When last we left the village (about 2 weeks ago) whose entire existence was to support pulling babies form the stream, a search party had gone upstream to find out where the babies were coming from. Meanwhile there were still babies coming down the stream. As you may remember, a very sophisticated infrastructure had arisen to pull the babies from the stream. The folks who took the lead, the “baby savers,” took their job very seriously and were valued. They often had to jump in and save babies who were coming down or might have to manipulate the equipment to pluck one from the waterfall. As befits their importance, they were paid very well and had an honored place in the village.

The baby savers executive committee, already threatened by the fear that the search party might find where the babies are coming from and put a stop to it, began looking somewhat critically at the entire operation:

Baby saver president: As you know, we have been looking into the “babies in the stream” issue. We have a lot of folks who care a whole lot about babies and have been giving  there time to make sure the babies are pulled safely from the water. However, it seems there is room for improvement.

Village baby saver: What do you mean improvement, we work our butts off.

Village baby saver 2: Yeah, we are up all night. Often I have to jump in. The water is cold.

Baby saver president: Well, we have started to keep track of your work and, to be honest, we are not doing some of the things we should. As you know, we pay you by the baby.

Village baby saver 3: Your point?

Baby saver president: Not to name names, but I think we should have thought through this more carefully. I’m not going to name names, but one of you pulls out a lot of babies. Many of these babies are blue when they come out and the baby resuscitators are complaining. They say you (not to name names) are too rough and push others out of the way so that you can get the most babies.

Village baby saver 2: They are just jealous.

Baby saver president: And one of you, again I’m not naming names, is just too old to do this. Your eyesight is poor and you don’t swim well. The resuscitators have to jump in and grab your babies but then you take credit.

Village baby saver 3: They need to step back and let me do my job.

Baby saver president: I suspect the search party will be successful and there will be many fewer babies going forward. So we are going to start posting how well you do on the wall over there and it may well be that some of you won’t be able to be baby savers any more. From now on, everyone will know how many babies you catch, what percent are blue, and how many went over the waterfall that you should have saved.

Village baby savers (talking at once): wait, that isn’t fair. How is it my problem if they come down too fast? What if more than 2 people are on a shift? I have a wife and kids to feed. Those resuscitators can kiss my…

If you want to see how hospitals do in regards to preventable mortality and certain procedures and use that to pick your hospital, the government’s hospital compare website is for you (go to this site). If you want to see if your hospital or surgeon has an unusual number of complications or just doesn’t do a lot of the procedures that you need, Propublica has a tool that compares individual surgeons (go to this site). If you want to float along and let a random person pull you out of the water and hope they do a good job, enjoy the ride and I hope you avoid the waterfall.

I am heading to Denver to help my friend John Meigs run for President-Elect of the American Academy of Family Physicians. John is an impressive gentleman and has been active in  trying to bring healthcare to all Alabamians. As he so eloquently states:

The premise of family medicine is centered in the value that an ongoing continuous relationship with a trusted family physician brings to an individual and his or her community.  The promise of family medicine is patient centered care that recognizes the value of the individual as well as the benefits to the larger community of true primary care with effective preventive care and chronic disease management.  This makes us the specialty with the potential to reach the underserved and hopefully make a difference in overcoming the barriers and social determinants of health that affect way too many people in a country as prosperous as ours.  The payoff is the triple aim we talk about of better care of higher quality leading to better health.

He will be an outstanding leader for our organization and will help to further our efforts to bring high end primary care to the American public..

John and the Academy by the numbers

120,900 – the number of physicians and students represented by our academy

4891 – the number of people in the town of Brent, Alabama, where John is from and still lives.

2778  – the number of people in Centreville, Alabama, where John practices.

160 – the number of days John is going to have to give up to the cause if he wins

33 – the number of years John has been in practice

26 – the number of years John has been involved with organized medicine

25 – the number of beds at Bibb County Hospital, where John practices

3 – the number of candidates for president-elect

1 – Last quote

At the heart of primary care is the idea that patients should have an ongoing relationship with a family physician they know and trust. I have that kind of relationship with my patients because I’ve lived here most of my life, and I’ve practiced medicine here for more than 30 years.

If you are a delegate, please consider voting for John. Thank you for your support!

'Let's make a quick stop in Vegas and blame it on an unruly passenger.'

Last night we were at a dinner party where I met an honest to goodness professional poker player. I have to admit that I have never met someone who makes money off poker. Living close to Biloxi (home of several casinos) and knowing a lot of smart people I do know folks who count cards in blackjack. These people tend to be regular folks who can keep a running dialogue in their heads that goes something like +1, +1, -1, -1, +1, hit at 18. Folks who like to go to the casinos for entertainment and can count cards tend not to because it take all of the fun out of it. Folks who try to make a living by counting cards get found out and put on a “No Fly” list for gamblers mostly because the house resents them.

This professional gambler didn’t wear fancy clothes or a lot of jewelry. Turns out she could count cards and win at blackjack, but prefers poker because poker is a game of skill and the house tales a cut then lets players play (to coin a phrase). She is even better at online poker which is where my interest was piqued.

