'I would've retired years ago but I forgot where I work.'

My mother: Oh, there are some people in this place you wouldn’t believe. They don’t even know where the are

Me: Well, in Alabama, they could’t be there at all. If your memory slips to bad, you are considered too sick for assisted living and have to be moved out.

My mother: Well that makes sense.

Me: No, back to independent living. It is illegal to provide assisted living those with memory problems in Alabama

My mom and dad moved from Louisiana to Marietta Georgia after The Storm (on the Gulf Coast we now date everything by August 29, 2005. That’s the day Katrina made landfall in Louisiana). They were in Baton Rouge and were in their late 70s when the storm hit. They had their own home and could drive without too much effort to get necessary items and run routine errands. They had lived in their house for 53 years and were comfortable.

Post Katrina, their lives changed substantially. Baton Rouge almost doubled in size from the influx of New Orleans refugees. What was a simple chore (driving to the store) became a nightmare of left turns into rapidly moving oncoming traffic unimpeded by traffic lights. They were older people living in a first ring suburb in the sunbelt south. If you were older with failing reflexes you had to make the best of it. Without a car there was no food, no doctor, no post office.

They moved into an independent living community for older individuals in Marietta (by my sister). It is like what my kids used to call a college “wonder dorm,” only for older folk. Separate apartments, common areas for dining and socializing. Difference is that in college the turnover is dictated by the ebb and flow of college life. At the facility my folks are in, folks tend to stay. They stay, that is, until they lose their independence or they pass away. On my weekly phone calls I hear tales of which person is losing touch with reality. “Mr Soandso is grabbing everyone.” I’ll hear one week then two weeks later “Remember Mr Soandso, well they had to take him away.” Ambulances are a regular occurrence with the inevitable return of the resident just a little less functional than before he or she left. If only a little confused when they leave, they are a lot confused when they return. Soon, they are removed to another facility. My folks can’t help but wonder when the inevitable will catch up with them as well as they notice their memory slipping with age.

Why have we not come up with a better way? As I told my parents, in Alabama it is even worse because, with any type of dementia, regular assisted living is out. Alabamians have to move into a “specialty care assisted living.” There are only about 300 of those in the state with a total of 3000 beds. To quote a recent article:

The quality of care can vary significantly from one facility to another. The best assisted living facilities provide comfortable and healthy homes for patients in early and moderate stages of physical and mental decline. But inspection reports reveal that many fail to adequately staff facilities and train workers caring for patients – leading to falls, errors, abuse and even death.

In Alabama, we have 89,000 people living with dementia. With only 3000 beds, what happens to the rest of these folks? Some are admitted to the nursing home, losing their independence prematurely. In fact, the Alabama Medicaid crisis is precipitated in part by the $808 million spent annually on dementia care (about 20% of the budget). Most are cared for at home by a “volunteer” caregiver. In Alabama it is projected that 302,000 caregivers provide care for these folks. This is $4 billion of unpaid care with a huge toll on the caregiver’s health.

The baby boomers changed our society. We embraced the car. We became much more mobile. Little remained untouched. Boomers are now hitting their seventies. Inevitably they will lose their independence. Inevitably, many will lose their cognitive functions. Will they (and their caregiver children) demand better care for those who are aging out? For my sake I hope so.

Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:


So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims.  The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

  • Clinton
    • supports policies to maintain and build upon the ACA.
    • increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
    • fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.
    • make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
    • invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
    • authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
    • proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
    • proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
  • Trump
    • complete repeal of the ACA, including the individual mandate to have coverage.
    • create high risk pools for individuals who have not maintained continuous coverage.
    • provide a tax deduction for the purchase of individual health insurance.
    • promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
    • promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
    • would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

  • Clinton
    • encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
    • would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
  • Trump
    • supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
    • would cover the low-income uninsured through Medicaid after repealing the ACA.
      • The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

  • Clinton
    • supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
    • supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
    • does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.
    • proposed to allow people ages 55 to 64 to buy into Medicare.
  • Trump
    • No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
    • supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.
    • supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

