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GhostScrooge was better than his word.  He did it all, and infinitely more; and to Tiny Tim, who did not die, he was a second father.

Charles Dickens, A Christmas Carol

The Governor awoke at midnight on January 1, the first full day of Obamacare and shivered. He knew that people who did not deserve healthcare would be getting it starting now. He could hear the clock chiming the quarter hour in the mansion and suddenly felt a cool chill. “Jefferson Davis, you leave me alone” he said.

“I am not Jefferson Davis, I am the ghost of healthcare past”


“No, YOUR healthcare past. Come”

They wonder into a Birmingham that no longer exists and saw the poor in the University Hospital. The Governor pointed to them and said to the ghost “see how well they are cared for. Most could not pay for their care and yet we cared for them as if they were our own family.”

The Ghost says “If they were fortunate enough to get here, you provided care, sure. In exchange they gave you their bodies for you to practice on. Is that a good trade off? Marion Simms, one of your fellow Alabamians practiced on slaves without anesthesia so he could repair white women with anesth…”

“Hold on a minute, I thought you said this was MY past”

“Point taken…”

The Governor was silent. He saw poor people in open wards with wounds that will never heal because of poor nutrition. He saw medical students doing operations with no supervision. He saw people dying of pneumonia because they were placed on the wrong antibiotics.

“Enough. I don’t like this. I went into dermatology for a reason.”

They then wondered over to Tuscaloosa.”Hey,” said the Governor,”there’s my old practice. Never needed to take insurance and sure had no call for them gummit programs. I’d see patients for free if they needed my care”

The ghost held up a web page “This says your practice takes Medicare, Medicaid, Humana Military, and Tricare. Aren’t those “gummit” programs?”

“Point taken”

They go to the Druid City Emergency Rooom and see a person with an obvious skin cancer who is uninsured being told that he’ll need to bring $400 to have his dermatologic surgery in Tuscaloosa or else drive to the residency clinic in Birmingham. They can tell that he doesn’t have the transportation and likely won’t go.

“Remove me,” the Governor said, “I cannot bear it.”

The ghost says “I will, but because of budget cuts I have to be the ghost of  health care present as well.”

“Say what?”

“I ran across a copy of “Putting Alabama Back to Work” and we think you should be reminded of what you said you would accomplish in regards to health care as Governor in 2009 (before Obamacare was passed):

  • Encourage health savings accounts – present in ObamaCare
  • Reject ultraliberal single payer – again, ObamaCare
  • Prohibit any person from being compelled to participate in any health care system – Obamacare
  • Portability of insurance across state lines – could work with ObamaCare, understand Blue Cross of Alabama had a little something to say about that.
  • Tort Reform – with the entire legislature Republican you should be able to do that. What’s the hold up?
  • Change Medicaid awards so that those states with more poor people get more Medicaid – Didn’t Obama try to do that for you?
  • Establish state run exchanges – uh, this is getting kind of redundant
  • Tax relief for individuals who own their own insurance plan – ok, now this is getting scary
  • Electronic medical record support
  • More primary care physicians”

“What can I say, I was a very forward thinking candidate”

The Governor goes back into his room and waits. Another cold chill hit him. An apparition enters.”Now, YOU’RE Jefferson Davis’ ghost”

“No. I am the ghost of healthcare future. I could show you a bleak world where people who make over $3000 but less than $30,000 a year are denied healthcare and left in counties devoid of health professionals to sicken and die, but I won’t. I am going to assume you meant it when you said you were a forward thinking individual and made those promises and you just let things get away these last three years. Let’s see what the future can hold…”

They fly over to the Department of Public Health and Medicaid Transformation and things are hopping. The director is excited at the new world of data. They overhear him say

“We measure the right thing over time, reassess and trend what we are measuring, and bring the measurements to the attention of the governor and the legislature every chance we get. If it is easy to measure, we measure it a lot. We have counties in Alabama where infant mortality rivals Zimbabwe. These numbers used to be hidden in a report on page 133. We are making them a part of the policy conversation. We have the opportunity to decide if we want to be better or not.”

They then go into another office in the same building where they see folks looking to other states and even other countries for solutions. Why? They hear

“Don Berwick said we “Yanks” have ignored lessons from other countries. Paul Grundy of the Patient Centered Primary Care Collaborative has been going about singing the praises of Denmark (and it is a compelling story) but we’ve discovered that even in countries with universal access, disparities exist. In England, for example, income predicts poor health outcomes nearly as well as it does in Alabama. We need to look for answers outside the box.”

They then move down the cramped hall to the newly established Office of Patient Engagement (thought to be important in reducing peoples “risk factors” such as obesity and lack of exercise.” The director is already letting her staff know that the Office is obsolete

“We need to move beyond patient engagement. This is a term that implies a lone patient overcoming adversity to move singlehandedly into better health. Let’s acknowledge that “It takes a village.” The lesson of Portland and other communities is that healthy people lead to more healthy people. The lessons of McAllen TX and Grand Junction CO is that the right doctors can keep patients from iotrogenic harm and the wrong doctors, well, the opposite is true as well. The community needs to be healthy together…”

The Governor awakens and looks out the window. The camellias are in bloom. He looks over towards the hospital. The doors seem to be still open. He calls out to his aide “What year is this?”

“2014” the aide yells back.

“And ObamaCare?”

“Still the law”

He calls the Health Officer:

“Don, the good news about being way behind is you don’t have to repeat the last 20 years. Did you know that a healthy woman, let’s call her Ms Cratchit, with a car who lives  in rural Alabama has a less than 1/100,000 chance of dying in childbirth in 2014  and her baby Tim has a chance of dying of much less than 1/1000. Did you know that  Ms Cratchit  with diabetes and no car, has a personal risk of death about twice that of her non-diabetic self. Tim has about a 1/100 chance of death. This needs to be changed.

“But Governor,” Don says, “about 50% of Alabama counties offer no provision for care delivery for pregnant women. What can we do?”

Don, what we KNOW is that access to contraception and  pregnancy delay until the medical problems are controlled improves outcomes dramatically. What we suspect is that effective transportation is much more important that a poorly prepared health care provider with no ability to provide pregnancy care. What we need to find out is how to leverage technology, realign incentives, or utilize non-licensed providers to improve outcomes further. We need to focus our improvement methods ON A COMMUNITY SCALE to improve measurable outcomes.”

…and it was always said of him, that he knew how to use ObamaCare well, if any governor alive possessed the knowledge.  May that be truly said of us, and all of us!  And so, as Tiny Tim observed, God Bless Us, Every One!