peter-steiner-i-m-sorry-sir-but-dostoyevsky-is-not-considered-summer-reading-i-ll-h-new-yorker-cartoonTime once again for the summer hiatus, where I spend some quality time with my family, work on other projects, and in general try to stay out of trouble and on the beach as much as possible. For those of you who are looking for a way to become more informed on health policy from a primary care perspective, I have put together several suggested areas of focus.

  1. Population health: The buzzword for the next year is population health. As those of you who read my stuff know, traditional medical care is necessary but not sufficient. America’s “best health care in the world” system will continue to be expensive (#1) and not very effective (#37) until we acknowledge that a whole lot more than doctoring goes into health. For a primer, RAND (link here) has published a synopsis on what works and what doesn’t in this arena. This paper is a good start. Once you get your feet wet, my friend and fellow blogger Josh Freeman has published his book Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System (available on Amazon) which, though focused on our broken system, has a lot of insight about how an emphasis on population health could take us in a better direction.
  2. Palliative care: Death comes to us all. As I watched the movie “The Judge” all I could think about while watching the Robert Duvall character was how movie Frank Burns was old now,which meant I was old, too. In the movie, Robert Duvall’s character has colon cancer (“Stage IV, the worst”) and is suffering from “chemo brain.” His chemo is administered by his GP in his lake house and, aside from hitting the dude on the bicycle and not remembering, it is a pretty idyllic cancer life. He apparently stops chemo and goes on to live for another year, dying  while fishing with his son after they have dealt with old baggage. While health care delivery wasn’t an integral part of the movie, patient choice and shared decision making was. We as Americans say we want that kind of life and death. We seldom get it. Atul Gawande lost his father several years back and has written an exceptional book entitled Being Mortal. It is an excellent read and provides insight into the mismanaged way we deal with chronic illness and terminal care as the inevitable happens.
  3. Obamacare: The Affordable Care act is 5 years old. When all is said and done, this act has begun the process of retooling our care delivery system. For the latest update on what is or is not happening, RAND has provided a summary of where we are after 5 years to get you up to speed (link here). You say you need to walk before you can run? Though I haven’t read is, Ezekiel Emmanuel is one of the architects of the law and has a book out detailing what the law was supposed to do and is doing (link here).  Emmanuel is an ethicist and a very good writer, and I suspect his book will offer some keen insights into why the law has been shaped in this way. From the observer perspective, Steve Brill’s book offers an exceptional synopsis of where we have been and where we are going. If the Supreme Court rules rules in favor of King (in King v Burwell) and dismantles the law, you can read what the conservative response may be for under $4 here. Hurry, though, if the law is struck down prices might go up.

Y’all have a safe and fun summer.




I look marvelous, but I don’t feel marvelous. Which is hokie-dokie for me, because, as you know, my credo is “It is better to look good than to feel good.”

Billie Crystal as Fernando Lamas

In 1948 some investigators from Boston University decided to take on conventional wisdom. They went to a nearby town  (Framingham, a 20 minute train ride away) and talked everyone in the town into giving a little of their personal data, blood, and health habits. They did this because conventional wisdom was that heart disease was brought on by personality  (“Type A”) and plain bad luck. What they found was not only was personality non-contributory in and of itself,  but they discovered a whole host of factors that actually did contribute to heart disease and were modifiable. The modern treatment of hypertension, diabetes, and high cholesterol, as well as the importance of physical activity and smoking cessation to the prevention of heart disease, all came form this study. The identification of the cause of 1/3 of strokes, atrial fibrillation, was made as a result of these serial observations as well. It has been estimated that the number of lives impacted as a result of these findings is in the millions and the amount of money saved in the billions.

These types of observational studies are important. Health care providers, stuck in the forest as we are, need someone to point out the trees. These types of observational studies on large populations are an important aspect of the forest-tree dialogue. Unfortunately the are also very expensive (current costs are several million dollars annually). In addition, the timeline is measured in decades making it an academic career killer for the first 20 years or so.