  • Clinton
    • proposes prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry
    • increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
    • reducing the market exclusivity period for biologics
    • and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
    • proposes to establish consumer oversight in federal agencies
    • penalize drug companies for unjustified price increases
    • allow importation of lower-cost drugs from countries with similar safety standards.
    • She also supports eliminating tax deductions for direct-to-consumer advertising
    • requiring FDA approval of advertisements
    • tying federal support for drug companies to their investment in R&D
    • increasing transparency of the additional value new drugs have over existing treatments
    • allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
    • proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
  • Trump
    • supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
    • supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

  • Clinton
    • released a $10 billion (over ten years) plan to fight drug addiction.
      • includes a federal-state partnership to support education and mentoring programs
      • development of treatment facilities and programs
      • efforts to change prescribing practices, and criminal justice reform.
      • direct federal action to increase funding for treatment programs
      • change federal rules regarding prescribing practices
      • enforce federal parity standards
      • promote best practices for insurance coverage of substance use disorder services
      • issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
  • Trump
    • Will build a wall on the U.S.-Mexican border
      • will help stop the flow of drugs and thus address the opioid epidemic.

Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services

  • Clinton
    • supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.
    • defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.
    • would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
  • Trump
    • called for defunding Planned Parenthood if they continue to provide abortion
    • He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
      • has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
    • would also work to make the Hyde Amendment permanent law
    • would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
    • would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.




As a family physician, one of the more fun conditions for me to care for is pregnancy, childbirth, and the well child checkups that follow.

I meet women at the start of their pregnancies and learn a little about their lives beyond their pregnant “condition.” I see them every month for a long stretch, meeting mothers, mothers-in-law, friends, and husbands along the way. As things progress I see them every two weeks, and then weekly.

By the time the weekly visits occur I find out what my patients are made of – and they get to know me, as well. Mama is very pregnant, and my job is to convince her that every day inside, even past the mythical due date, is good for the baby. I then get to witness the miracle of childbirth (and occasionally play a larger role).

In my practice, mother and baby come back to visit weekly, monthly, and then annually as the children reach toddlerhood. We continue to have conversations around the new family and the transitions up until the age of three.  After that, if the child is well, we are limited to an annual “Hi, how are you doing?” For the most part, they are moving on with their lives as a young family and fortunately do not need my help. In the words of the Lone Ranger,”My work here is done.”

However, it isn’t quite as easy as that. Doctoring is a funny gig when it comes to personal relationships. I’m sure there are others just as funny, dentistry probably being one. I see these folks back for a visit after a couple of years, or at a community activity, or elsewhere in Mobile and surrounds, and the mothers will proudly say to their (very embarrassed) twelve-year-old,  “There’s the first person who ever saw you.” We’ll make some small talk — what do you say to a twelve year old after nine years? — and typically the mother will ask about my family and my kids.

Because, as it turns out, while they were sharing a part of their story with me, I was sharing a little of my story with them. I used my children as examples for feeding and discipline problem-solving, as both good and bad examples. I discussed my wife’s meal-time solutions for feeding grown-ups and kids at the same table. In other words, I shared with them as they were sharing with me. A little piece of my version of how we put our kids to bed has entered into the bedtime strategy of many of the families that I have cared for. If “Good Night Moon” did become a successful part of their ritual, I hope they think of Dr. Perkins in a really good way (after the toddler is actually asleep, of course).

I don’t get to care for a lot of young families any more, given my other duties, but I do still see folks that I have cared for over the last twenty years, people with whom I have shared family anecdotes in this manner in the hope of leading them to better health.

It has been six months since my wife’s death. Many of my patients, coming in for a variety of reasons, or running into me around Mobile, have wanted me to know that they are here for me just as I, and our family, and some of my
wife’s child-rearing strategies, were there for them. It has meant a great deal to me.

Nurse: Dr Perkins, Mr Smith called. He said he called his insurance company and they told him that if YOU will fill out the form saying he REALLY needs the Lantus insulin, they will pay for it.

Me: I have filled out that form. That insulin is Tier 2 on his insurance. It isn’t that they won’t pay, it’s that he has to pay 50% of the cost until he reaches his maximum which is $7,000 in a year.

Nurse: He won’t like that.

Me: (exasperated) Have him call President Obama. Or, if he’d prefer, give him George W Bush’s number.

