The Affordable Care Act: Blessing or Curse?

This morning the Secretary of Health and Human Services, Kathleen Sebelius, was testifying before a committee of the United States House of Representatives. Nominally, the subject of the hearing was the mess that is the healthcare.gov Website, about which we've been hearing so much since people started trying to use it on October 1.  To say the Website crashed and burned would be very charitable.

But of course the give-and-take at the hearing ranged much more widely, and there was much discourse on the Affordable Care Act that went far beyond the fact that people haven't been able to sign up for new health insurance coverage through the Website.  That is as it should be, because the hearing should have been very short if it were about nothing else:

Rep. Gerrymander: "The Website is a disaster."

Sebelius: "Yes, it is.  President Obama said to me, 'You didn't build that,' and he's right, I didn't.  If I had, I should be fired.  But it's a mess, and I'll see to it that it gets straightened out.  It's a temporary problem, and it won't keep anyone from signing up long before the deadline.  Oh, and by the way, a Website that seems to have been designed by incompetent fools doesn't have anything to do with the merits of the law or the wisdom of imposing an individual mandate."

Rep. Gerrymander: "Thank you, Madame Secretary.  Mr. Chairman, I yield the balance of my time to the American people, so the 24-hour news channels can go back to their special coverage on twerking."

But members of the committee had a lot to say about the Affordable Care Act. Occasionally they actually asked Secretary Sebelius a question instead of just prattling on, and every so often they even allowed her as much time to answer a question as they spent asking it.

The dividing line between Democrats, who like the ACA, and Republicans, who don't, was not subtle.  One Democrat representative said the ACA would achieve universal coverage, putting an end to the problem of having 50 million uninsured Americans.  That is so obviously delusional that I'm sure the only reason she wasn't immediately removed to a psychiatric institution is that she is a Member of Congress.  Even the most ardent proponents of the ACA know it will not do that.

Some people who will be newly eligible for Medicaid won't sign up.  Some who are not, and who will face a penalty if they don't sign up for health insurance and pay for it, will choose to pay the penalty, because even with whatever subsidy they might qualify for, they still would have to pay more than they think they can afford in premiums, and the penalty is a lot cheaper.  Some who will be newly eligible for Medicaid live in states where Medicaid is not being expanded.  The Supreme Court told Congress it doesn't have the power to force the states to expand Medicaid, and some won't.  Those people are out in the cold, and they'll stay there.  Some people will actually go from having some sort of coverage to having none.  Their small-business employers will drop coverage, or their employment status will be changed so they don't qualify, and they'll be forced into the exchanges, where they will discover the penalty is cheap compared with the premiums (see above).  Others have individual coverage that doesn't meet the requirements of the law.  Those policies will be cancelled, and the new policies they could get instead, through the exchanges, will be more expensive, and they will pay the much cheaper penalty and go without insurance.

So the Congresswoman who made that claim for the ACA was either indulging in hyperbole (to put it mildly), or she cannot do arithmetic and thinks reducing the number of uninsured by about 60% (from 50 million to 20 million) is the same as reducing it to zero.

[Oh, by the way, if you're wondering about the 10-12 million undocumented immigrants, they're not counted in the 50 million, so if you want to count them, make it 60 million uninsured, and the total left uninsured after the ACA is fully implemented will be 30 million.]

So the glass is half full.  Not full.  I hope the Congresswoman isn't too thirsty.

Much of the rest of what I heard was also untrue, and I gave a little thought - but only a little, because it may not really matter - to whether the people saying these things really believed them and were just mistaken, or whether they are liars.  The fact that all this was taking place on Capitol Hill strongly favors both, because these are people highly skilled in saying false things and say them so often that they begin to believe them.

Sebelius, for example, said that the newly insured will be able to see primary care doctors and stop going to emergency departments, where the care they receive is very expensive and ineffective.  Multiple lies in one statement.  Wow!  An artist!

The newly insured may have Medicaid, though expanded Medicaid coverage. Try calling a primary care doctor's office to become a new patient and wait for the response when you say your insurance coverage is Medicaid.  Dr. Smith is not taking new patients.  (Translation: Your kind ain't welcome 'round here.)  Maybe your new insurance is not Medicaid.  Dr. Smith may very well still not be taking new patients, because there is a serious shortage of primary care doctors.  My internist, who has a strictly office-based practice, providing adult primary care, hasn't been taking new patients for years.  When I started seeing him as a new patient, the answer I got when I first called for an appointment was that he wasn't taking new patients.  Then I made the case, to the receptionist, for being an exception to his not taking new patients: (1) my mother-in-law had been his patient; (2) my wife was his patient; (3) I was a resident when he was junior faculty, and we'd known each other for 30 years.  If you think those things made it a slam dunk, think again.  I wouldn't have been surprised if she'd still said no.