It appears that some folks in Britain have taken up the longitudinal study baton. The UK Biobank has taken information on 500,000 folks (with their permission) and committed to tracking these people over time. The first major report from this data bank came out in the Lancet this week. Having almost a decade of data, they looked at who died and what was associated with death. More usefully, they have put the data on a website so you can see whether or not to purchase a long-playing record.

They only enrolled folks between 37 and 70 and of the 500,000 only 2% died. Because of the length of the study, the model only works for 5 years out (Framingham has good data for 10 years out for most things they look at and longer for some). For guys, they found that if a guy said his health was excellent, it was. That was the single best predictor of 5 year mortality. For women, a history of cancer was associated with an increased risk of death, For both men and women, a slow self reported walking pace was associated with an increased risk of death. A history of smoking? Still bad news for both sexes and current smoker even worse. Things that didn’t have an effect at 5 years? Blood pressure, Average monthly beers. Cell phone use. Beef intake.

I fully expect more to come out of this effort. As of today, though, my UBBER age is 40 and I feel marvelous. What’s yours?

download“If the entire materia medica at our disposal were limited to the choice and use of only one drug, I am sure that a great many, if not the majority, of us would choose opium; and I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.”

Macht DI. (1915) The history of opium and some its preparations and alkaloids. JAMALXIV:477–481

Disabled, chronically abandoned

(Sign held by a young woman protesting in front of a pain clinic shuttered by the DEA last week)

Often in nature, a substance is found (or some believe God has placed a substance) that has serendipitous properties in humans. One of the first instance of humans discovering this was with the milky substance found in a flower now known as the poppy. Thousands of years ago, someone (we think an Arab adventurer) for whatever reason ingested that the milky substance in the “proto” poppy plant and found it relieved his pain. For the next thousand years, through cultivation and trial and error the opium poppy was born in China. Papaver somniferum. 

Pain is a funny thing in people. It is a mechanism almost all of God’s creatures have to tell them that if they stay in their current situation bad stuff might happen to them. One of the things we are taught in medical school is how to get people to describe their pain. We tell students to get people to use a 1-10 scale with “1 being a paper cut and 10 being an elephant sitting on your chest.” Did you know there are a lot of people whose paper cuts are a 10? Once the situation has resolved, we have chemicals in our body that connect with the pain receptors (there are 4 such receptors, with mu being one) to relieve the pain and give pleasure. The opium poppy, which likely could only move back and forth and doesn’t need a lot of pleasure materials, has been bred to have 12% of its latex made up of these pleasure drugs (morphine, codeine, and to a lesser extent thebaine which was used to make hydromorphine).

Having a drug that reduces pain is lucrative. Having a drug that causes pleasure is more lucrative. In the 1800s, German scientists were able to extract pure opium from the poppies. Although available for pain relief, the larger market was in euphoria production in shops (mostly in China) using water pipe technology. Ironically, it was declared illegal in China (where the poppies were grown) but was smuggled by the British into China and sold to the opium dens to offset the imbalance of trade they found themselves in from importing tea. Only fair, I suppose.

We don’t need flowers today. Thanks to the God-given ability of humans to reverse engineer, the world produces about 700 tons of narcotics. Most of this medication makes its way to the US. We have 5% of the population and account for 99% of the hydrocodone use in the world (active ingredient in Vicodan), 83% of the hydrocodone use (active ingredient of Oxycontin), and 37% of the world supply of Fentanyl. We consume twice as much per capita as the next highest nation. Within our country, even, there is much variation with Alabamians consuming 2 1/2 times (1 1/2 prescriptions per person) as much as Hawaiians. The misuse of these drugs contributes to 17,000 deaths annually, as many as ovarian cancer but without a ribbon to raise awareness. Deaths aside, there is the problem of diversion. Many people get a prescription for 90 Vicodan, take 60, and sell 30. There are willing markets of buyers and many physicians are unaware that their sweet little elderly lady patient (who has the medicine in her urine) has a side business.