Prior to 2006, people on Medicare did not have prescription cover. Folks on Medicare would be discharged from the hospital after their congestive heart failure was made better through diuresis only to go home to a Lasix free household and re-accumulate fluid. Predictably, within the next several weeks the patient would be back again, drowning in their own fluids. We would try to cobble together enough samples and inexpensive generics to keep these folks out of the hospital. Another strategy was to talk them out of eating so they could afford the “good” medications.

In 2003, as part of the Medicare Modernization Act, Medicare Part D was created. The law, rather than directing Medicare to negotiate with the drug companies directly, created opportunities for private companies to “compete” for patients and to negotiate with drug companies. While not ideal, for the first 10 years it worked pretty well. My patients were able to get necessary drugs (with an emphasis on generics) for relatively reasonable prices.  Part D Providers were required to have drugs in each of the therapeutic classes making care relatively straightforward. Patients with congestive heart failure could be on the medicines necessary to avoid readmissions. Pharmacies were reimbursed for their services and pharmacists were elevated to part of the care team.

The design of the benefit was a little different from that of traditional medical pharmacy benefits. Instead of non-specific co-pays, the design included “tiering” (having a group of drugs that has low out-of-pocket costs and another group that is typically equivalent and name brand but less cheap) and included the concept of co-insurance (instead of paying a flat $25 co-pay, one might pay 25%-50% of the costs) for the so-called specialty drugs. At relatively high level, the out-of-pocket costs were capped which protected the patient to an extent but only after about $7,000 had been paid. The law dictates that only the Part D Providers may negotiate and that the federal government is directly prohibited from doing so. The patient, as is alway the case, doesn’t get to negotiate with anyone.

After 10 years of flat growth, the costs of drug benefits are rapidly escalating. This is being passed on to the consumers. The reasons are several fold. First, number of specialty (Tier 4) drugs have increased from 20 to 200. These drugs typically require coinsurance and thus result in  a lot of the out-of-pocket increase. One pill of a new cancer drug might cost $1000 and might cost the patient $500 until his or her deductible is reached, typically at about $5,000. Second, a number of plans have moved drugs formerly covered under a co-pay into a tier requiring coinsurance.  Approximately 60% of Medicare beneficiaries are in plans that have had common drugs such as Crestor and long-acting insulin moved into a tier where coinsurance used instead of a co-pay. The law does not set limits on coinsurance and some of the rates are as high as 50%.  Lastly generic drugs, which used to require the lowest co-pay, are being priced much higher and are being placed in co-insurance tiers by insurance companies.

This increase in prescription costs is not limited to Medicare beneficiaries. Many people with high deductible “bronze” plans purchased (family deductible about $12,000) on the exchanges are noticing the same thing. The EpiPen controversy, in part, is a consequence of people moving to these higher deductible plans without looking into exactly how the savings in premium might translate into increased out-of-pocket costs. In fairness to patients, having spent some time trying to figure out what the out-of-pocket cost might be for an EpiPen under a given insurance, I do not blame them for being confused.

What should our response be? Over 70% of Republicans and 90% of Democrats feel that the government should be directly involved in price negotiations, at least for Medicare. If not directly, similar rebates to those given to Medicaid would potentially lower costs for all consumers.  Lastly, patients can ask for substitute medications rather than use those that require significant out-of-pocket outlay. For the EpiPen, where the manufacturer has been “ruthless in fending off competition and in getting support for its predatory pricing practices, including within the US and the EU” it may not be possible but for others it never hurts to ask.

Over half of all Americans pay under $400 annually for out-of-pocket medical costs of all types and many pay nothing. As health economist Uwe Rheinhart pointed out last week, we need to get everyone engaged in the health system  to create the political will to fix it.  We can accomplish this by strengthening the penalties for non-participation so that  everyone will be affected. Or we need to get over this notion that everyone deserves access to healthcare and only the rich should be protected at all times from anaphylaxis. After all, J. Wellington Wimpy didn’t get a hamburger every time he asked.



Are you going to provide free clinics for sick underprivileged children? Will you do in Alabama what you do on mission trips to other states and countries?

