy should be, but certainly even those who would disagree with me would agree that we need a policy!”

But, on reflection, I don’t know that they do. I think that a great deal of the perseverance of our “non-system” of health care has been a result of a consensus among our leaders to NOT talk about this issue, to NOT grapple with it, to not have to take a position one way or another on whether health care is a basic right.

This is because, if one does take a position, there are implications, and things that we would then have to do.

If health care is a basic right, then we need to provide it to everyone. We can no longer diddle around with partial fixes, tinkering around the edges, covering (maybe) children but not their parents, covering people who are poor — as long as they are children and their mothers and are really poor and not working — but not those who are poor, or nearly-poor, depending on which state you are in. Or, for that matter, working-class, or, in increasing numbers, middle class.

But the problem is most people in power, including most politicians including the President, don’t want to have to take a position against health care being a basic right. It sounds, well, mean. There aren’t many people, except, well, mean people (and maybe some reactionary ideologues), who are willing to defend this position.

So we have shows such as “Sick Around America”, the Frontline “sequel” to T.R. Reid’s “Sick Around the World” (which Reid disassociated himself from). It interviewed insurance company executives who said “sure we can insure everyone”. If we make it mandatory and can make a profit, everyone. Hmm. The cost would be ridiculous. And the option of single payer was never mentioned. There is a lot more that has to be decided if we agree that health care is a basic right, like how to provide it, how to pay for it, and what will be and will not be covered. I mean, sure, other countries seem to have solved that problem, and we could model a system on one or more of theirs, but where’s the fun in that?

And if we agree that health care is not a basic right, we solve that problem, but we have other ones — like all these uninsured, and underinsured people.

• And folks not getting preventive care but rather incredibly expensive curative care.
• And companies like our automobile companies going bankrupt in some part because of the cost of health insurance.
• And, oh yeah, people dying in the streets.

For the record, I do believe that we need a policy on health care as a basic right, and my belief is that it should be. Perhaps the most important reason is social justice; we all share in the public good. This is what virtually every other nation of the first world has long realized. When T.R. Reid asked the leaders of the countries he visited for “Sick Around the World” how many of their citizens went bankrupt as a result of health care debts, they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

The health of our society depends upon the health of all of us.

• When people crowd our emergency rooms, not with minor illnesses, but with serious illnesses that could have been prevented with earlier treatment, that is a scandal.
• When parents cannot afford their own health care and their illnesses threaten their ability to keep providing for their children, that is a scandal.
• When people stay in jobs they hate, or forego the opportunity to start a new business, because they rightfully fear being uninsured, that is a scandal.
• When our friends and neighbors, parents and children, only take partial doses of their medicine because it is a choice between that and not eating, that is a scandal.
• When a hard-working man with chest pain can see the billboards advertising the superb heart care available at our local hospitals and know they are not meant for him because he is uninsured, that is a scandal.

When we are all in it together, we all have an interest in making the system be as good as it can be. The efforts of those of us who are more educated, more financially able, more vocal, more empowered will ensure that the needs of those who are less able to lobby for themselves are also met.

Just as our nation cannot survive half-slave and half-free, or with only half of adults having the vote, we cannot survive with only some of us having access to health care.

We need to do this for all of us, for, after all, ultimately, we are our brother’s and sister’s keepers.

http://medicinesocialjustice.blogspot.com/2009/04/does-nation-need-clear-policy-on-right.html

The Coastal Research Group
http://coastalresearch.org/about/

Further remarks of Dr McCanne:

Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine at the University of Kansas School of Medicine. I was fortunate to have been in the audience when Josh delivered his comments above at the Twentieth National Conference on Primary Health Care Access, sponsored by The Coastal Research Group.

Words on paper (or on a computer monitor screen) can express concepts, but they fall short in expressing the passion and inspiration communicated to the audience during the presentation of the speaker. This was one of those moments I’ll remember forever.

Josh had to leave before the discussion of a reactor panel assembled to respond to his comments. One physician from Nebraska expressed his views of health care as a matter of justice – comments which also moved me deeply. Another physician from Texas was not inclined to support health care as a right, and then he read us a passage from the Bible.

I’ll ask you, does the nation need a clear policy on a right to basic health care?