It turns out opioids have a downside. They are addictive, meaning that they cause aberrant behaviors on people unable to get access to the drugs by buying pills from the guy down the street. They cause a physical dependence. People who are suddenly denied access will suffer from physical symptoms such as nausea, vomiting, and profuse sweating. Chronic use results in tolerance, meaning that it takes an increasing dose to get the same effect. If you are going to create a market, what better product to sell?

As detailed in this New Yorker article, this problem has been a long time coming, and we in the healthcare field are complicit. Beginning in the 1980s, scholarly articles encouraging the addition of narcotics to our inadequate pain treatment regimes have been published. Some very smart people believed that treatment of chronic, non-cancer pain with opioids could work  “with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” In the 1990s makers of legal narcotics (Purdue in particular) began marketing their products to physicians and patients as safe for everyday ailments such as neck and back pain. With a team of 5000 sales people, a bonus system that encouraged “market growth,” and the assistance of the Joint Commission which began requiring hospitals to evaluate and treat pain, over $1 billion worth of Purdue’s Oxycontin was sold in the US in 2000.

So, God placed this wondrous drug in the proto-poppy for what reason? If used correctly, say for the pain associated with metastatic cancer, it is truly a miracle. If used by people to mask the psychic pain of living in America and written by physicians who are just too busy to talk to their patients, it is probably not what God intended. If given by physicians to folks in exchange for sexual favors thus feeding their addiction it is almost certainly not what God intended.

Perhaps God put the proto-poppy on earth to test physicians. We can make a lot of money selling these poppy derivatives but we can also get in big trouble. The test for us is to use it correctly.



Samuel Shem, House of God (Quoting the Fat Man’s Laws)

On rounds a while back in the hospital, we had a patient who had come from ICU and was being cared for by our team. He was a little older than our average patient (he was in his mid 80s), a little sicker (his kidneys and liver were failing), and a lot scared (I don’t want to die, doc. I want to feel better. I want to go back to how I was. Don’t let me die). He was getting a lot of blood draws, had a catheter in, and was getting IV fluids and a strong diuretic. Thanks to “big data” we now have calculators that we can plug in certain data and determine the likelihood of the patient being alive at 3 months, 6 months, and a year. In this patients case, there was a 50% chance that he would be alive in 3 months. As much as I wanted to, I was not ever going to be able to put him back together. I was also sure that he would have at least one or maybe two more trips to the ICU before he died. The sad thing is, those trips to the ICU might just cause him to die sooner.

Americans have believed that the US Healthcare system is the best in the world despite the fact that we consistently rank last among wealthy countries in almost every category measured. We are the most expensive in the world, spending twice what the next highest country spends.. It appears, that we have mistaken excess for quality. It also appears that we physicians are complicit in selling this belief to the public.

I often have patients say to me “do everything.” Often, they make that statement as the end of life is rapidly approaching. In this country, everything comes with a steep price-tag. Part of that price is monetary, For example we spend $1.25 billion in Medicare recipients for cancer care with 25% of that occurring in the last month of life. Part of that price is in shorter life-spans (from the Dartmouth Atlas):

Ironically, research has found that in patients with chronic illnesses, more aggressive interventions result in shorter life expectancy, probably because of the risks associated with hospitalization. This indicates that the best strategy for extending the life of people with chronic illness is to focus on those activities that provide a survival benefit – better control of blood pressure for people with diabetes, for example – rather than on “heroic” end-of-life care.

It turns out that the Fat Man was right. For a lot of people, symptom management (What would you like to be able to do?) with the reduction of aggressive care actually leads to a longer, better life.

