Can corporate power continue to keep Americans sick? Maybe the election will help

Do you think that insurance companies should be allowed to deny insurance to people with pre-existing conditions? If not, you are in agreement with most Americans, 81% of whom feel this way according to a survey conducted by the Commonwealth Fund, the Harvard School of Public Health, and the NY Times for the report Being Seriously Ill in American Today (the link is to the Commonwealth Fund site discussing the study, and you can download the PDF there). That is a lot of people, and is why most politicians give at least lip service to the idea. Of course, despite the fact that you may have heard Republicans who are currently in Congress saying that they support it as they ran for re-election, the fact is that virtually all of them voted against it when they voted to repeal the Affordable Care Act (ACA, Obamacare) and, when that was unsuccessful, to strip it of its major impacts. This protection was one of the most important of ACA’s rules, and is highly valued even by most Americans who profess to hate Obamacare, Obama, love Donald Trump and vote for the Republican Party. And this is, in no small way, a reason for the Democratic takeover of the House.

Sadly for the GOP supporters who want their pre-existing conditions covered, their love is not being reciprocated by their elected officials. As discussed by the President of the Commonwealth Fund, David Blumenthal, in an article in The Hill, 20 Republican-led states, led by Texas, are filing suit against the federal government arguing that they should not have to enforce the ACA’s ban on refusing insurance to people with pre-existing conditions. What is more is that the federal government, under the GOP and the Trump administration’s Department of Justice, is refusing to defend the suit; this means that they are not arguing in favor of the law of the land, but more that they are not defending the right of the American people to have this guarantee. Tough luck, 81% of Americans!

Of course, this would not necessarily mean that people with pre-existing conditions (about 52 million Americans, depending upon a fairly strict definition*) would not be able to get insurance, although it is likely that many (such as those with terminal cancer) would not. It does mean that they could be charged much higher premiums for their insurance, though. This would go back to what is called “individual rating” where the individual’s health risk determines the amount of their premium, as opposed to the “community rating” required under ACA. And, of course, as discussed in another Commonwealth Fund brief this would also impact the premiums of those actuarially deemed to be a greater risk: mainly older people (including those Trump and GOP voters), but also for many conditions, women – the majority of the population! Even the insurance companies are not sure what to do as they set their rates for 2019.

It is clear that President Trump is doing all he can to distract people from the result of the November 6 elections – he is a master of distraction – such as by firing Attorney General Sessions the next morning. But the Democratic House of Representatives will not be confining itself to investigations of him and his campaign, but also moving forward with legislation to accomplish what are seen as “progressive” goals, or goals I would reframe as “actually in the interests of the people of the US, as opposed to the billionaires and large corporations. Health care is the foremost of these. It will start with ensuring that the important provisions of the ACA are kept in place, in particular the protection for those with pre-existing conditions. The House can do this because it is current law, and it can block any Senate effort to change it.

Moreover, the House is likely to work on advancing the goal of “Medicare for All” in the coming session. This is the opinion of Sen. Bernie Sanders (D-VT), the most well-known advocate for single payer, makes this point clearly in an excellent interview with Rolling Stone’s Matt Taibbi. This will not pass the GOP-controlled Senate, and may not even pass the House, but the effort will definitely be made and it will have strong support, a big change from the Clinton plan of the 1990s and even ACA when single payer was “not on the table”. Establishment Democrats, beholden to their own very wealthy donors (especially Wall St.) may not be happy to go against corporate America, but they will if they have to and they will have to because their voters want it. As Sanders says, “…it’s wildly popular. And that’s what Democrats have got to do.”

On one side, we have the interests of the vast majority of the American people. There are those without health insurance coverage, including those who would be eligible for Medicaid under ACA if they lived in states that had expanded Medicaid, but have the misfortune of living in Republican-controlled states that did not. This will get better soon, as three states, Idaho, Nebraska, and Utah, just voted to expand Medicaid, and Maine will likely do so now that its soon-to-be-former governor won’t be around to veto it. It is a popular program, even in these “red” states. But those who will still be uncovered in the 14 states that remain is a lot of people. Then there are the people who have insurance, but terrible insurance, with absurdly low annual and lifetime caps, that should not be legal. But they are. Then we have the people who have more “standard” employer based insurance, who are being killed by the premiums, deductibles, co-payments, and co-insurance costs. Then we have those who are on Medicare who are unable to afford a Medicare Supplement policy to cover the things Medicare doesn’t – especially the 20% of the cost, since Medicare covers only 80%. Maybe not so big on a $100 office visit (although $20 is a lot for many people) but a big deal for a $5000 hospitalization.

