Through pestilence, hurricanes, and conflagrations the people continued to sing. They sang through the long oppressive years of conquering the swampland and fortifying the town against the ever threatening Mississippi. They are singing today. An irrepressible joie de vivre maintains the unbroken thread of music through the air. Yet, on occasion, if you ask an overburdened citizen why he is singing so gaily, he will give the time-honored reason, “Why to keep from crying, of course!

Lura Robinson, It’s An Old New Orleans Custom, 1948

It is a month today since Danielle’s death. I had already planned to go to New Orleans for my 30th medical school reunion by myself prior to her death, as she was to be playing Amanda this weekend in a local production of Glass Menagerie. The play is set in St Louis. Tennessee Williams, the writer of the play, once said “America has only three cities: New York, San Francisco, and New Orleans. Everywhere else is Cleveland.” Clearly, he set it in St Louis for a reason. Danielle was a New Orleans native, and she understood those reasons.

I lived in the Faubourg Marigny (a neighborhood just outside of the French Quarter) while I was in medical school. After we married, Danielle and I moved to the Irish Channel, a neighborhood that is quite gentrified now but was much less so 34 years ago. For those of you who know New Orleans, we were one block off Magazine and spent many afternoons there walking and window shopping.

After moving to Mobile we found ourselves in New Orleans many times a year. We would go to Danielle’s mother’s house and, after a suitable time, we would make an excuse and go to Magazine Street. The children had valuable grandparent bonding time, and we had New Orleans time. This became less frequent as the children grew older. After Katrina, both of our immediate families left south Louisiana and so our visits were limited to special occasions. We still made it about three or four times a year, however, enjoying many delicious meals with our friends and extended family, and spending time window shopping on Magazine.

This weekend, I played hooky for much of my 30th reunion. Staying with friends of ours in their uptown home, we drank wine and remembered the old times. New Orleans being New Orleans, we went to the Boogaloo Festival and heard the Lost Bayou Ramblers. We spent time among the thirty-somethings, watching them  frolic in the old (not very clean looking) Bayou St. John canal. It was hot. All in all, a very New Orleans experience.

At the reunion events I did attend, word quickly spread about my wife’s death. Many came up to me and offered condolences. Most of them only knew Danielle peripherally, so I didn’t have many in-depth conversations. “So sorry for your loss,” they would say. “Thank you for your kind words,” I would mumble back. Since many of these old acquaintances are no longer married to the spouse they boasted in medical school, discussions of marriage and relationships are typically avoided at these reunions altogether. One of the more awkward moments, in fact, was when we toasted to those who helped us get where we are and the person next to me said: “Wait, am I toasting my EX-wives?”

I guess my loss really hit me when I was driving down Magazine Street on my way out of town. I saw all the familiar buildings that were built before we were born and will likely be there after our deaths, and I realized that my loss is not just the Danielle of today. My loss is the life we built together and the life we expected to continue to share. That loss includes our shared experiences and memories. Our stories. Our jokes. I realized that I had lost not only Danielle but our shared New Orleans.

“So sorry for your loss.” For those who knew us, it is a shared loss and I am sorry for your loss as well. For others, I really do appreciate the sentiment, even though I may respond less than enthusiastically at times.

 

I have a saying I use with my patients who are prone to fret as they grow, and feel, older.  “Every day on the green side,” I say to them, “is a good day.” Now that my wife, Danielle, is no longer here to share these days with me, I appreciate very much the effort she put in to making our “green side” as pleasant and inviting as possible.

We recently spent a long weekend mucking out the backyard pond and removing several dozen crawfish so the tadpoles and dragon flies would come back. They are back in force. The blueberry bushes, including the new ones we brought at the Botanical Gardens plant sale, are producing berries and the birds are, with the help of a netting reminder, leaving them on the bush long enough to stay ripe. The chickens continue to lay even after the flock has been reduced to a more manageable three birds. The citrus trees are loaded with fruit. Even the leak in the fountain has slowed, allowing me to keep the water feature flowing and providing the birds with a place to bathe. Here, in Danielle’s urban patch of green, the promise of renewal that spring brings to the gulf coast continues. Danielle is still with us, in her way, here on the green side.