What can you do? Take advantage of being well and determine what you would like others to do for you when you are sick. The CDC has some good information on advanced care planning. Only 20% of Americans have done so. If you suffer from chronic illness, have a conversation with your physician about what your expectations are regarding your last year. Only 25% of physicians report having such a conversation. Limit your care seeking behavior to what really is necessary. One in three Americans who die have seen over 10 physicians in the last 6 months and yet they still died (and perhaps sooner than they might have). When it is clear that a cure is not possible, seek symptom relief. Programs providing palliative care improve length and quality of life. In Alabama, only 20% of hospitals have such programs. Makes it hard to follow the Fat Man’s advice.


Dr Perkins, can you come see this baby? Something about it just makes me feel uncomfortable.

I walk into the exam room to evaluate the week-and-a-half-old baby that was being seen by our new nurse practitioner. The child had a late morning appointment, the mother having called at 8 because the baby “wasn’t feeding.” No fevers, nothing else out of the ordinary per mom (although the baby did up having a fast heart rate). But as soon as I walked into the room, I quickly agreed with the nurse practitioner. The child was sent to the hospital for a “septic work-up” and was indeed septic.

Dr Perkins, I just don’t feel good. I have this chest pain when I go to sleep at night. Not during the day, mind you, only at night. That’s right, it hurts right there when you mash down.Why, yes, I have been getting a little short winded when I walk the golf course but isn’t that just weight gain?

Despite the reassurance that reproducible chest wall pain brings, based on reduced exercise tolerance we went ahead and obtained an EKG. To make a long story short, 3 vessel disease.

It was quite the Monday.

Despite running a busy department, I do a lot of clinical medicine. Trained in the underserved environment where I continue to practice today, I care for all ages, do some minor procedures, deliver babies (and now the babies of the babies I delivered). As my practice has aged with me, I see a lot more older than younger folks and find myself diagnosing more dementia and less strep throat the older I and my patients get.

Being comprehensive defines my specialty along with continuity, coordination, and first contact care. We preach to our learners the importance of these attributes, we test our graduates on the comprehensiveness of their knowledge, and we criticize ourselves for allowing our scope of practice to shrink. Now there is one more piece of evidence that should make us think twice about that cushy outpatient job ($50,000 signing bonus, no call, no hospital, 15 minutes to the beach). The Graham Center has authored a very elegant study that links scope of practice with actual practice. They found that doctors who were able to do more (were more comprehensive in their approach) had Medicare patients who were less likely to be hospitalized and who had better care-seeking behavior. By better, I mean that they cost the system about 15% less.

Not measured in this study were quality and patient satisfaction. This is important. As one of the commenters points out, sometimes comprehensiveness can be misused.

[F]or some populations with higher disease burden, high comprehensiveness (or scope, as we say) may be counterproductive. PCPs that maintain “too much” comprehensiveness for patients who need more contributions by other providers may be doing so because of lack of coordination with specialists, inadequate supply of alternative providers, an inability to recognize limitations, or resistance to “letting go”. Whatever the reason, the decreasing value of expanded scope in high risk individuals is a phenomena we have seen in numerous populations.

Despite these limitations, this is important.  In the words of Kevin Grumbach (one of the smartest people I know) on NPR (one of the best sources for information I know)

the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.

“It goes from a matter of philosophical preference to actually showing that this saves money,” Grumbach says.

david-sipress-are-we-there-yet-new-yorker-cartoon (1)

When I was growing up my sisters and I would play the “Are we there yet” game. For those of you who do not indulge, this game is played by getting in the car, allowing the adults to begin the journey, then about 5 minutes into the ride begin asking “are we there yet?” in a rapid fire fashion using the most annoying voice one can muster. The adult’s role is to sit and ignore the game as long as possible and, when the time is right (generally about 5 minutes in) turn to the back and say “WE ARE HALFWAY, NOW SHUT UP.” At that point, the game is over and, in my family car, generally transitioned to the pinching game (“Allen is pinching me”).