So how many people is that altogether? I don’t have the numbers, but it is certainly the large majority of the American people. In fact, 90% is probably a conservative guess, which would mean 10% of Americans have insurance with affordable premiums, copays, deductibles, or are so rich it doesn’t matter. Of course, this small group includes not only most legislators, but corporate executives, pundits, and even many liberal leaders. Remember: the median US household income is about $61K, and a household (not individual) income of $150,000 is the top 8% and of $200,000 the top 3.65%!

Who is on the other side? Well, drug companies, consistently the #1 profit industry in the US. Insurance companies, making huge amounts of money skimming from the “health care expense” pool. Large health systems, doing very well, thank you. In other words, incredibly wealthy vested interests and their lobbyists that contribute a lot to politicians. This is not a fair match-up either way, most of the people vs. most of the money.

But maybe the “most of the people” finally have a chance. Wouldn’t that be a refreshing change?

Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

The Commonwealth Fund has recently issued its 2018 Scorecard on State Health System Performance. This scorecard has data for each state (+ DC, so 51 spots), measuring performance against a variety of metrics evaluating access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities. Because the Scorecard has been issued 2013, Commonwealth can compare the current year’s rankings and performance to previous ones, seeing how states get better (or worse) on these individual measures as well as on overall performance.  

There is not much change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota, Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas, Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the only change being Florida dropping 5 spots to join the group and displacing West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are not only unchanged, but remain far ahead or behind of their nearest competitor. The top regions are still the Northeast and Upper Midwest, with the West dragged up by Hawaii and Utah but otherwise an average to low average group.

Commonwealth also ranks the states on degree of improvement of their scores in each of 43 different indicators. More indicators improved than went down, which in itself is a good thing, but there are a lot of caveats. For one thing, it doesn’t measure amount of improvement, or how much less a state might have improved compared to others. For example, Oklahoma joins the list of the top 5 states with improvement on the most indicators (17, to rank it #4), and yet dropped two places in the overall ranking, from a dismal 48 to 50^th! This is not good. More important, however, were the areas in which indicators fell for many states and for the nation as a whole. This include rising death rates (a really big one!), including a 50% increase in deaths from suicide, alcohol, and drug use since 2005, rising obesity, and gaps in care with a rising disparity between and within states.

Many of the improvements are in areas that have been focal points of public health policy, like decreasing smoking. This is good, but this long-time-coming advance over the tobacco industry’s heavily funded effort to get people to continue to smoke, and young people to take it up, has still not been entirely won. More important, the lessons from the anti-tobacco campaign have not yet transferred to the other well-funded high-profit threats to health, notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately, each of these struggles seems to need to rise up almost as if the others hadn’t been joined; activists can and do learn from the previous ones, but so do industries that manufacture unhealthful commodities. These industries replicate the strategies that tobacco used to delay change for so long. The main one, of course, is the liberal application of money to politicians. The same lobbyists who worked for tobacco work for sugar, and guns, and alcohol; the color of their money is still green, and politicians still enjoy receiving it.

While it is true that many politicians from both major parties have been recipients of such largesse, the retreat from reality-based policy that is the hallmark of both the Trump administration and the Republican Party in Congress has major impact on the causes of illness and will continue to do so into the future. One good example of the latter is the aggressive retreat from environmental regulation, personified by EPA administrator Scott Pruitt, rolling back auto-pollution emissions standards (a decision currently being challenged by a coalition of states led by California). Another is the firm resistance to common-sense regulation of guns, which result in over 30,000 US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations on semi-automatic weapons and high-capacity magazines, waiting periods and background checks, absolutely would decrease the number of these deaths (the majority, by the way, are suicides), but are blocked by legislators feeding from the gun-industry funded NRA trough.