Sudden cardiac death. That, in stark “doctor words,” is how she left those of us still on the green side. Although because of prompt paramedic response she still had a heart rhythm on and off after arriving at the hospital, it soon became clear that, clinically, she had left us on that Sunday, three weeks ago, while still in the house. I like to think that, once called, she decided to stick around. At the very least, she intends to make sure that the crawfish population stays down so she can continue to watch the dragon flies from the kitchen window. I choose to believe that is the case in part because draining that pond was very hard work.

Very few people study sudden cardiac death (SCD) in the general population, mostly because there is little clinical information to be had after the fact. If people make it to the hospital while having their heart attacks, we can mobilize millions of dollars of equipment and personnel to preserve their heart function. When we know that a person is at significant risk for sudden cardiac death, we implant defibrillators which stand at the ready to shock the heart back into compliance should it get out of kilter.

Most SCD happens to relatively healthy people, as it did with Danielle. As documented on the American Heart Association web site, every year about 300,000 people will succumb to SCD. This is about 15% of the deaths that occur in America annually. Of those, about half of the men and two-thirds of the women will have no reason at all to suspect a problem. The modifiable risk factors (hypertension, hypercholesterolemia, diabetes mellitus, kidney dysfunction, obesity, and smoking) have all been brought to the attention of the public. Improvements in management of hypertension and diabetes and reduction of smoking has lead to a reduction in all deaths from heart disease, including SCD.  A surprising number of these events occur during exercise (which tends to make the news and provides an excuse  for those who embrace the couch potato lifestyle). Jim Fixx perhaps is the most famous victim of sudden cardiac death while exercising. For the most part, habitual exercise is protective. That is, once it becomes a habit.

In Danielle’s case, genetics clearly played a role. However, saying “genetics plays a role” is not the same as saying “it runs in families” like red hair. There is a complex interaction between genes that makes us all unique. Family history doubles the risk of SCD. A rare event becomes half as rare. So far, researchers have identified 23 different gene areas that might play a part. Mathematics suggests that finding a pattern useful for screening or targeted treatment is still many years away.

So, what does this mean for SCD? In the words of the investigators, “Our ability to accurately identify individuals most at risk for SCD within the population remains poor.” Preventing SCD, as of now, is the same as preventing all heart disease. Eat right, exercise regularly, monitor blood pressure and get checked for diabetes if you are one of those at risk. Make exercise a habit and report unusual symptoms such as passing out, chest pain while exercising that improves with rest,  or unusual amounts of fatigue. Fund emergency services adequately but realize they are not the answer. Support policy efforts to make exercise more accessible.  Bike lanes are one such example. Support policies to reduce exposure to cigarette smoke and access to healthy food. Support research but realize the research will be difficult and expensive to perform.

How about for those of us still on the green side? Support dragon fly habitats. Eschew backyard crawfish breeding. Plant fruit trees. And remember, every day on the green side is a good day.

Two weeks ago today I lost my lovely wife.  Coronary atherosclerosis. That is what the death certificate says. My family and I have received an outpouring of love and heartfelt sympathy from our community of twenty-five years. We will never be able to repay their kindness.

Danielle was a craftsperson when it came to her writing. She would work for hours (or days) to express a thought or concept in just the right way. Medical writing was a mystery to her with its passive voice and weasel words. Early in my career I tried to enlist her help with one of my “scholarly” articles. We soon reached an agreement that I would write what I needed and she would pretend to read it once published and say “that’s nice dear.”

This blog was a collaboration and was different. Our attempt was to write it for a layperson with an interest in health care, a passion for doing the right thing, and a desire to connect the dots regarding the flaws in our care delivery system. If we succeeded it was because of her. If we failed, I take the blame. I only hope I can continue and not embarrass myself too much without her contributions.

Danielle was a healthy, fit, active women who unfortunately had a terrible predisposition to cardiac disease and no sensation of cardiac pain. In other words, no “warning signs.” She did not smoke, was not overweight, and ate mostly vegan. Her “coronary atherosclerosis” would have been as much of a surprise to her as it was to the rest of us. Here are my thoughts, at two weeks out:

  • Disease occurs randomly. Being adopted, she had limited knowledge of her family history.Had she known that that was a possibility, there are only a couple of things she could have done to change the outcome.This is true for many people who suffer from illness and disability. Victim blaming serves no purpose and is an incorrect response. This we all need to stop.
  • That being said, risk factor mitigation only makes good sense. Eat right (a diet low in fats and animal protein, high in fiber, and minimize processed components), exercise daily, avoid cigarette  smoke and alcohol in excess. While it didn’t save her life (nor any of us eventually) this type of living likely gave her 10-15 years she would not have had. And gave us that time as well. We all need to try and live in harmony with our bodies.  As a community we need to provide these opportunities.  Farmers’ markets, community gardens, and bike paths all contribute and should be supported.
  • Human connections are very important. What I learned of Danielle after her death was how important her friendship was to many people. I cannot count the number of people who have come up to me to say that at a vulnerable time she reached out and help him or her through the rough patches. As a primary care physician I am brought in at times of crisis. We need people like Danielle who will take an interest and have a serious discussion about concerns with folks who are vulnerable. Things like this prevent crisis. Please reach out to someone who seems distress and ask them what can be done to help them. While churches can serve that purpose, activities involving the arts, informal interactions within the community at open air markets and dog parks, for example, are where such interactions take place. As a community we need to build in these opportunities for casual interaction.
  • Illness, random or otherwise, in America is expensive with insurance and cost-prohibitive without it. We are very fortunate that we had health insurance through my employer and enough money to cover incidental costs.  Without insurance, the hospital would be able to put a lien on my house if I didn’t have the money. While the ACA is not perfect, it is what we have at this time. President Obama has made it so that, at least in those states that have expanded Medicaid, bankruptcy for medical bills is much less common. Please support the Medicaid expansion.

Enough rationality. For those who know us, I miss her every day in ways both big and small and I know you do as well. For those who did not have the opportunity, hug someone and go back to helping us continue the fight.

Aloha, Danielle.

 

“Last year (2015), the Science and Security Board moved the Doomsday Clock forward to three minutes to midnight, noting: ‘The probability of global catastrophe is very high, and the actions needed to reduce the risks of disaster must be taken very soon.’ That probability has not been reduced. The Clock ticks. Global danger looms. Wise leaders should act—immediately.”

Bulletin of the Atomic Scientists, 2016 Doomsday Clock update

Here in Alabama, it is one minute to healthcare catastrophe. The legislature passed, the governor vetoed and got caught in a sex scandal, the legislature overrode and made law a bill which reduces Medicaid to a level not seen in any of the other 49 states. The program exists as a federal-state partnership and Alabama’s partner has every right to back out if we don’t hold up our end of the bargain.

So what, you say, I have Blue Cross.

As fellow Alabama physician Pippa Abston documents, everything is connected. Our doomsday clock has been inching closer and closer to midnight ver since 2003 when Governor Riley failed to pass a funding package to deal with the problem. In the interim we have cut mental health services to the bone, have reduced services that maintain the elderly in their home, have reduced payments such that eight rural hospitals have closed and another 2 dozen are on the critical list. The next tick of the clock spells disaster. Woman’s and Children’s Hospital in Mobile, 71% Medicaid. Children’s of Birmingham, 57%. Midnight is only a minute away.

In the cold war era we actually planned to survive the nuclear holocaust. Fallout shelters stocked with food, instructions on how to “duck and cover” and other propaganda gave us a sense of bravado in the face of certain annihilation. We were fortunate that the balloon never went up because our survival was never guaranteed.  In fact, policy makers were well aware of the futility of their efforts.

Today and tomorrow are the day when we decide whether to let clock click to zero for health care in Alabama. Don’t believe in the false security of private insurance. Our system is built on Medicaid. Call your state senator and tell him or her you support using BP money for Alabama Medicaid.

Alabama is still poised to unleash the Death Angel. The night after we wrote that post I suffered a tragic loss. Danielle Juzan, my wife and silent collaborator of 33 years was stricken and died of a heart attack at the age of 55. As you can see from the attached article, she was a wonderful, passionate woman who pushed me to stand up and do the right thing regardless of the personal or professional consequences. She was also a marvelous writer and those who have read this blog over the years will never know how much she added to these posts.

She was a fixture in the local community and fought hard for improvements to Mobile, Alabama. Her attachment to our community was what made this work so important. Over the years I have looked at several jobs in places that are better positioned to provide healthcare for all citizens. Each time  Danielle would give me the reasons not to leave our house (we just got the garden where it needed to be, we are getting a dog park, etc) and ask me if we couldn’t stay in Mobile a while longer. I would agree that we had a nice life despite the seeming callousness of the public officials and we would go back to tilting at the windmill that is improving the care of the underserved in Alabama.