Our Governor’s journey through the changing healthcare landscape has been evolving. In 2010, while campaigning for Governor, he had some deeply held beliefs regarding the newly passed Obamacare:

I started laying the groundwork for Alabama’s rejection of Obamacare by pre-filing a Constitutional Amendment to prohibit any person, employer, or health care provider from being compelled to participate in any health care system. It also codifies Alabama’s 10th Amendment rights over this issue. I have real-world solutions that will result in affordable and accessible health care for all without bankrupting our nation or pushing us closer toward a government-controlled, single-payer system.

The Supreme Court decreed the Medicaid expansion part of ObamaCare to be coercive in 2013 (As an aside, for it not to have been coercive it would have had to meet the following criteria (1) related to the general welfare, (2) stated unambiguously, (3) clearly related to the program’s purpose, and (4) not otherwise unconstitutional.) 26 states elected not to take the expansion, preferring to stick with the (poorly funded, focused on wasteful inefficient care delivery) old program. Our Governor announced that we would be one of the states refusing the Medicaid expansion:

The Affordable Care Act–or ObamaCare–and Medicaid expansion is taking our nation deeper into the abyss of debt, and threatens to dismantle what I believe is one of the most trusted relationships, that of doctors and their patients. Essential to ObamaCare is Medicaid expansion–a federal government dependency program for the uninsured. …

Now they are telling us we’ll get free money to expand Medicaid. Those are your hard-earned tax dollars. Our great nation is $17.2 trillion in debt and it increases by $2 billion every single day. That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.

The good news is that his view continues to evolve. Over the objection of our state senators, he is now ready to accept Medicaid expansion IF there is a work requirement, along with a few other conditions:

“It would have to be in the private sector and there would have to be some requirements on it,” Bentley told reporters in December. One specific requirement he mentioned was that he’d like to see the system tied to employment. “(Recipients) need to be working on getting a job, or having a job.”

A couple of things, Governor, to consider before you start playing the pinching game with Senator Pittman. 72 percent of uninsured adults who are eligible for Medicaid coverage live in a family with at least one full-time or part-time worker. More than half (57 percent) of these adults are working full- or part-time themselves. The overwhelming majority of workers earning less than 138 percent of poverty—81 percent—don’t have coverage through their employer because their employer either doesn’t offer it or it is unaffordable to them.The Kaiser Family Foundation recently looked at the main reasons for not working among unemployed, uninsured adults likely to gain Medicaid coverage if their state adopted the Medicaid expansion. It found that 29 percent were taking care of a family member, 20 percent were looking for work, 18 percent were in school, 17 percent were ill or disabled, and 10 percent were retired.

Maybe we really are halfway there.

“…the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped. “ ~ Last Speech of Hubert H. Humphrey

When people think of Qbamacare, they think of the insurance aspect. A lot of the law, however, was  designed to deal with a health care system in crisis. No aspect of our healthcare system was more in crisis than the care of our seriously mentally ill. One reason is a lack of private insurance (many folks with serious mental illness can’t hold down steady jobs, which is how America distributes its private health care dollars). Secondly, if these folks had coverage it tended to be Medicaid, and Medicaid is known to be a poor payer, so poor that many general med-surg hospitals closed their in-patient psychiatric units in an effort to limit their “exposure.” Thirdly, through a quirk in the Medicaid enabling legislation, freestanding psychiatric hospitals were not allowed to bill Medicaid for services even if the folks were admitted to their hospital. (50 years ago, state and local hospitals provided such care, and Congress did not want to shift that expense to a federal program.)

The Obamacare act was designed to right many wrongs, and included was a effort to fix this problem. In a section called the Medicaid Emergence Funding Demonstration Act, it provided funding to freestanding psychiatric hospitals to:

provide $75 million to the new demonstration to determine whether it will improve access to psychiatric treatment, lower costs, and reduce crowding in general hospital emergency departments (EDs). At the end of the 3-year trial period, the CMS will make recommendations to the US Congress about the feasibility of offering the program nationwide.