Not only politicians are recipients of graft; a recent New York Times exposé provides evidence of pharmaceutical companies using ostensible “speaker’s fees” to actual provide kickback payments to physicians who are big prescribers of their drugs. The article emphasizes payments to doctors who practice pain medicine and are in a position to prescribe large amounts of the opioids manufactured by these companies. Sadly, this is almost as unsurprising as the graft going to politicians to compromise our health. What we should be is outraged about it, and working to combat it. Certainly the politicians do not seem to be. In the conclusion to her “controversial” speech at the White House Correspondents’ Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking water.” It is harsh, it is true, and it is almost as bad as the news that the government of Michigan will no longer be providing free bottled water, even though the tap water is still unsafe.

Flint, of course, is a majority minority and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned water is not coincidental with the makeup of its population, and it not a coincidence that it is in Michigan. The Commonwealth Report illustrates a wide divide between those states that have better and those that have worse health status. Largely, the map is geographic with northern states better and southern states worse, but there is a tongue of northern states in the worse group, heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to Michigan. What these states have in common with most of those in the south is control by Republicans who in most cases have not, in most cases, expanded Medicaid for their citizens. Expansion of Medicaid was a central part of the Affordable Care Act, but a Supreme Court left the decision on whether to do so optional for the states; those that have not done so have worse population health status. This is exacerbated by changes in federal policy that have increasingly made access to health care worse and more expensive in most states, with the impact felt most in states that have elected Republican government and that voted for President Trump.

In another blog post, First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse, the Commonwealth Fund notes that*:

·        About 4 million working-age people have lost insurance coverage since 2016

·        The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

·        The uninsured rate among working-age adults increased to 15.5 percent

·        The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent

·        The uninsured rate increased among adults age 35 and older

·        The uninsured rate among adults who identify as Republicans is higher compared to 2016

·        The uninsured rate remains highest in southern states

·        Five percent of insured adults plan to drop insurance because of the individual mandate repeal

This is also not good news. Much of the problem is because employer health insurance costs (much of it passed on to workers) have been rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted by the great Don McCanne in his Quote of the Day) calls for price controls, noting that much of the cost (in lower wages) that workers bear for higher health insurance is not obvious to them, and they would thus have sticker shock from a Medicare for All program. Dr. McCanne notes that a current California bill, AB 3087, calls for price controls, and is supported by unions but opposed by industry and the California Medical Association so it has little chance of passage, suggesting that this solution is not more palatable to the powerful. He calls for well-thought out Medicare for All program, saying:

Now would it be that difficult to let people know about the hidden costs of health care that they are already paying? Do people really prefer being kept in the dark by an opaque financing system rather than being enlightened by the transparency of financing through an equitable tax system, especially if the amount being spent is somewhat less for all but the wealthiest of us?

I do not think so. It is time to do something to change a status quo that is unacceptable for the health of so many as well as unaffordable. It is time to do the right thing.

*Also summarized by Dr. McCanne

US Health Rankings remain low and #Trumpcare will make them worse!

On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37^thin the world”  ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.

But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.  

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.

And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from  cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.

So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017)  I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.

Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI),and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.

So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”.  But they will, and we need to move up in the rankings, to be closer to other OECD countries.

Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.

The urban-rural divide and the health of people in both settings

I recently wrote about the impact of the massive vote for Donald Trump by “white working class” voters and how it will have repercussions for their health, as well as that of others, if the policies advocated by the Republican majority (as exemplified by Secretary of HHS nominee Rep. Tom Price) are implemented. And there is little doubt that they will be implemented, but slowly, so people are less aware of what is being done to them. As Medicare is increasingly privatized, as vouchers that cannot cover the cost of health insurance for those with chronic disease are implemented, “Medicare for all” will increasingly seem a poor idea. And people’s health will suffer. I wrote about the cynicism of the AMA and the AAMC in endorsing Mr. Price; they are doing more than “kissing the ring”, as a colleague suggested. They are lauding the fact that one of “theirs”, a doctor, will be in this role, not an insurance executive. But if anyone had a doubt about whether having an “MD” at the end of your name guarantees a concern for people’s health, Mr. Price is the poster child for “not so”.