As I grieve, I continue to check my e-mail and am thankful for the hundreds of expressions of sympathy that I have received. For those of you who read this, thank you so much. While nothing will make it better, it is comforting to know that Danielle has touched so many.

Immediately after her death we were challenged in a message as to accuracy of the position that Medicaid (not the expansion, access to Medicaid at all) saves lives. The commenter suggested that the evidence for improved health was wanting. He pointed out that before the passage of the ACA, Oregon randomly gave several thousand people who were uninsured Medicaid coverage and followed them and several thousand uninsured for a couple of years to see what would happen. The results were as follows:

Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk. Medicaid coverage also had no statistically significant effect on employment status or earnings.

The science is pretty clear, access to health insurance over a two year period for relatively healthy people improved some aspects of their lives but is no panacea. How these findings are interpreted depends on if you live in a red state or a blue state:

Their conclusion is as follows:

In its totality, the research on Medicaid shows that the Medicaid program, while not perfect, is highly effective. A large body of studies over several decades provides consistent, strong evidence that Medicaid coverage lowers financial barriers to access for low-income uninsured people and increases their likelihood of having a usual source of care, translating into increased use of preventive, primary, and other care, and improvement in some measures of health. Furthermore, despite the poorer health and the socioeconomic disadvantages of the low-income population it serves, Medicaid has been shown to meet demanding benchmarks on important measures of access, utilization, and quality of care.

For you, Danielle. Continue to help me keep fighting the good fight.

When asked about folks possibly dying from lack of access if we fail to maintain a Medicaid system that meets federal requirements:

“We all die sometime,” Trip Pittman (R-Montrose) said.  “We’re all mortal. We all have a finite period of time on earth. I think sometimes we confuse saving lives with extending lives.”

Wow! The state of Alabama has passed and overridden the Governor’s veto of a budget that, per the Medicaid commissioner, does not allow us to meet the federal requirements to stay in the “voluntary” program. There was a hearing on the impact of the budget on Thursday. In the lead-up to the hearings (found here) Senator Pittman was quoted as saying that the reason was that “I think there are legislators who need to more fully understand the workings of Medicaid.” A fair statement; as I have as I previously explained (here) the funding of Medicaid in Alabama is incredibly complicated. The hearing included a very informative presentation by the Medicaid Commissioner that can be found here.

Highlights of the Commissioner’s presentation are:

  • Counties with the highest unemployment have the highest Medicaid enrollment
  • Administrative costs are only 4%
  • Cost per enrollee have remained the same but the number of enrollees has increased by 30% since 2008 because of Alabama’s sluggish economy

And, the part that got Senator Pittman’s attention:

  • 1% of enrollees account for 30% of costs with 35 tragic cases accounting for almost $40,000,000 in cost to the agency

Senator Pittman’s response (heard here starting at 4:39 and accompanying article by Glynn Wilson here) would have made international news had this been one of Obama’s surrogates. Many of the federal requirements he  finds onerous provide healthcare to the “undeserving.” For example, the Feds require Medicaid to cover those who are receiving Social Security disability checks:

“[The eligibility rules]may be too liberal,” Trippman said, and “not discerning enough on whether somebody is really eligible.”

Giving to deserving people, it seems is OK. It’s  just that those who could get out and work, in the Senator’s estimation, need to get off their disabled rear ends and find jobs that provide health insurance.

He was then asked to reflect on the 35 most expensive cases:

“We’re spending more than 40 percent of the money on children in their first year of life,” Pittman, said, and added: “We’re spending a lot of money on the elderly, at the end of life. I think as a society we need to debate and look at all of these things. If not, you’re going to get into rationing.”

He then proceeds to outline possible solutions, beginning by referencing Bernie Sanders (8:30 on the video):

“[Bernie Sanders] said 80% of the costs are for elderly and for people in this state in the last few months of their lives and for people with chronic illnesses and the elderly. The reality is that we have to have some discussions about quality of life, about the expenditure of money, and about the cost. You know in this country the transfer of wealth from working to non-working, for every dollar you transfer from working to non-working you are transferring $7 from young people to old people. That’s a moral debate and that’s something people need to start talking about.”