Alabama applied for and received funding to do just this and the community mental health center in Mobile (Alta Pointe) took the money and opened many more beds to help relieve the congestion. The next thing that happened following the demonstration in Alabama? The slicing of the state mental health budget by 25% and the closing of acute crisis beds at several state hospitals. Thanks Obama!

The difference between Obamacare and other programs was the inclusion of evaluation and outcome measures in these pilots. This particular program is being looked at and so far has been found wanting.

So what’s the status? CMS reported on MEPD progress at the end of one year in a mandated report to Congress (see CMS Report To Congress On The Evaluation Of The Medicaid Emergency Psychiatric Demonstration). CMS’ endorsement was tepid – it stated it did not have enough data to recommend expanding the demonstration, but that it supported allowing the demonstration to continue through the end of its authorization in 2015.

At a year, though overall hospital costs were down, length of stay was the same, as was the rate of discharge to the home environment. In other words, the care by the measures agreed upon was the same. Anecdotally, though many benefited, in Alabama care delivery was not improved. In the words of a spokesperson from the Alabama Hospital Association:

“Most of the hospitals feel that the number of patients in departments continues to increase and the length of time it takes to get people into beds is increasing,” Blackmon said.

The national evaluators apparently felt that there were more comprehensive ways to provide care, so this program will likely not be reported favorably to congress and will end.

Which brings us to yesterday’s news story. Alta Pointe, which opened a hospital in response and is now the effective state facility of the seriously mental ill in Alabama (though with little state money), has been using this “demonstration” funding to provide services previously paid for by the state. Now that the demonstration is going away, they will likely close their 100 beds, leaving only 34 crisis beds for approximately 2,000,000 people. Congress has an opportunity to pass a stand alone to continue the program but, given the outcome and the mood in congress, this is unlikely. Alabama has the opportunity to replace the money with state dollars. Given that they are looking to cut half a billion from existing programs and didn’t budget for this expense, not likely either. Don’t think the citizens of lower Alabama are in the mood to pony up an extra $2,000,000 annually in donations, either.

In the words of one commenter:

Let’s look for’s isolated sob stories to make our hearts heavy and give in to another tax hike. Nonsense. Cut the programs. Cut the departments. Cut the government in half.

So what will happen? Fortunately, space under the bridges is available and serves the dual purpose of allowing the non-afflicted to get to where they want to go. If it gets too cold, those with serious mental illness can commit crimes. Alabamians are always willing to pay for jail cells..


One of the advantages of living in Alabama (state motto: “We dare to defend our rights” which sounds much less like an angry, red faced person yelling when translated into Latin: Audemus jura nostra defendere) is that others are always more than happy to come here and help us defend our rights. The most recent came in the form of a “essay” from a rights defender in the Arkansas legislature (%uninsured before Obamacare 22%, % after 12%). Senator Bryan King (with help form the Alabama Policy Institute) examined Arkansas’ efforts and has issued a strong warning to us Alabamians. He dared us, at least as much as he could on, to defend our rights. In his assessment, Arkansas did not do so with the following consequences:

1) Arkansas’ leadership was misled into thinking that they were being allowed through waivers to do something state-based, flexible, or innovative, which was, in Senator King’s eyes, untrue. He provides some examples of innovative things Arkansas was not allowed to do. They were not able to make healthcare access a privilege that came only through hard work, for example. They were unable to place burdensome restrictions on Medicaid recipients to force them to chose between medication and food. They were not allowed to arbitrarily identify certain segments of the population as unworthy of health care and deny it to them. This alone—not being able to deny the unworthy access to healthcare—is reason enough to defend our rights.

2) Arkansans are now dis-incented to work. Senator King points out that many Arkansans are sitting around sucking up free health care because if they make over 133 of poverty they will have to pay “thousands” for healthcare (Senator King must not have read the guidelines for premium assistance and cost sharing under ACA, which provides health care very inexpensively to the working poor). Better to spend time in the doctor’s office, I suppose. Keeping those deadbeats out of my office and into a low-paying job with no health coverage is something we should certainly want to continue as a state.