The other big divide demonstrated by the election is urban-rural, and this one is also real. A majority of the people in the US are jammed into small geographic areas, urban islands. Maps that portray “red states” and “blue states” seem to be an ocean of red because of physical size; think New Jersey  (population about 9 million, with 8700 square miles, more than 1000 people/sq mi) vs. Montana (just over 1 million, in 147,000 square miles, less than 7 people/sq mi). The contrast is even greater if we look at counties; most of the population of even “blue” states is concentrated in a few urban counties, although, conversely, there are many “blue” seas and islands in “red” states, cities like Houston, Dallas, San Antonio, St. Louis, Kansas City, etc. The media has recently been awash in articles about the way that our Electoral College system advantages rural areas; because of the 2-Senate-seat-per-state rule, a Wyoming voter has 5 times the clout of a Californian. See, for example, Steven Johnson’s “Why blue states are the real Tea Party” in the NY Times, December 4, 2016. He points out that at the time of the writing of the Constitution, the urban northern states were in debt while the southern states were solvent – largely through the magic of the free labor of slavery. Now cities are the engines of our economy; they are where ambitious and educated young people go, leaving rural areas increasing older and poorer (as well as whiter).

But we need to remember that there is tremendous need in rural America, as there is in the inner city. Rural areas are poor, and underserved both medically and in terms of social services (as well as, of course, in the other things you’d expect – access to groceries, for example). Those rural areas that are located in “red” states are even worse off, because those states spend far less on health care and social services in the first place so that their more isolated communities are in the worst shape. And yet, as Johnson points out, they get far more federal aid for tax dollar contributed: New Jersey receives $0.61 on the dollar while Wyoming gets $1.11. The Trump campaign, and the Republican Party, strongly appealed to voters in these areas, but Trump and his proposed cabinet all live and work in cities; they are not rural billionaires. Tom Price is a suburban doctor; he does not deliver care to the rural poor, as do Rural Health Clinics.

So there is tremendous need in rural communities, but their political clout, which is both unfair and anti-democratic, is not being used to actually help the people there, but rather to limit positive policies in urban areas. The North Carolina “bathroom law”, to force people to use the restrooms of the gender of their birth, was a reaction to the city of Charlotte (a blue “lake”) making it legal for people to use the restroom of their current gender. The most well-publicized efforts currently are threats by Trump and his people to forbid cities from declaring themselves “sanctuaries” for immigrants (see NY Times debate on whether sanctuary cities have a right to defy Trump, December 1, 2016; “yes” by Cesar Vargas and “no” by Jan C. Ting). These cities are trying to exert their local control over such important issues, while states (generally supported by rural populations that do not actually have to deal with these problems) try to restrict their ability to do so. These hypocrites are against government regulation when it comes to their rights to carry guns or graze their cattle on public land (things they want to do), but are all for it when it comes to things important to others, like deciding who can marry, where one can go to the bathroom, whether people can get an abortion or even contraception. “Those who deny freedom to others,” said Abraham Lincoln, “deserve it not for themselves”, which I first learned as a young stamp collector; it appears at the 4 cent American Credo stamp.

If the selective interpretation of what “freedom” means is not enough, if rampant discrimination and bigotry is not enough, there are other, health related, concerns that go with this divide. For example, federal funds for HIV care go to the area where patients are from. However, a large percentage of gay HIV patients leave those areas for the cities where they are more accepted. Thus the cost of providing that care is borne by the cities, while the money flows to the rural areas where services are not available – and often the victims themselves are not welcome.

A recent article published in Science Direct by Jason Beckfield and Clare Bambra, “Shorter lives in stingier states: Social policy shortcomings help explain the US mortality disadvantage”demonstrates that the lack of social services in the US leads to shorter lives than in other Organization for Economic Cooperation and Development (OECD) countries, i.e., the rich countries. The “highlights” of their study are that:

• The US combines a laggard welfare state with shorter life expectancy compared to the OECD.
• Fixed-effects models show associations between life expectancy and social policy generosity.
• US life expectancy would be 3.77 years longer if the US welfare state were just average

In this article “state” refers to nation-states, comparing the US to other OECD countries, but similar differences can be seen among the US states, again depending upon their social services, including public health and access to health care. This is supported by a new study from the Commonwealth Fund which finds that “adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs”. A third of U.S. adults “went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs”, as compared to as few as 7-8% in other countries. They were also the “most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.”