He goes on to say that the cuts will be made, the impacts will be felt, and people will react to what ultimately happens.

There you have it. Willing to turn away $5,000,000,000 and dismantle a state’s care delivery system , so we can find out in our own little laboratory of democracy just how people will react. Again, wow!

'I hate it when people vote with their feet'

‘I hate it when people vote with their feet’

About 10 years ago, Mobile County landed one of the last large pre-recession “smokestack” projects. Competing against multiple states, the state and the county ultimately gave a lot of money in anticipation of “29,000 jobs during construction, and 2,700 jobs paying an average of $50,000 to $65,000 annually once the plant is operational in 2010.” One of the more controversial aspects of the corporate welfare was the amount paid by Alabama and Mobile County ($1 BILLION) as compared to the benefit accrued. Many of the skilled construction jobs were filled not by locals but by a nomadic group of people who traveled from places like North Carolina and Virginia, lived in campers for several months, and left to go to the next big construction job. Our corporate welfare went not to Alabamians but to people from all over the south who sought employment by “voting with their feet.”

Our legislature is electing not to spend $85 MILLION on adequately funding Medicaid. They are going to begin holding hearings on the budget they just passed next week, focusing on finding out why healthcare is so expensive, where the waste and fraud is, and finding out how to “fix the program.”

State Rep. Paul Lee, R-Dothan, said he believed a part of the Medicaid issue might be that the system does more “handing out” than “handing up.”

“We have children in need and elderly in need. …We need to start encouraging those that are able and willing to go to work rather than sitting and waiting for a check to come in,” he said.

“We can fix Medicaid in 24 hours if we could make our own rules (versus federal regulations) and do it the way it should be done.”

The first person to suggest that states should be given much greater leeway to “fix programs” was Ronald Reagan. Pointing to the migration of blacks to the north during World War II and to the migration to the energy belt in the 1970s, he suggested that America was not composed of static folks tied to a community, but was instead a moveable army of workers and others who would move from their current state to another if services were inadequate. Like the construction workers were drawn to Alabama. Or perhaps like poor, sick folks might leave Alabama

Do poor, sick people move from a low-service local to a high-service one? Do wealthy folks move to areas with low taxes? Are we finally entering a Reaganesque utopia to which the Ayn Rand capitalists will move after we eliminate Medicaid funding, creating a little Somalia  right here?

As it turns out, the great migration of poor sick people to blue states after Obamacare never happened. Folks it seems are content to stay put and use the Emergency Department near their family rather than move to an expansion state. The exception are the chronically homeless, as it turns out that up to 40% are rather nomadic  and identify service availability as a reason to relocate. This is about 40,000 people nationwide.

What about the converse? Are wealthy entrepreneurs leaving for the promise of lower state taxes? Despite what the moving company “data” reveals, the truth is nope. In a very well done study by the Center of Budget and Policy Priorities using IRS data which combined income and address change information, it turns out:

  • 70% of folks never leave the state in  which they were born
  • The income tax status of the state does not correlate with the movement of people in or out in general
  • If anything, poor people are MORE likely to move to a low tax state, which probably correlates with lower housing costs
  • Old people are more likely to move away from snow

People move for two reasons, jobs and family. Well, warm weather as well for old folks.

Reagan’s belief was based on a theory by Charles Tiebout, a rather obscure economist, as well as personal observations about blacks moving north and and Houston’s energy-sector driven growth. Tiebout’s theory was based on faulty assumptions, and Reagan’s observations were not really contextual (the reason for the black diaspora was a little more complex).

Folks that vote with their feet, it seems, are nomadic. They come to either work on large construction projects or to seek out services to substitute for their lack of a permanent residence. It is probably more realistic to fully fund services such as Medicaid rather than fight the federal government and hope for an influx of wealthy Ayn Rand followers. I do not think this will come out in the hearings.

 

 

From al.com, italicized  comments mine:

Lawmakers appropriated $700 million from the General Fund for Medicaid next year, $85 million short of the governor’s request.

From an Urban Institute paper about Alabama published in 2004:

An overarching issue is the defeat of the tax reform proposal, which implies that the vast majority of Alabamians prefer lower taxes to improved government services or possibly even maintenance of the current level of services.