Me: So, I would think that on-line poker would be dominated by computers masquerading as real people

Poker-lady: Not so. Computers are actually not very good at poker.

Me: Really. But they are really good at chess

Poker-lady: Chess is a game where all of the elements are known. When a computer loses at chess it can go back and analyze every move, learning from its mistake and not making the same one again. In poker, there is too much uncertainty. The computer doesn’t know the opponents hole card or betting strategy. Computers don’t do well with uncertainty.

Turns out there is one bot (Cepheas) that is now able to hold its own in a type of poker (head-up limit Texas hold-em). This computer will play a single person (head up) and win money over time if the bet size is prescribed (limit). The computer is the work of AI investigators at the University of Alberta who, aside from trying to build their school’s endowment, are interested in solving the “imperfect information” game. Chess is an example of a perfect information game where all players have all information. In poker, everyone has limited information regarding their situation as well as their opponents’ situation. You know what your hole cards are but not your opponents’.

Doctoring, it turns out, is a game of imperfect information. I know what I have prescribed (medications, exercise, less calories) but have to ferret out what my opponent (patient) is holding (But doctor, when I said I only drink water, I meant to say a liter of soda pop. Does that make my sugars higher?). For years, programmers have tried to write code to do what I do and have been unsuccessful. The folks in Alberta are now working with diabetologists to create a program to help with diabetes:

“It turns out that one of the things a doctor does so well is come up with robust [recommendations] … And that’s what our poker programs have to do, they have to be robust to ‘what are the cards my opponent has, and how does my opponent play?’ ”

So, one day I might be able to use the wily computer to help me with my patient who “just can’t get controlled.” For most of my patients now, the flop is hypertension, diabetes, and hyperlipidemia, Until I get a bot, I’m assuming they have non-compliance and a lack of physical activity as their hole card. Does that make me a cardsharp?


Me: This patient was admitted 10 times in the last year. She needs a good doctor to help her use the system better

Resident: Dr Perkins, she goes to the emergency room because she is an addict. And that is when she is taking her psych meds and not hearing the voices. She’ll only take the pain meds and won’t take any medicine for her diabetes or her blood pressure because they are (air quotes) poisoned (air quotes) 

Me: Don’t you want a challenge?

Resident: Her psychiatrist won’t tell us what medicine she is on or even whether or not he is actually seeing her. Claims it violates the (air quotes) doctor-patient  (air quotes) relationship. And don’t get me started about her drug problem. She has been kicked out of every treatment facility within 50 miles and there is ONLY ONE of them that take Medicaid, anyway. 

Me: Don’t you want a challenge?

Resident: Dr Perkins, don’t do this to me. Let me just refill the diabetes medicine that she won’t take…

Medicine in general has not historically functioned effectively outside of the here and now, meaning we try to fix broken people.  There is a parable that is often used to illustrate the problem with this approach, the parable of the babies in the river. In the story a village mobilizes to deal with a crisis (babies are found floating in a river) and the town folk eventually take on saving babies as their purpose. Finally, the story goes, someone suggests going upstream to determine where the babies as being put into the water. Delivering care to those suffering from complex illness in an academic health centers as I do is much like living in that village. We find ourselves pulling people out of the water meanwhile wishing someone could go upstream and fix the problem. Academic medicine has put together a list of things called the Milestones that our doctors should be willing and able to do. One of these suggests that family physicians should be willing to take that walk upstream and stop the babies from being put into the water in the first place.

The most complex patients do not simply need blood pressure and diabetes medications. Those who are “really sick” typically have multiple poorly controlled chronic illnesses, multiple physicians, and expensive care-seeking behaviors, and no primary care because they do not see a reason to add “one more doctor” into the mix. Also these are people who have problems with housing as either they tend to be impoverished from their illness or they suffer from illness as a consequence of their poverty. They lack access to healthy foods because they tend to live in food deserts associated with poor neighborhoods but also tend to require specialized diets that cost more. They also are more likely to have sought and receive disability and so must live on a fixed income. In addition these patients may have suffered from access to an over exuberant healthcare system and suffer the after effects of having had multiple surgeries and having been on multiple medications with serious side effects,

Atul Gawande wrote of a physician who focused on caring for these complex patients (information and link found here). Caring for these complex patients requires practice based resources such as timely access to clinical services and coordination of services, knowledge of community resources such as housing and healthy food, and a clinical quarterback. The payment structure, although changing, has not changed sufficiently to reward practices that “look upstream.” In addition, medical students and residents come from a model where “the here and now” is rewarded both financially and professionally so they are not looking to move “upstream.” For us to get healthier, our doctors need to be able to focus on the stream AND look upstream as well.

In our training site, we are working on create an nurturing and supportive environment that will allow us to care for these patients. Our hope is that we will allow our complex patients to receive better, more effective care.  Our hope is also that it will provide a lab for our students and residents to see that by partnering with the community, providing “non-medical” things such as housing and appropriate dietary information, and improving access to resources they can care for these patients in addition to providing care for the rest of the community. We will start building this “Chronic Disease Medical Home” annex to our patient centered medical home. I will use this space on occasion to  discuss our progress. Wish us luck!

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.



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