This is not good for our country, not good for our health, and not good for our lives. And as far as we can see, the new administration’s plans are not to fix it but to make it worse.

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism -- and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout,firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.

There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.

Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.

Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.

Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.

And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.

So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.

 

Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.

And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism -- and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout,firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.

There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.

Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.

Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.

Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.

And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.

So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.

 

Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.

And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

Insurance coverage and access to care in the US

In the New York Times’ “Upshot” of October 24, 2016, Dr. Aaron E. Carroll discusses “Why the U.S. Still Trails Many Wealthy Nations in Access to Care”. He notes the increase in insurance coverage of the American people since Obamacare, but also that insurance coverage is not the same as access to care. He cites the most recentCommonwealth Fund survey of international health systems to demonstrate that, compared to most of the other ten wealthy countries that were studied, Americans have greater difficulty getting an appointment and being seen. (Canada is worse than the US in many of these measures, but not all; see discussion below.) Indeed, he also notes that when the populations of these countries are divided up between above-average and below-average incomes, the folks with below-average income in most of these other countries have better access than the above-average in the US.

A major reason that Carroll cites for the poor access is the low percent of primary care physicians in the US, a fact supported by data from the Organization for Economic Cooperation and Development (OECD, the “rich countries” group). It is true. There are not enough primary care doctors -- family physicians and general internists and general pediatricians -- to meet the access needs of the people of this country. There are plenty of excellent specialists; in fact, in many major metropolitan areas there are too many of them, sometimes leading to too many interventions that both increase the cost to the system and the risk to patients. Traditional “supply and demand” economics would suggest that limits on demand would force a constraint on the number of specialists, but it hasn’t happened yet; none of them are starving. This is because, in medicine, supply often drives demand rather than vice versa. When are people finally getting enough procedures, and when does it cross into too many? People don’t understand medical care, what is “good” for them and what is “too much”, much less the cost-benefit ratio. Indeed, doctors usually do not. But they do know what they know how to do, and that it will make them money.

This is a major area that having sufficient primary care physicians would help. If everyone has a family doctor that they can trust, whose income is not tied to procedures or referrals, they can help you to understand these complex issues. But there are far from enough; less than 30% of doctors in the US are in primary care, compared to 50%+ in other wealthy countries, and that is dropping as fewer students choose primary care careers. Many reasons for this are cited by studies (the culture of academic medical centers, status, work-life balance, etc.) but the real bottom-line reason is the bottom line: primary care physicians earn way less than most other specialists. Not just a little, but often half or a third as much as the highest paid specialists. Pay for primary care is going up with demand, but 10-15% increases will not change specialty choice; between income increases for primary care and decreases for specialties (heaven forfend!) the ratio needs to be at least 70%. Specialists know this; they want primary care doctors to do all the things that they themselves are not able or don’t want to do for their patients and are not opposed to primary care salaries going up -- although of course they themselves don’t want to see their own incomes go down.

Getting the care you need is a combination of having enough providers for you to be able to find and get in to see, and adequate coverage. Insurance, as we have long seen even before Obamacare, is not all the same; there is good insurance (although hardly, any longer, great insurance) and lousy insurance, and there is no insurance that is both cheap and of high quality (although, again, there are plenty of plans that are costly and of poor quality). Premiums are the tip of the iceberg; deductibles (how much you have to pay out of pocket before your insurance kicks in), co-pays (how much you have to pay each time you access care), co-insurance (what percent of “covered” care you have to pay) also impact on out of pocket costs. As, of course, does the overall cost of care (by providers) and drugs (by drug companies), and what services are not covered by your insurance.

As an example, if you are over 65, try figuring out what plan to buy for your Medicare Drug Coverage (“Part D”). There are the monthly premiums. And the deductibles. And the co-pays. And those vary by type of drug (generic vs. brand-name, preferred vs. non-preferred), and sometimes they are by a fixed $-per-prescription amount and sometimes by a percent. And if you order by mail it is different. On the bright side, most vendors offer you a calculator into which you can put the drugs you take, and it puts it all together and tells you which is cheapest for you. Until, of course, the drugs you take change.