3) We are threatening Arkansas’ safety net for the truly needy. This argument goes something like the way lifeboats are filled on a sinking ship: the Medicaid net is mighty frail, and if more childless adults are added, it will break and all the women and children will fall into the ocean, um, that is, the uninsured void. As Arkansas now manages to get only half of her children vaccinated, the safety net their may actually already be a little frayed. But, none the less, we should aspire to be better (worse?) than Arkansas and decline the expansion. No sense in keeping folks HPV-negative for free, is there?

4) Arkansas opted to not go with the traditional expansion, which cost them more money. This is, per Senator King, is a reason not to expand at all. If we can’t go in a Cadillac, let’s not go at all.

5) Provision of healthcare to the poor already costs states a lot of money (the Senator points out that it is 35% of Alabama’s general fund, not pointing out that the bulk of that money is a provider’s tax that would not be collected if not for Medicaid). Per the Senator, this is a deal breaker.

Governor Bentley has recently appointed a “task force” to identify ways “real ways to make health care accessible and affordable to everyone while also combating the shortage of primary care physicians in 65 or the state’s 67 counties.” I suspect this article was targeted at the members of the task force. Expanding Medicaid would be an important tool to accomplish the governor’s charge. In addition, it would bring 30,700 jobs into the state, shore up the rural (and urban) hospitals, and provide currently uninsured citizens citizens access via the same provider network current Medicaid recipients receive care. Our 15% uninsurance rate post-Obamacare would be reduced to about 7% if we were to accept the expansion. Yeah, but you say, where does that money come from? Obamacare, as expertly explained by Dr David Bronner, takes the money states were already getting to take care of their poor (disproportionate share funds) and moves it into the Medicaid expansion program. If you don’t take the expansion, you no longer get those funds. In our case, the $14 million/year that used to come to us is going somewhere else.

Fittingly, the state motto was taken from  the poem “What constitutes a State?” written about the Gordon Riots in England. Adopted by Alabama in 1939, the rest of the line is as follows:

Men, who their duties know,

But know their rights, and, knowing, dare maintain,

Prevent the long-aimed blow,

And crush the tyrant while they rend the chain:

Wonder in this case, if our elected officials choose to deny Alabamians access to healthcare, who the tyrant is?




Obamacare is 5 years old this past week. There have been many articles (such as this one on the economics of the lack of death panels and this one on how Obamacare zombie day never arrived). There are two very interesting articles that offer a fuller accounting of what Obamacare has accomplished.

The first was published in Medscape, an industry publication that goes mainly to physicians (thanks to our librarian Jie Li for calling it to my attention). Using a “by the numbers” approach, it shows how much has changed in 5 years. Some of the more interesting numbers:

37.2 million: Number of Americans who were uninsured in the first 9 months of 2014, a decrease of 23% from 2010, when the ACA was passed.

2.3 million: Number of young adults who gained coverage from 2010 through September 2013 by staying on their parents’ health insurance plan up to age 26 years

30,700: Jobs that Alabama would have gained each year through 2020 if it had expanded its Medicaid program.

900,000: Number of Americans whose individual or employer-sponsored health policies were cancelled for 2015 because they did not comply with the ACA.

$7.4 billion: Drop in uncompensated care for hospitals nationwide in 2014 resulting from ACA exchange coverage and Medicaid expansion.

87%: Percentage of 2015 enrollees in ACA exchange plans in the 37 states using who receive a premium subsidy in the form of a tax credit.

$3960: Average premium subsidy (annual) in 2015.

$15 billion: Amount saved so far by 9 million Medicare beneficiaries receiving prescription drugs as a result of the law’s shrinkage of the infamous Part D “doughnut hole.”

Yeah, you say, but at what cost? Turns out, less than government was paying before:


The second article of interest is a “fact check” on a statement President Obama made while celebrating the anniversary of the signing of the bill:

The Affordable Care Act is “a major reason why we’ve seen 50,000 fewer preventable patient deaths in hospitals.”

