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Friday, July 26, 2013

Can we have an informed discussion about health care reform?

One of the responsibilities that I enjoy a great deal and take most seriously as an educator is getting people to think about and to look at issues from all perspectives. Yes I do have my own opinions about many things, but I genuinely try to get people to form their own opinions based on an informed analysis of the facts. I am also willing to change my opinions when the facts no longer support them.

In this vein, I find the national debate in the U.S. about health care reform very frustrating. While I admittedly support the Affordable Care Act (aka, Obamacare), I also know it is imperfect. If any health care policy wonk were designing health care reform from scratch, they would likely not come up with Obamacare. Yet I also recognize that health care reform is a political process, and that political outcomes, based on compromise and tradeoffs, never completely satisfy anyone. In addition, we cannot forget why we need health care reform in the first place, which is because our current health care system is wasteful, harmful, and not sustainable. Doing nothing is not an option, and I believe that Obamacare is preferable to maintaining the status quo.

One of the biggest ironies about Obamacare is that while most Americans oppose the overall law, they support most of the provisions in it, particularly the requirements denying lifetime limits on coverage or on preexisting conditions. They also see changes to their own health insurance plans, changes that would have come with Obamacare or not and are usually at the behest of their employers facing continued premium increases, and blame them on Obamacare. (And clearly those who have fundamental disagreements with Obamacare, or just want to see the President fail no matter what, exploit this to their advantage.)

Probably the main reason why I find the health care reform debate so frustrating is that most Americans do not understand many of the core issues around health care delivery and finance. In particular, they do not understand the difference between health insurance and health care expenditures. Very few Americans, only the very wealthy, can afford to pay for all health care costs. Instead, we all pay for health care insurance. Furthermore, free markets do not really work in most areas of health care, and it is debatable whether we should even try to make them work, as I noted in this blog during the height of the debate over health care reform legislation.

This ignorance is best exemplified by postings such as one on an anti-Obamacare site. The quote at the top of the women's health care portion of the site (reproduced as a picture below in case the site changes) lays bare how badly people misunderstand health insurance (private or public): "I had a hysterectomy, I have no need for maternity coverage, but I have to now pay for it. I have to pay not only my own premium but I have to subsidize everybody else." (Kudos to JD Kleinke for pointing out this site in one of his blog postings. I also agree with another posting of his that Obamacare is more conservative, i.e., less liberal, than Medicare.)



The person quoted on this site obviously misunderstands the concept of health insurance. How many people not needing a hysterectomy subsidized this woman's hysterectomy? She obviously does not understand that the whole idea behind insurance is that we "subsidize" each other's needed care, so that when we need it ourselves, it is available for us. If we start lopping off this condition or that procedure from health insurance, then we soon lose the whole concept of insurance. (This is one of the reasons why most Obamacare insurance exchange plans will be more expensive than cut-rate plans that offer meager coverage and can be terminated at any time.) Carrying this woman's logic to an extreme, does she now no longer support paying for women who need a hysterectomy, since she no longer needs one?

Another manifestation of this thinking concerns Medicare. The famous quote "keep your government hands off my Medicare" (last couple paragraphs of this Washington Post article) best demonstrates how little many people truly understand about Medicare. Less blatantly, however, many elderly people who think nothing of demanding anything and everything from Medicare are the same people who are opposed to other forms of government-run health insurance, especially Medicaid for the poor. Yet these seniors do not realize that they are getting several-fold more benefits from Medicare than the contributions they have made over their lives (Fried, J (2008). Democrats and Republicans - Rhetoric and Reality: Comparing the Voters in Statistics and Anecdotes. New York, NY, Algora Publishing.).

But I do agree with those who argue that we cannot provide unfettered access to any and all types of care to everyone, seniors or otherwise. We do need to make some decisions as a society about what constitutes adequate health care coverage, and who should pay what. There are some areas where competition and free markets work in health care, and those should be encouraged. But the notion that we can buy less costly insurance policies, covering only this or that, really does not make sense.

I am willing to explore all the possible options for health care reform. Some conservative ideas make sense. But before we can have those discussions, a good proportion of the population needs to understand some basic realities about health care and its financing, and be willing to have an honest discussion about them.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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