This is insane, of course, but only if you happen to care about what works best for actual people, and not what makes the most money for private for-profit companies like insurers. Drew Shenaman, cartoonist for the Newark Star-Ledger, in the accompanying editorial cartoon, makes it very clear what the real reason is that insurers are pulling out of Obamacare. Their interests are not our interests. Surprise!

 

So we have excellent quality medical care available in the US, if you are geographically and financially able to access it, except sometimes it is not needed and done anyway. We have too many doctors in some specialties and far too few primary care doctors, and even they are not distributed well across the US. We have insurance companies that are focused on making profits, rather than on providing access, and sell complex, difficult-to-understand products that often have a “gotcha” at the point when we are most vulnerable. While access to appointments may be a little better in the US than in Canada (but not other countries), cost to the individual is way higher in this country than in Canada; access to care has both financial and non-financial components.

Not everything can be reduced to dollars, but a lot can. The money spent on health care in this country should be spent on providing health care, not on profit for insurance companies, providers, drug companies, and the like. If private insurance is to be part of the system, it needs to be non-profit and highly regulated. There need to be more primary care doctors, and the way to make this happen is for them to get paid much closer to the same amount of money for the work that they do as other specialists. Medicare can and should lead the way on this. Physician distribution should be fixed by augmenting the incomes of doctors in rural areas, not punishing them. None of this guarantees quality care, but without it quality is a pipe dream.

Obamacare was good insofar as it went. It didn’t go far enough, and now we need to fix it.

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 3 (of 4 parts)

This is part three of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

The VA is an example of how quality can be and is compromised when public sector funding is cut. In the area of public health, it can have an even greater impact, and no fewer apologists. When, under cost-cutting mandates from the state of Michigan the city of Flint changed its water supply from treated Lake Huron water to the industrially-polluted Flint River, the complaints of citizens were ignored. When concerned health care providers, like Dr. Mona Hanna-Atisha (pictured), raised warnings about rising lead levels in the children of that city, she was attacked and vilified. But she was right and they were wrong, or, perhaps worse, lying. Poisoning our children to save money. If individual health care is jeopardized when those responsible are being rewarded for cost-cutting, we can do a truly impressive job of harm when we destroy the public health infrastructure. And let us not forget that a major reason this was able to happen was Racism; that they were not “our” children, at least not those of the state authorities.

We need more emphasis on quality. Indeed, quality, not cost-cutting, needs to be our primary metric. Spending less should only be acceptable when quality is not negatively impacted. I realize that this is also subject to interpretation; “quality” has almost as many different interpretations as “waste”, and is frequently (if, hopefully, usually unconsciously) associated with “what benefits me”. I am talking about health care that is of benefit to most people, and is considered basic – keeping patients clean and out of their own filth, feeding them, treating the diseases that we know how to treat, doing surgery when it is of clear benefit, not having excessive waits for specialty care that compromise outcomes. And, most importantly, not providing financial incentives for limiting care. From a cost-cutting point of view, money is fungible, whether it comes from ‘cutting the fat’ or cutting needed care; but from a healthcare point of view, there is a big difference. (I refer to healthcare here as “caring for people’s health”, not the industry of the same name!)

This is the big issue, and it is amazing to me that it sometimes seems like such a mystery. If most of our incentives are to cut costs, to keep our jobs or to make bonuses or to keep our agency functioning, costs will be cut. Even when those cuts negatively affect quality, in real and dramatic ways. The argument for privatization goes something like “the private sector can do it better because, motivated by the opportunity to make profit, they will discover efficiencies that government employees do not, and run a ‘leaner ship’”. The problem is that, while there may be some examples of this happening, what usually happens is that costs are cut by cutting services, and making off with the profit, or bonus. The ship is made lean by cannibalizing its parts, and the only thing which is certain to be maintained in fine working order is the lifeboat in which the parties responsible hope to escape in while the rest sinks. This scenario is repeated over and over again, whether services are actually provided by private and for-profit organizations (think drug companies, insurance companies, nursing homes, and increasingly hospitals) or whether “private sector incentives” are built into publicly provided services, as in England at Mid-Staffordshire, or, increasingly, in the US in Medicare.