To make a long story short, the answer is that this statement is correct and is the consequence of the improvements in quality dictated by the ACA.

The question has to be why only a 41% approval after 5 years when it is reducing costs and improving quality? Maybe people are disappointed that the death panels are working in reverse?

26%/12%: Percentages of Republicans and Democrats, respectively, who said in March 2015 that an ACA government panel helps make decisions about patients’ end-of-life care. As in a “death panel.”


“As you may know, a health reform bill was signed into law in 2010. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it?” (Kaiser Family Foundation tracking poll question)

The Affordable Care Act was signed into law in 2010. Most of its controversial provisions were delayed for 2-4 years, partly to allow the taxes to pay for the subsidies to ramp up and partly, I suspect, to put some distance between the passage of the law and the reelection of the lawmakers. The distance aspect was not nearly as successful as it could have been, as many folks developed a deep and persistent hatred for the law. Kaiser Family Foundation, a non-partisan group focused on health care access, has tracked public opinion since the law was signed. In April 2010, 46% of Americans viewed the law favorably, 42% unfavorably and 14% had no opinion. In March 2015, favorables have gone down to 41% and unfavorables have stayed roughly the same. In other words, opinion has not changed much in the past 5 years.

Part of the reason that people are ambivalent is that until they approach mid-life, their interactions with the health care system are limited. Half of all Americans spend less than $300 annually on health care. Basically, some folks may have noticed that their contraceptive method was a little cheaper (thanks, Obama) and some may have noticed a higher co-pay for their once a year visit for allergy symptoms (thanks A LOT, Obama). Once people hit 65, they are in the Medicare system. This system is being affected by changes in care delivery but not in a way noticeable to the average consumer. Even so, 46% of those over 65 view the law in an unfavorable light. (What, Medicare doesn’t pay for Viagra? THANKS FOR NOTHING, Obama).

Many changes in health care were put into motion prior to the passage of the ACA. These include efforts to improve Medicare quality (Bush), improved access through better funded community health centers (Clinton, Bush) and money for better health care information technology (Obama). With the ramp up to ObamaCare being several years, almost anything that folks notice that is different from when they previously sought care (What, no cough syrup for babies anymore? Damn you Obama!!!) is blamed on Obama.

This brings me to the story of my friend, John Waits. He is a rural family physician who lives in Centreville, Alabama. He has a wife, several (I believe 5) children, and a passion for rural medicine and for his adopted home town. I have known John for about 10 years, and he has consistently wanted to bring training to rural Alabama. Through a combination of a Bush administration program designed to improve access for the poor (expansion of community health centers) and a program included in the ACA designed to take money away from large hospitals and move it into communities where it can do the most good (Teaching Health Centers) he was able to do just that. Although the funding was through the ACA, the idea, like many included in the law, was much older and was a bipartisan idea.

The funding for the teaching health center side needs to be renewed, and so John has been speaking out a bit. Not calling attention to our lack of Medicaid expansion. Not calling attention to the fact that we only have one statewide insurer so no real competition. Simply asking our delegation to pull the Teaching Health Center idea from the ACA and make it a separate idea to allow him to continue to train doctors for rural Alabama, in rural Alabama. posted a nice story about it.

Someone forwarded me the story, so I sent John a congratulatory email: subject line, IGNORE THE COMMENTS. There are now 230 comments on the article at The commenters are projecting what they believe about the ACA onto poor John’s program, including at least one former patient who will not see him OR ANY DOCTOR whose boss is the “gummint.”

The lesson for all of us, I suppose, is to be like John and keep on trying to do the right thing. Read more about Teaching Health Centers (here is a place to start). Call your representative and ask for the Teaching Health Center program to be continued (it is currenty in the SGR repeal bill stalled in the Senate). Mostly, be like John and do the right thing even at some personal cost. And always: ignore the comments.



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