Senator Jim McClendon, explaining why he is sponsoring not one but TWO lottery bills

The legislature in Alabama is meeting in special session starting today to see if they can find more money for the General Fund budget. The budget passed in the regular session was about $100 million short for what was needed to maintain the Medicaid program at its current bare bones level. Medicaid and corrections are the major programs funded by this complicated and convoluted budget process and, as you can imagine, the constituency tends to be silent. The legislature comes back into special session today to determine whether Alabama will become the first state to reduce Medicaid funding below the threshold required for the match.The funding possibilities are as follows:

  1. Governor Bentley’s proposal- a $225 million lottery, with proceeds going to the General Fund. Would require constitutional amendment. Money not available for about a year.
  2. Jim McClendon’s bill, which would include electronic lottery machines in four counties – Greene, Jefferson, Macon and Mobile – with a bond issue to pay for Medicaid in the coming year. Would require constitutional amendment.
  3. House Minority Leader Craig Ford, D-Gadsden, said he’ll bring a lottery-only bill that would set aside lottery proceeds for education. Another Ford bill would include casino gambling as well.  Would require constitutional amendment. Money not available for about a year.
  4. The legislature may create a compact with the Poarch Creeks, allowing them to offer more types of gambling in exchange for an annual fee or a cut of the proceeds. Critics worry that under federal gaming regulations, a lottery could open the door to Creek expansion without a compact. Unclear how this would work. Likely would draw a lot of attention form the feds.
  5. They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
  6. They may, and possibly will, do nothing and allow Medicaid to become a non-compliant program

If they fail to act. the feds will do one of two things. Because the program’s recipients are disproportionately poor and of color, the feds may sue under the Fourteenth Amendment and require us to find $100 million to maintain a $6 billion program, maintain access to healthcare for ALL Alabamians, and not force the layoffs of tens of thousands of individuals who work in healthcare. Conversely, the Supreme Court has ruled that Medicaid is an optional program. The feds may just allow us to opt out and allow our natural experiment to continue. Let’s see how many folks will come to Alabama instead of Ecuador for mission work.


I will be appearing at a press conference on Friday, August 5th as a representative of the Alabama Academy of Family Physicians. Beside me will be representatives from the Alabama Academy of Pediatrics, the Alabama Hospital Association, and the community. We will share the following message. This message is being shared in across the state in a series of press conferences beginning Monday:

On August 1st (tomorrow), Alabama begins applying cuts to the state’s Medicaid system that will impact the quality of care all Alabamians receive. In Alabama, Medicaid:

  • Provides health coverage for eligible children, pregnant women, and severely disabled and impoverished adults
    • About 1 million Alabamians
    • More than half the births in Alabama
    • About 47 percent of Alabama’s children
    • About 60 percent of Alabama’s nursing home residents

These cuts are devastating and dangerous. Because Alabama already operates a bare bones program, the following will occur:

  • Reduction of payments per visit to primary care physicians by 50% beginning tomorrow
  • Reduction of reimbursement rates for ambulatory surgical centers, all other specialty physicians, dentists, optometry, hearing and other programs
  • Elimination of the prescription drug coverage for adults for the first time
  • Elimination of adult eyeglasses
  • Elimination of outpatient dialysis
  • Elimination of prosthetics and orthotics
  • Elimination of Health Home and Physician case management fees
  • Consideration of a pharmacy preferred provider program

As a result of the Medicaid cuts put in place August 1, my colleagues in primary care are being put between a rock and hard place. Medicaid rates will not cover the cost of keeping the practice open. My primary care colleagues will either accept fewer Medicaid patients, limit the number of office locations, lay off staff – including nurses and other clinical staff. In some cases they will make the very tough decision of closing their practice and moving to a state that has a more hospitable practice environment.

So what? Turns out primary care doctors are the economic engines of small communities and provide economic vitality to all communities.  Combined, we support 83,095 jobs and generating $11.2 billion in economic activity, according to a report by the Medical Association and the American Medical Association. Specifically:

  • Jobs: Each physician supported an average of 9.5 jobs, including his/her own, and contributed to a total of 83,095 jobs statewide.
  • Output: Each physician supported an average of $1.3 million in economic output and contributed to a total of $11.2 billion in economic output statewide.
  • Wages and Benefits: Each physician supported an average of $758,744 in total wages and benefits and contributed to a total of $6.7 billion in wages and benefits statewide.
  • Tax Revenues: Each physician supported $46,148 in local and state tax revenues and contributed to a total of $404.9 million in local and state tax revenues statewide.