Profit may not be a great incentive to provide better health care, and is an uncertain to very poor guarantee of quality, but it is an excellent incentive to generating profit. Think of drug companies like Turing and its former CEO, Martin Shkreli, the poster child for unfettered greed, and his 5000% increase in the price of pyrimethamine, or of Valeant, the Canadian pharmaceutical company that recently doubled the price of secobarbital, an 80 year old barbiturate, in anticipation of California’s assisted suicide law. Think of the increase in price of colchicine, a drug that was used (in its plant form) to treat gout in ancient Egypt 3500 years ago, from 10 cents to $5 a pill when the FDA “encouraged” its manufacturer to conduct new studies and banned the generic (finally reversed last year, with generic colchicine again available.) Think of the insurance companies whose profit was baked into the ACA, making it costly and still not covering everyone. The ACP has recently called for government controls on drug pricing. The fact is that you can’t count on private for-profits to provide quality, unless you really trust Martin Shkreli.

Interestingly, in contrast to the Triple Aim advocates, critics of Sen. Bernie Sanders’ proposal for National Health Insurance system, Medicare for All, assert his math must be wrong, that we couldn’t both save money and deliver quality health care to everyone. (The Chicago Tribune editorial endorsing no one in the Democratic primary says: “Sanders first amused Americans who know their fiscal math with proposals for free college tuition, expanded Social Security, $1 trillion in infrastructure spending, "Medicare for all" .... The nonpartisan Committee for a Responsible Federal Budget calculates that his economic plans would push the top federal tax rate to about 77 percent”).[1](By the way, they really mean the topmarginal federal tax rate, which was, for the record, 90% when I took civics in junior high.) I don’t know if they are disingenuous or purposely befogging the issue, since it is clear that every other developed country delivers care to all its people for, usually, 1/3-1/2 of what we spend per capita in the US, with much better outcomes by most or nearly all measures.

So why are cost estimates in the US so high, when other developed countries do it for so much less? A great deal of it is that profit is built into the system. When we read about the problems of our system, we hear from insurers, who think providers charge too much, and providers, who think insurers pays too little, and each with an army to try to get what it wants. It is not because we care too much about patients. In Canada, there is a single payer national health insurance program (called “Medicare”) where the government pays the bills for largely privately-delivered care. The fact that it is private delivered is part of why their costs have risen second only to ours, but there is some central control. In Switzerland, there are multiple payers, insurance companies that are, however, forced to charge the same amount and provide the same basket of services, and be non-profit. How do they compete then? Why, on service to their patients! What an incredible idea! If you call your company to complain and can’t get through, you switch to another! As long as our system is predicated on building in excessive profit for providers, insurers, and drug companies, it will be fantastically expensive, albeit a full-employment program for those people trained to try to get bills paid and, on the other side, to deny payment. And it will be about cutting costs, not improving quality.

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[1] http://www.chicagotribune.com/news/opinion/editorials/ct-marco-rubio-tribune-endorsement-clinton-sanders-0310-md-20160309-story.html

Are primary care practices prepared for complex patients? Is this even the right question?

The goal for our national policy should be that every person have the best health status that they can. One component of this, although certainly not all of it, is access to high-quality appropriate health care services. This means that people can receive the care that they need, when they need it, and do not receive unnecessary or harmful care. Access includes both financial and physical (geographic) access, and also access to high-quality care (see, for example, "Et qui vendit pellucidum", a recent blog post by my friend Dr. Allen Perkins).

One part of having access is that there need to be sufficient numbers of providers, appropriately trained and distributed to meet those health needs. It also means that those providers should have no reason or incentive to preferentially provide certain types of care rather than others, or care to certain people rather than others. Unfortunately, the profit motive skews this in the US; we have redundancy of profitable services like “cancer centers” and “heart centers” in major metropolitan areas, with hospitals competing for the same pool of patients, while in other areas even primary care is unavailable. We have excess capacity in some areas (every hospital, for example, needs an MRI or patients might go somewhere else, even if the number of MRI scans the population needs doesn’t justify it; providers prefer to take care of less-complex patients – a single joint replacement in an otherwise-healthy 45 year old with an athletic injury is more profitable than, and thus preferable to, doing a joint replacement in an 80 year old with multiple medical problems).

