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I was asked to mount my horse and take a poke at the Alabama ObamaCare opponents in our statewide newspaper chain (found here). My arguments were: a) there is a law b) it is a legal law in the opinion of the Supreme Court, and c) though not perfect it resolves many longstanding problems. Not earth-shattering but not uniformly well received in Alabama.

On the other hand, not uniformly poorly received either. I received many congratulatory e-mails from both folks I know and those I don’t know. The most touching was from a person who I don’t know. She thanks me and wants me to reiterate that the old system was broken. From her e-mail:

From my personal experience over the past few years, I embrace a national health care plan. In 2001 my ex-husband was diagnosed with colon cancer. It was advanced, and he almost died. We were “covered” by an individual health care plan that routinely denied claims for follow up health care and tests (e.g., nine months from the date of his colon resection, a colonoscopy claim was denied – deemed “routine exam” by our insurer). Meanwhile, the monthly insurance premium rates skyrocketed – we were getting an adjustment every six months. When our 2-person premium with an annual deduction of $2,500 each reached an amount of more than $1,700 per month, we dropped the insurance. We simply couldn’t pay it any longer, plus pay all the medical bills that the insurer denied. I shopped extensively for insurance – no one would insure him.

After a year or so of flying without a net, I was able to enroll us in a Blue Cross “open enrollment” program that they occasionally offer. Of course, it didn’t cover any pre-existing conditions for the first 12 months. Still, I felt incredibly lucky to stumble across the opportunity.

Also in her e-mail is a request for me to remind folks that preventive care is important and is covered as well…


Here in the south, we often seem to be bristling up and posturing on the outside while quietly doing the right thing. That is happening in Alabama as it relates to care delivery, much to my delight. Per an op-ed by Jim Carnes in today’s Press Register:

If [ObamaCare] survives the multistate challenge it will face this spring in the U.S. Supreme Court, Alabama will be well on its way to securing an expanded and fairer health insurance market for everyone, and a stronger safety net for low-income workers and their families.

That outcome will be thanks to the work of a commission Gov. Robert Bentley appointed to study the ins and outs of implementing a key aspect of the reform, despite his strong opposition to the law.

Mr Carnes points out that the combination of expanded Medicaid and these exchanges  will be a boon to the 15% of Alabamians who currently lack access to anything but emergency care and care provided by the charity of others. Once the law is fully enacted, people will qualify for subsidies to purchase insurance:

One crucial step for expanding coverage in Alabama will be the creation of what the law calls a state health insurance “exchange.” This will be a user-friendly marketplace where people who need insurance can compare and choose plans and get assistance for paying their premiums, on a sliding scale determined by income.

The full report of the Commission is found here. In addition,

The Affordable Care Act requires all states to offer Medicaid coverage to people earning up to 133 percent of the poverty line, or just under $30,000 for a family of four. That’s more than 12 times Alabama’s current Medicaid income limit. Alabama Medicaid estimates the change will bring coverage to around 500,000 more Alabamians.

Thank you, Governor Bentley, for setting aside your personal feelings and putting the groundwork for implementing the Affordable Care Act in Alabama into place.

I have a neighbor who is riding his bike from Mobile Alabama to Springfield Missouri to call attention to the need for better mental illness care. They happen to have a son who suffers from mental illness and thus (as many of us do) got involved because of their own son and then become involved with an organization that has a much larger purpose. Not only is D. G. riding his bike across country but his wife, Connie, is an officer in the local chapter of NAMI. Part of D.G.’s reason for taking this on, he says, is that

Even if we don’t raise money, if I can change the attitude of just one person relative to mental illness, it’s worth it. We talk about every other disease but we won’t talk about mental illness. There’s just such a terrible stigma associated with it.

Mental illness has been stigmatized since Biblical times. with Descartes being the most recent scapegoat. Part of the stigma was, I suspect, due to the nature of the affliction. Unlike pneumonia with its fever and coughing, those afflicted with mental illness have no outward manifestation, so the common belief seems to be that if they would only try hard enough, they could control their behaviors. In modern times we have devised treatments but the situation has not improved as much as we would hope. Some people don’t respond to the medications. Others may respond partially but feel so fuzzy headed that they want to stop the medication. Others respond so well that they feel normal, so figure they are cured and quit taking the medication for that reason. All in all, not a good illness to have and very difficult to treat, but an illness just like many other chronic illnesses. Because of the need to keep people taking medicine that makes them feel bad even when they are feeling better, mental health professionals developed “Assertive Community Treatment” options that include (from Wikipedia)

  • a clear focus on those participants (clients) who require the most help from the service delivery system;
  • an explicit mission to promote the participants’ independence, rehabilitation, and recovery, and in so doing to prevent homelessness and unnecessary hospitalization;
  • an emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial rehabilitation or treatment setting to the “real world”;
  • a participant-to-staff ratio that is low enough to allow the ACT “core services team” to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or “farm out” most of the work to other professionals;
  • a “total team approach” in which all of the staff work with all of the participants, under the supervision of a qualified mental health professional who serves as the team’s leader;
  • an interdisciplinary assessment and service planning process that typically involves a psychiatrist and one or more nurses, occupational therapists, social workers, substance abuse specialists, vocational rehabilitation specialists, and certified peer specialists (individuals who have had personal, successful experience with the recovery process);
  • a willingness on the part of the team to take ultimate professional responsibility for the participants’ well-being in all areas of community functioning, including most especially the “nitty-gritty” aspects of everyday life;
  • a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of the day or night to keep crises from turning into unnecessary hospitalizations; and
  • a promise to work with people on a time-unlimited basis, as long as they demonstrate a continuing need for this highly intensive and integrated form of professional help.

The goal is to maintain the client’s ability to function in society, despite a high cost and potential loss of freedom. If done right, it is expensive. Unfortunately, it is often easier to allow people with mental illness to wander about with no access to care and walk on the other side of the street as we seem to do commonly here in Alabama.

As we fight to destigmatize mental illness and offer appropriate treatment to those who have it, society seems to be moving to stigmatize other folks with certain types of chronic illness. The most recent example is that of diabetes mellitus. I went to a presentation about health coaching at the National Rural Health Association meeting. This presentation discussed a model of care that, although less intensive, offers many elements of Assertive Community Treatment. The goal of the therapy is to move folks with diabetes to a disease-free  state by working with them to encourage lifestyle changes, medication compliance, and disease self-management. It is surprising how rapidly the conversation turns to “disincentives” such as more money in insurance premiums, encouraging “self control” through shame and stigmatization, and “if only they would stay out of McDonald’s.”

As we come to understand how much of our healthcare costs can be reduced through positive lifestyle modifications, I hope that we can celebrate the triumph of modern medicine over the frailty of the human condition. Instead we seem to be moving to punishing those who are less than perfect. A trend I will continue to fight.