When these cuts take effect, doctors will leave. Consequently it much more difficult for any patient in the state – including those on private insurance like Blue Cross/Blue Shield – to make an appointment with a doctor of their choice at a time convenient for their schedule. Jobs will leave these towns, towns will die.

Isn’t Medicaid full of fraud? Turns out, not. In fact state lawmakers recently conducted an extensive review of Medicaid’s funding and operations. Our program is one of the most frugal health plans available.

What needs to happen? In order to protect the state’s fragile healthcare system from collapse and ensure that all Alabamians have access to the doctor of their choice, legislators must find a long-term, sustainable solution to fund Medicaid, and shore up funding for the coming year.

How can you help?  Visit IamMedicaid.com  for more information and go HERE to contact state leaders to let them know how you feel.  Encourage them to protect Alabama’s healthcare system by fully funding Alabama Medicaid. Let them know that you are concerned and you vote!

“Trade, we are going to fix it; health care, we are going to fix it; women’s health issues, we are going to fix it,” Trump said.

Mobile, Alabama August 21, 2015

I was in of of the 30,000 (well, more like 15,000) people in stands at Ladd-Peebles stadium when Donald Trump announced his health care position. My late wife Danielle Juzan live-tweeted the rally as well.Whatever was wrong, he said, he would fix it.

My friend Josh Freeman just posted a blog where he cites the JAMA article written by President Obama to detail the successes and failures of the Affordable Care Act (now in year 6 of being enacted and year 4 of implementation). Bottom line, in those states that have expanded Medicaid, poor much better off. In all states, health insurance for those working still too expensive. In all states, quality of care is beginning to improve. It is widely assumed that a Clinton/Kaine administration will work to strengthen the gains made through Obamacare.

Trump declined to explain how he would lower insurance costs (other than saying “more competition”), but he did specify how he would deal with those who lack insurance. He said that the government would negotiate with hospitals to cover the uninsured.

60 minutes, September 27, 2015

In the evolution of Donald Trump’s health care policy, he has transitioned from universal coverage. As a business man with interests in many countries, he has seen the impact of more healthcare delivery in countries such as Scotland and has admired the ease and efficiency of care. In one of the debates, in fact, he expressed his admiration for other country’s care delivery.  “As far as single payer, it works in Canada. It works incredibly well in Scotland.”

“We will repeal and replace disastrous Obamacare,” Trump said. “You will be able to choose your own doctor again.”

Donald J Trump’s acceptance speech, Republican National Convention

Upon wrapping up the nomination, the Trump campaign fleshed out his healthcare position (found here). Aside from “repeal and replace with something terrific” the plan is a little light on specifics. However, as this is a presidential candidate and we have to assume he has a shot at being elected, I feel compelled to analyze his stated position on how almost 20% of the GDP will be managed and 25% of our tax dollars will be spent. The key points are as follows:

  • Want universal coverage? The Trump position is to eliminate the mandate BUT keep the pre-existing condition coverage. Policy analysts are a little confused about how this would impact the care delivery system.
  • Like a bare bones policy? Trump proposes eliminated limits on intrastate policy sales. So your company might buy your insurance but there may be no local care delivery options, so you might have to drive to Delaware for care.Now THAT would be bare bones.
  • Allow deductions of premiums from income taxes and use of a healthcare savings account. A nice position to take if you want the vote of young, healthy people. As most chronically ill people make very little money and spend a lot on healthcare, this does not benefit those who are sick.
  • Require price transparency. Now this one, I can get behind. Check out health care blue book, kinda coming anyway.
  • Block grant Medicaid. Theory is “States know how to use the money best.” Bill Clinton did this with “welfare” (actually cash payments known as TANF) in the 1990s. The outcome? Total money available was reduced and less money was spent on child care (increasing the penalty to working parents who needed assistance). In fact, half of the money the federal government sent for TANF-like programs went for things like middle class tuition reimbursement.
  • Allow people to negotiate with foreign drug companies. This started out as “Medicare ought to negotiate for lower drug prices” but has ended up “feel free to mail order drugs from Canada.” Kinda odd how our negotiator-in-chief let that happen.

Should make for an interesting debate.