In other words, we have been crying wolf for a long time and have always found a work-around. This crisis has been precipitated by past loans from other accounts, one-time payments such as the BP settlement, and other work-arounds coming due and not by Obamacare. 

 

But for the first time they said one option could be to eliminate prescription drug coverage for adults, which would save an estimated $50 million to $60 million in state dollars.

“If we have to live within our means, then we have to make some very tough decisions,” the governor said.

The estimated savings on the prescription program do not take into account increased medical costs that would result from people not getting their medicines.

Wow! Words fail me…

Azar also said Medicaid would not be able to proceed with the plan to begin providing managed care through regional organizations, a move intended to slow the growth in costs and improve health outcomes.

“Together with the Alabama Legislature, we have made significant progress in the way the Alabama Medicaid Agency operates, making it more effective and efficient,” Governor Robert Bentley said. (February 9, 2016)

What a difference a month makes!

The Centers for Medicare and Medicaid Services earlier this year approved a waiver to allow the change and could provide up to $747 million over five years to help with the transition.

Elimination of prescription coverage was one of 10 areas of potential savings mentioned by Bentley and Azar today.

Various combinations of the cuts could be considered and would have to be approved by the Centers for Medicare and Medicaid Services.

Another savings option Azar listed would be for Medicaid to consider a pharmacy preferred provider. That would save an estimated $19 million to $30 million in state dollars.

But would eliminate money we use for matching, I suspect, thus multiplying the  reduction of services

Other programs mentioned, and the estimated savings in state dollars:

— Eliminate eyeglasses for adults: $300,000 – Probably will limit employment opportunities

— Eliminate outpatient dialysis: $3.7 million – 500 people dead or sitting in the ED waiting to get close enough to death they quality for emergency dialysis

— Eliminate prosthetics and orthotics; $500,000 – Hard to work without a leg

— Eliminate Program of All Inclusive Care for the Elderly (PACE): $2 million – putting 150 people into nursing homes, resulting in a net cost to Alabama

— Eliminate Health Home and Physician case management fee: $16.6 million – Adding even more people to the nursing home

— Eliminate primary care bump (pays doctors at Medicare levels): $14.7 million – Reducing the docs taking Medicaid

— Reduce administrative costs: $3.5 million – Reducing efforts to reduce waste,, fraud, and abuse I suspect

— Reduce reimbursement rates for ambulatory surgical centers, doctors, dentists, optometry, hearing and other programs: Zero to $50 million. – Reducing access for these programs and furthering the reputation of Alabama as home of the halt, lame, blind, and toothless.

Please call your state Senator or Rep if you live in Alabama and demand that they revisit the Medicaid budget. Please retweet this under #CanYouHearUsNowAl and #alpolitics

Marin_acupucture_chinese_medicine_cartoon

Public health has an odd place in medical education and the physician’s practice. Although clearly required as a part of the curriculum, it has historically been underemphasized.  By historically, I mean since 1848. Medical schools were created to train doctors in the science of the person (singular) but not in the science of people. Someone had the bright idea of offering further training to doctors (further detailed here) to allow them to have a broader perspective:

To earn this postgraduate certificate, students took courses on“preventive medicine and sanitary science, personal hygiene, public health administration, sanitary biology, sanitary chemistry, special pathology, communicable diseases, sanitary engineering, and demography” as well as“special courses and lectures in infant mortality, social service work, mental hygiene, oral prophylaxis, the prevention of ear, nose and throat disease, hygiene of the eyes, industrial hygiene and medicine, eugenics, genetics, and sanitary law.

Because it was a post-graduate degree, rather than create a cadre of “super docs” it moved public health out of the medical school entirely.

In 1998, the Association of  American Medical Colleges urged medical schools to incorporate public health by “first, teaching students the practical fundamentals of the core disciplines that underpin the effective application of population health; second, giving students experiences in studying real populations; and, third, integrating the teaching and learning into all parts of  medical curriculum rather than relying solely on a stand-alone population health course.”

In the last 20 years, medical schools didn’t answer the call.  From the requirements for medical school curriculum they are required to provide instruction in the following:

  • The recognition and development of solutions for health care disparities
  • The importance of meeting the health care needs of medically underserved populations
  • The development of core professional attributes (e.g., altruism, accountability) needed to provide effective care in a multidimensional and diverse society

As someone with an interest in the health of the population, I sought more than just “recognition.” My medical school offered a joint degree (MD/MPH) which allowed me to obtain instruction in the health of people (plural) in addition to health of a person.

