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Monday, May 9, 2016

Health care: of United, and citizens

The disturbing news item of the past week—assuming we discount the increasingly routine reports of terrorist bombings, boats packed with desperate migrants capsizing, the global temperature relentlessly rising, and Russian military bombast—is that the nation's largest health insurer, United Health Care, is withdrawing its involvement in the state exchanges of the Affordable Care Act (ACA), aka Obamacare. United is opting out due to the high costs of participation, and their departure effectively passes those costs along to other insurers, and of course, to us, the insured. The citizens in states where United was an important option will now have fewer options, and likely face higher premiums and/or deductibles.

Detractors of the ACA perhaps see this as something of a vindication, but the details behind this story suggest that is very misguided. The high costs to United of involvement in Obamacare are really all about sick people getting care they actually need. The very point of the Affordable Care Act is to bring coverage, and thus access to care, to those formerly left out entirely. It is, apparently, working.

The result is that people for whom health insurance was formerly out of reach now have a way into the system, for themselves, and the costly baggage of their neglected pathology.

That is the prevailing speculation about United's financial woes. The population gaining access via the ACA tends to be poorer, and sicker. Since this is a group that traditionally did not have health insurance, they have, in many instances, foregone care whenever possible. Any insurer that is the first point of entry for this group will encounter the pent-up need they have borne, and the costs attached to addressing it.

We can speak in terms of baggage, pathology, and costs if we approach this topic from the perspective of United executives, or financial analysts. But I am an unapologetic humanist, and I much prefer to use alternative language, and put human faces to this. We are talking about suffering and stoicism; forbearance, and foreshortened lives. We are talking about people who neglect their health, and maybe even that of those they love, because they can't afford to do otherwise.

I have at times seen the faces of those caught up in this narrative. In one terribly tragic case, a member of a cousin's family—and thus, arguably, a distant member of my own—died at 34 of melanoma. Let's call him John.

He first noticed the abnormality on his skin when in-between jobs, and thus, without health insurance. In his early 30s, he didn't have cash reserves to pay out of pocket for medical care. So, he waited until once again employed, and once again insured, to have that skin lesion assessed. The wait proved lethal. During those months, the melanoma had metastasized. A system of portable health care coverage that transcended employment would certainly have save the life of this young man, only recently married.

Then there was the case, many years ago, of a young mother—let's call her Jane—I met in a homeless shelter in New Haven. She, too, was in her early 30s, with a 4-year-old daughter at her side, when I saw her for an on-site “check-up.” She was severely limited by shortness of breath and heart failure, and would never be otherwise.

It need not have been so. A couple of years prior, she had developed a pain in her calf. I no longer recall the exact circumstances. The pain started out mild, but progressed, and became fairly severe. It was like nothing she had experienced before. Any of us, with a severe, unexplained pain in our leg, would have gone to see a doctor. She did not, because she had no insurance, and no doctor. A doctor visit for her meant finding something to do with her daughter while she spent many hours waiting to be seen in the emergency department. She tried her best to avoid that, by toughing it out.

That proved a tragic mistake. The pain in her leg was a blood clot. As they inevitably due when neglected, the clot broke, sending fragments into her lungs. Blockages in her lung were life threatening, and resulted in a 911 call, a trip to the hospital by ambulance, emergency care, and a stay in the ICU. The inconveniences the patient hoped to avoid were, obviously, massively amplified. The damage to her heart and lungs was permanent, so her health, and thus her life, were ruined. And, the costs to the system were vastly higher than earlier care of the leg would have been in the first place. Everyone lost.

John and Jane, and the millions like them, are the rebuke to those who see United's reticence as the basis for an “I told you so” about Obamacare. United doesn't like the costs, but it's not as if those costs weren't with us all along. People like John and Jane have been paying them, and generally without the option United has of saying: no thanks. They have paid with years lost from their lives, and life lost from their years.

One potential solution to this, routinely brandished heresy here in the U.S., is a single payer system. Ironically, many of those who see this as radical, heretical, and anathema are quite adamant about the protection of Medicare, which is, of course, a single payer system for those 65 and older. If Medicare worked like the private system, then perhaps it would cite the high costs of care in Florida, where a lot of older (and all too often sick) people settle—and withdraw from the state. If we don't like the idea of our older relatives in Florida being abandoned by their health insurer, perhaps we might choose to see the United disengagement from the ACA through that same lens. Maybe health insurance really should be a universal right, not a business decision.

The other implication is of the “I have a hammer, and so I see nails“ variety, as president of the American College of Lifestyle Medicine. Eating more optimally, being active, avoiding tobacco, and hitting a few other highlights of living well has the potential to eliminate some 80% of all chronic disease: heart disease, cancer, stroke, dementia, and diabetes. From my perspective, the human bounty of this—more years in life, more life in years—more than amply makes the case. For those inclined to other currencies, however, we may note that the financial advantages would be astronomical.

I favor universal access to our so-called “health care” system, and thus, something more like Medicare for all. Colleagues and I have published a detailed model that differentiates the elements of care that should be a human right, from those that are reasonably discretionary. I see no heresy in the mix, but if others do, well, vive la difference.

The greater opportunity, however, is not limited to how we cover the costs of caring for pathology that needn't have developed in the first place 8 times in 10. It is in preventing it. That requires turning what we have long known about lifestyle as medicine into what we do. It requires a cultural and political commitment to actual “health” care, rather than just after-the-fact disease care. Bluntly, it requires the honesty to acknowledge that a culture lamenting the high and rising prevalence of diabetes in its youth, while continuing to peddle at every opportunity soda, toaster pastries, and multi-colored marshmallows as part of a complete breakfast reeks of hypocrisy.

As for the status quo, United is a business, and has the option of renouncing its high costs. The people paying for business as usual with their lives do not.

David L. Katz, MD, FACP, MPH, FACPM, 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. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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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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