I grew up in Baton Rouge, Louisiana. My parents moved there in 1959 so my father could go to graduate school at LSU. After a couple of non-academic jobs my father took a job at LSU in academia and we moved to an area near campus. So near, in fact, that on Saturday night I could see the glow from the lights at Tiger Stadium. The Baton Rouge I knew was mostly college professors and their kids and mostly “white” although my neighborhood had it’s share of brown and black college professors kids. The schools I attended were good schools. The Baton Rouge I knew was a good place to grow up.

I looked at Google Maps to try to get my bearings and determine if I knew the area where Alton Sterling was shot. I realized that though I didn’t know the area, I KNEW the area. Some auto repair stores, several convenience food stores, a dialysis center, and a couple of cell phone shops. The area is over 80% minority and has lost 10% of its population in the past 10 years. The median household income is less than 50% that of the Louisiana average and Louisiana is a poor state. I suspect you have driven through this area as well. Often by accident. Checking the door locks to make sure the doors are secured.

Race is a funny thing. The construct of race dates from the 1700s and, though there is some controversy, seems to be more tied to a desire to boost folks of certain color or ethnic make-up than to be a clarifying concept with any basis in science. Though life expectancy clearly does track with self identified race, many “whites” have African ancestors and many “african-americans” have more native American than African ancestry. Some point to sickle cell disease as evidence of a racial component of disease but the disorder clearly  tracks with factors other than black skin color.

A better construct is this study,  reported by Vox last year. Instead of being a dichotomous variable (black-white) or even a categorical variable (race is now often sorted into as many as eight categories, including “two or more”) the investigators suggested that how you self-identify your  “race” is actually a compilation of attributes that include skin color and genetics but also include such attributes as religion, social-status, power relationships, and dialect. Instead of being assigned at conception, race becomes a more dynamic construct. Other research identifies the act of ANTICIPATING being a victim of racism is clearly harmful to the health of the victim, regardless of any objective, “scientific” status of the victims “race.”

None of this brings back Alton Sterling. If, however, we could stop seeing things in the South as “black-white” maybe we could make some progress. Once we do that, here are some other things to work on:

  • Improve public transportation
  • Acknowledge that access to healthcare is a right
  • Hire public servants who are of the community and train them appropriately.
  • Demilitarize the police force.
  • Disarm the citizenry.
  • Stop being scared of “the other” because they live in poverty
  • Most importantly, stop making the poor and disenfranchised the victims of our fear.


  1. Ebola
  2. 9/11
  3. Stealing grease
  4. Batman and Robin “Ice to meet you”
  5. The lemon tree theft
  6. Farmville
  7. Miley Cyrus’ “Wrecking ball”
  8. GMO tomato-nicotine hybrid
  9. Horse meat in commercial food
  10. Donald Trump’s presidential run

10 things predicted by the Simpson’s before they became “a thing”

There is a running gag over several years in “The Simpsons” television show about series of movies which included an action hero named “McBain.” Loosely based on a combination of Bruce Willis and Arnold Schwarzenegger, in the movies McBain’s nemesis is Senator Mendoza from some unnamed Central or South American 1980s drug cartel country. In one of the most “haunting” scenes, McBain’s long-term partner is shot as he is outlining his plans for retirement. In fact,he actually takes a bullet intended for McBain while showing a picture of his recently purchased retirement boat, aptly named ” Live-4-ever.”  McBain is shown holding the body of his fallen comrade, crying out “MEEEENNNDDOOZZAAA!!!!”

Federally Qualified Health Centers (FQHCs) have been around since the 1960s. They were modeled on a South African system for effective care delivery to the disenfranchised. One of the first was started not too far from me in Mound Bayou, Mississippi.

The health center model that emerged targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics in both rural and urban areas around America. It was a formula that not only empowered communities to establish and direct health services at the local level via consumer-majority governing boards, but also generated compelling proof that affordable and accessible healthcare produced compounding benefits.

Over the years the federal funding has been generous, though much of the funding comes from patient generated revenue (money for seeing patients).  The Centers are also eligible for grant money for facility development, staffing increases, and offsets for seeing the uninsured among other things. The funding streams vary quite a bit from state to state, with those in Alabama being more heavily reliant on federal grants and less so on patient care. Legislators loved them because they put money in local, impoverished areas. Republicans in particular loved them because of the “block grant” nature of the funding. The local folks were best able, so the saying went, to determine where the money could best be spent.