A recent survey of primary care providers in 10 countries by the by Robin Osborn and colleagues from the Commonwealth Fund, “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”[1], published in the December 2015 issue of Health Affairs (only the abstract is available free on line) sought to determine whether primary care physicians (there are, at least in the US, other providers like NPs and PAs who are not physicians) feel competent to provide various types of care. The 10 countries were all wealthy and highly developed (Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). All but the US have some form of universal health care, although the way that it is organized (e.g., single-payer government health insurance in Canada, a national health service in the UK, multiple non-profit insurers in several others) varies from country to country. In most countries, “primary care” meant family physicians or GPs, but in others (including the US), it also included general internists and general pediatricians.

The researchers found both similarities and differences by country in the percent of primary care practices that had confidence in their ability to adequately address population health needs, especially those that are increasing because of the aging of the population. For example, the confidence of these practices in managing patients with multiple chronic conditions was generally high (from 70% in Canada to 88% in Germany and the Netherlands; the US was at 76%). Fewer practices were confident in other areas, and there was greater variance. For example, 92% of practices in the Netherlands and 81% in the UK had high confidence in providing palliative care, while Sweden (25%), the US (41%), and Canada (42%) were much lower. Similar variations existed for other services (see table); for example, confidence in dealing with patients with substance use related issues were much lower (from 16% in the US to 41% in the UK).

The authors also surveyed whether practices had a number of characteristics that many experts think are important for being able to effectively and efficiently manage complex patients. These included use of electronic health records (European countries were ahead, but the US and Canada, late adopters, are catching up), team based care, after hours care not requiring visiting the ER (the US is very low), access of patients to their medical records (the US is very high as this is one of the criteria for “meaningful use” payments from the federal government), communication between different hospitals, specialists, and ERs with the primary providers (all over the board including in the US), and many other areas.

Of course, these surveys reflect the experiences of physicians in different countries, and are thus subjective rather than compared to some iconic “gold standard”. People do not know what they do not know, or haven’t experienced, or cannot even imagine; their experiences are context-dependent, and so cannot be directly compared. For example, the survey asked whether physicians thought that (their) “system works well; only minor changes needed”.  Only 16% of US doctors answered positively, with the high being in Norway, 67%. However, in the UK the number was also very low – 22%. How can we interpret that? In all of these countries, save the US, including the UK, everyone is covered. 78% of UK physicians may not believe that their “system works well; only minor changes needed”, but what would they think if the alternative was a non-system like the US where there are large numbers of uninsured people? Would they think that a better system? Probably not, but can’t tell from this data.

Finally, and perhaps most important, the survey does not look at whether there are a sufficient number and appropriate distribution of primary care providers to meet a country’s needs even when the practices are well-organized. It is my impression that the answer to this question is closer to “enough” in most of these other countries; I am certain it is not in the US. In our country, the financial rewards for subspecialization and the “lifestyle” (and sometimes financial) rewards for urban location are major determinants in our distribution of providers across specialties and geography. There are far too few primary care providers as a percentage of all physicians, and while family physicians are far more equitably distributed than other specialists, there are still big geographic disparities. Among the many “solutions” that have been suggested, I believe that only one will work: eliminate, or at least dramatically decrease, the income differential between primary care and subspecialties. This is not as far-fetched as it seems; as I have discussed before, high income for some specialists and procedures are not market-drive but are set by policy; Medicare sets these rates.

As far as geographic disparity is concerned, this is an issue that most effects primary care and a few other specialties (psychiatry, general surgery) since most subspecialists practice only in urban areas where there are sufficient populations to use their services. This also can be addressed by money: pay providers differentially more for more rural practice. We also need to provide financial resources to support these practices not only for income, but for wrap-around care. Support must be provided to these practices so that they can afford the capacity to care for the complex problems addressed in the survey.

A general practitioner from Denmark (not one of the 10 countries surveyed) told me about how his anesthesiologist son-in-law really liked his work. I chuckled about how much he must make. He told me no, actually in Denmark GPs make more. This is a good illustration of how our assumptions are context bound.

It is also the way we need to go in the US.

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[1]Osborn R, Moulds D, Schneider EC, et al., “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, Health Affairs 34, no.12 (2015):2104-2112, doi: 10.1377/hlthaff.2015.1018