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

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

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

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

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

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

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

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

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imagesThe physicians had a special relationship back in the pre-forties. They were respected by the entire community; the were looked upon as gods in their own rank.

Chandler Bramlett at age 74, as quoted in Health Care in Mobile: An Oral History of the 1940s

The Alabama Academy of Family Physicians flew me to Washington DC last week to represent the interests of family docs to our congressional delegation. I have been up to the Hill several times representing the interests of my rural colleagues, but this was the first time I was exclusively representing physicians. When you are representing all of rural Alabama’s health care needs, people tend to give you a lot of respect. When you are representing the economic interests of a group of people who, although relatively underpaid, still make in the top 3% of Americans and the top 1% of Alabamians, respect is not nearly as forthcoming.

I had the privilege of having John Waits as the other half of the small Alabama delegation. John is a family physician in Centreville, Alabama, who has established an FQHC and is in the process of using the Teaching Health Center mechanism to bring family medicine training to his small town with the first class starting this year.

The five-year, $230 million Teaching Health Center Graduate Medical Education (THCGME) program is designed to boost the number of primary care residents trained in teaching health centers (THCs), which are community-based ambulatory care centers that operate a primary care residency program.

Unlike Medicare GME funding, which goes mostly to hospitals, THCGME funding goes directly to community-based sites. The funding is tied to specific health care workforce goals, and THCs must report annually on the types of primary care training programs offered, the number of resident positions, and the number of residency graduates who care for vulnerable populations in underserved areas.

That’s the good news. The bad news:

One area of concern, however, is the funding uncertainty for the future of the program…. The THCGME program is funded only through 2015, which creates a challenge for the THCs…. Unless Congress provides additional funding for 2016 and beyond, THCs may have residents in the middle of their training without THCGME payments to support them.

It was this message we chose to bring to our delegation, asking them to help us make a difference.

We were doing OK with our message except for two little roadblocks. The first, especially problematic for our deeply Red delegation, is how the program got its start. It was included in the Affordable Care Act. Given that we were there on a Wednesday and the vote scheduled for Thursday was REPEAL OBAMACARE (which won 229-195 on a partisan vote), no one in our delegation could see a way to supporting a part of a law which was described this way by one physician congressman:  “Obamacare is terminally sick and we need to call the time of death.”

The second obstacle was, well, the physician congressmen. While Alabama has no physician members, our delegation tended to defer health issue specifics to a group referred to as the “Doc Caucus.” Formally known as the Republican Doctors Caucus, it was formed by Republican House physician members and includes all 15 GOP physician members as well as a psychologist, two dentists, and three nurses. Their issues (from their website) include: Repeal ObamaCare and end federal government’s involvement in healthcare; Encourage (but not mandate) state based high risk pools; Encourage (but not mandate) adoption of Electronic Health Records; Tort reform; Medicare and Medicaid reform (through competition and the repeal of the IPAB); Allow health insurance to be purchased across state lines (not through the exchanges in ObamaCare); Transparency of quality data (different than what was in ObamaCare or outlined by Dr Berwick while he was at CMS); Fix the sustainable growth rate.

Rather than move backwards, I would encourage them to listen to one of their former colleagues, Bill Frist, and consider using the Affordable Care Act to effect change by fixing the payment system:

“We are convinced that reforming our nation’s health care system to prioritize quality and value over volume will not only improve health outcomes and the patient experience, but also constrain costs and produce systemwide savings.”

“Care is organized around what the patient needs, not around what is expedient for an individual provider,” says the report. “Information, such as lab tests, referrals, notes and updated medication lists, is shared seamlessly among health care professionals without the need for patients to intervene.”

Maybe the American public should get to be the gods for a change.

 

 

 

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