One class in particular sticks with me. It was a health policy class taught by a professor who was a self-described Maoist. Communism in the mid-1980s was scary and having a person who admired a communist leader was more than a little controversial. I would leave my basic science lectures at the medical school and go to a class where we discussed how China had markedly improved the health of their citizens with “barefoot doctors” who indeed were barefoot, and had minimal training. They transformed the Chinese countryside by providing primary health care services, and focused on prevention rather than treatment. They provided immunizations, delivery for pregnant women, and improvement of sanitation. To my medical school classmates they were in no way doctors. To my public health classmates they were a model for the future.

Fast forward 30 years, and we are coming around to learning that China was onto something. People from the community are much more likely to work to improve their community and care for their friends and neighbors. Known as community health workers in this country, they are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables the workers to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. It looks like we are going to start employing these folks to help improve the health of the citizens of Alabama.

Unfortunately, I’m afraid my physician colleagues won’t recognize a good thing when they see it. After all, it’s only been 150 years.

563333352-crowe

“Unless there is a public outcry, I don’t see any changes.”

Alabama Senate President Pro Tem Del Marsh on passing a Medicaid budget that reduced payments to physicians, hospitals, and would end all “optional services” including home health programs, hospice, outpatient dialysis, adult eyeglasses and PACE, a program to help some elderly people avoid having to be admitted to nursing homes

How do you create a public outcry? That is the question for the 500 dialysis patients who rely on dialysis to continue living.

Dialysis is a funny thing. When Medicare and Medicaid were established in 1965, renal replacement therapy (known by lay folks as dialysis) was known to save lives. People who had lost kidney function from diabetes, polycystic disease, or some other malady, unless they were fortunate enough to be a part of an experimental protocol, would die from a build-up of toxins in their body. If they were enrolled in a protocol or had the good fortune of living near a place that was experimenting with renal replacement therapy, they would live.

In the late 1960’s, a report came out that identified renal replacement therapy as established as opposed to experimental. In addition, because of the “experiments” funded through Medicare, the number of people on dialysis increased by a factor of 10 (from 1,000 to 10,000) and the number of physicians performing dialysis increased dramatically. This set the stage for the hearings in the 1970 where this testimony was heard:

I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a non-competitive line, was found out,and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up? (U.S. Congress, House, Committee on Ways and Means, 1971b)

Following this, the house and the senate passed and President Nixon signed a bill creating a dialysis benefit for those eligible for Medicare.

Fast forward to today. In America we have 400,000 people on dialysis. They have to have their blood cleansed 3 times a week. If they do, they can live a relatively normal life. If they don’t, they can develop shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia) and when it gets bad enough that they’re deemed to be near death, they  are given dialysis via the emergency room.

Most people on routine dialysis have it paid for by Medicare. Who gets it on the federal nickel? To quote CMS, these folks are eligible:

  • You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
  • You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
  • You’re the spouse or dependent child of a person who meets either of the requirements listed above.

If you don’t meet these criteria, and require renal replacement therapy, you pay cash (between $52,000 and $73,000 per year), obtain coverage from Medicaid, wait in a state of anticipation until you need emergent dialysis (costing about $300,000 a year as a strategy), or die.

Alabama would be the first state to take it away from ALL Medicaid recipients. Texas does not pay through Medicaid but instead pays through a separate fund.  They were able to take away dialysis from undocumented folks. Because of the pesky EMTALA laws passed by President Reagan, hospitals are required to provide EMERGENCY treatment. The consequence?  A bunch of folks who hang out at the hospital every day getting their blood drawn to see if they win the emergency dialysis lottery.

So, back to my original question. You see, Alabama is $100 million short on their Medicaid budget. On a budget of about $6 billion, that would seem like a small number.  Alabama legislators, though, are ready to make a stand. The 500 Alabama citizens on dialysis will either die or spend the rest of their days hanging out next to the emergency room so that we can prove the value of “low taxes”  unless there is a “public outcry.” How do you stop folks entrusted with the health and welfare of the citizens of Alabama if they are able to murder 500 people to prove a point? I can’t figure it out.

 

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