One of the goals of the  Affordable Care Act was to move the money from direct funding programs into programs where the money followed the patient. It was hoped that this would give patients incentives to seek more effective care. It clearly would cut down on shenanigans such as this criminal case in Birmingham where the CEO bought a building, leased it back to the FQHC, videotaped his assistant in compromising positions, and made off with $14 million of federal money. As outlined in an article today, this money was money NOT used to deliver care to homeless individuals, poor folks, and others in need for whom it was intended. In fact, though they were receiving money to care for the homeless, they created barriers of transportation and distance to keep the poor, sick folks away. This money then made its way to the CEO’s pocket.

The ACA, as designed, would allow all the poor, including the homeless, to use Medicaid for their healthcare needs. This would allow a patient to identify the best care for his or her situation. We, in Alabama, have chosen not to accept the law as designed. Instead we have allowed it to be implemented  in a manner inconsistent with the design. We allow those in charge of implementing the law at the state level as well as those in charge of local care delivery to siphon money off. Then, when the system fails, we shake our fists at the clouds and blame Obama.


Q: How many magicians does it take to change a light bulb?
A: Depends on what you want to change it into.

Turns out, weekends are especially hard. On weekdays, I would get up, do chores (mostly dog and chicken related), go to work, then come home. Either Danielle would have supper ready or, increasingly, we would go out because it was too much hassle cooking for two. Then I would settle down to do a little work and Danielle would do her thing until it was time for bed. Our days would overlap mostly at supper. The weekends, though, would be when we did OUR thing.

Danielle: Remember, tonight is Art Walk Friday

Me: Ok, but I’ll be about 6 because I have patients

Danielle: Well don’t be late because we’re meeting folks at the Bike Shop for dinner at 7:30 and I have to see the show at the Skinny Gallery. And then tomorrow we have to go to the symphony, and then…

Even on days like this when I was on call, we would carefully plan our trips and errands around my rounding schedule.

Now I have had to change my weekend routine.  Change, as they say, is inevitable.

Q: How many Marxists does it take to change a light bulb?
A: None. The light bulb contains the seeds of its own revolution.

Ranking things seems to be the new “news.” Almost everyone has put together a list of best and worst based on some criteria or another. My kids tell me these are called listicles. having the list without information in the title, so I understand, encourages folks to “click” ensuring more ad revenue. USA Today’s offering today was “The least healthy cities in America.” As everyone in America clicked to find out how their city fared, we in Mobile were (dis)honored to be #4:

4. Mobile, Ala.
>Premature death rate:
 490.3 per 100,000
> Adult obesity rate: 36.1%
> Pct. adults without health insurance: 12.9%
> Poverty rate: 19.9%

The average Mobile adult feels in poor mental shape for five days a month on average, far longer than the 3.5 days the average American feels in such a state. Poor mental health outcomes in Mobile may be tied to multiple unhealthy behavioral and socioeconomic factors in the area.

Mobile’s 36.1% obesity rate and 29.6% inactivity rate are both far higher than the corresponding national figures. Additionally, nearly one-fifth of area residents live in poverty, and 7.0% of the workforce is unemployed, each some of the highest such figures in the country.

Wow. For those with a memory for these things, in 2013 Business Insider tagged us the 3rd most miserable city in 2013. At the time I pointed out

The results of that survey, Perkins said, made it clear that Mobilians suffer from poor mental and physical health in large part because the city’s built environment is not conducive to being active. Access to healthy foods in poor neighborhoods is also poor, he said.

If Mobile wants to work its way off these lists, it’ll take change (see figure). We’ll need to invest in infrastructure  such as parks and bike lanes so people make healthier choices. Increase the minimum wage so folks have time to use these amenities to get and stay healthy. Expand Medicaid so folks are not one illness away from bankruptcy. Focus our care delivery system on health instead of on making money off of illness. In other words, while change may not be inevitable for Mobilians, it is the only way to get off of these lists.

Or, we could just double down on our football success:


At ALABAMA: It takes five, one to change it, three to reminisce about how The Bear would have done it, and one to throw the old bulb at an NCAA investigator.