So you have insurance now, but you still can't find a primary care doctor, or when you do find one, getting a timely appointment is no mean feat.  So, you call the office when you're sick, and you are offered an appointment the second Thursday of next week.  By then, you figure, you'll be over whatever it is that ails you, or you'll be dead, and it doesn't seem prudent to take the "watchful waiting" approach to see which it is.  "Really?" you ask.  "Nothing sooner than that?"  "If you think you need to be seen right away, go to the ER," says the receptionist, trying to be helpful but condemning you to a two-hour wait on a Monday afternoon, when every emergency department in the galaxy is swamped.

Secretary Sebelius doesn't really believe the ACA will reduce ED visits by people who can be seen in a primary care doctor's office instead.  She knows better. She was governor of a state, and she's a cabinet secretary, and it's not possible to have that resume and be stupid.  Well, maybe it is, but I've listened to her, and I'm pretty sure she's not stupid.  She cannot possibly believe what she said.  And that makes her a liar.  Surprise!

Then there is the part about emergency departments being terribly expensive and ineffective.  Is that so?  Well, let's look at those claims.  If you go to the emergency department because you have a fever and a cough and are worried you have pneumonia, does it cost more to provide the care than it would if you go to your doctor's office?  Well, you see a doctor and are examined.  Then you have a chest x-ray.  The doctor looks at the x-ray, and tells you that you do have pneumonia.  Discussion ensues about whether you are sick enough to be treated in hospital.  You and the doctor agree that you are not.  You leave with a prescription for an antibiotic suitable for pneumonia.  The cost of providing that care is no higher than if you'd gone to the doctor's office.  But there is no way for you to know that.  You don't get a bill showing the cost.  You get a bill showing the price.  And the price will be high compared to what you'd pay if you went to the doctor's office.  That's partly because the ED has higher overhead, but mostly because the ED has to provide care to people who cannot pay, and everyone else must pay more to make up for that.  Your doctor's office has no such obligation.

How about the "ineffective" part?  At the emergency department you didn't need an appointment, although you may have had to wait.  The ED never closes.  You saw a doctor, and a chest x-ray was ordered.  Where did you go for that?  Down the hall.  Some primary care doctors' offices can do basic x-rays and lab tests. Many cannot.  Your doctor read the x-ray himself.  He does that all the time, and he's really good at it.  No waiting for a radiologist to read it, although one may have read it right after it was done, depending on how busy she was.  Oh, and by the way, while your regular doctor may be pretty good with illnesses, how about injuries?  Emergency physicians see all comers, all the time.  They have to be knowledgeable about everything, and what they are best at is figuring out if what you have is going to cause you serious harm or kill you.

Does that sound "ineffective" to you?  When I heard that word, I didn't take it personally.  I know Secretary Sebelius is just saying something that many folks inside the beltway say all the time, even the ones who know better.  And I know if she ever needs to see a doctor right away for something that's really worrying her, and she goes to an ED for that purpose, "ineffective" will be the word farthest from her mind.

There is no question that the ACA, when fully implemented, will reduce the number of uninsured in this country by 50-60%.  And that is a good thing.  But having insurance is not the same thing as having timely access to high-quality medical care.  That is what people want.

There is one place where people have timely access to high-quality medical care 24-7-365.  You know where that is.  It's where I work.  Can we take care of everyone's health care needs in the emergency department?  Of course not.  But in a health care system that serves so many so poorly, providing care in a way that is highly fragmented and often chaotic, in the ED we do our best - which is pretty darned good -  to pull it all together and provide excellent care to everyone who shows up.

If Secretary Sebelius, or anyone else inside the beltway, thinks we are too expensive, or ineffective, or that the ACA means people won't need us except for true emergencies, they are seriously misinformed or just being careless with the truth.  I'd like to give them the benefit of the doubt, assume they are seriously misinformed, and keep striving to correct that.  It might help if this blog were required reading for them.

Space on a Plane and the Loss of Civility

Earlier this month I flew from Pittsburgh to Seattle for a medical conference.

I am not a frequent flyer any more.
 
When I concluded my six-year tenure as a member of the Board of Directors of the American College of Emergency Physicians, I suddenly had much less reason to travel, and the airlines are interested only in how much you have flown lately, not historically.

Once one is not a frequent flyer, all the little things one took for granted disappear: the shorter line (when there is one) at TSA Security Theater (acknowledgement to a lovely colleague from Georgia who calls it that); an earlier boarding zone; no extra fee for checked bags; and an upgrade once in a chartreuse moon (blue moons happened more often than upgrades for me).

So, bereft of all those little perks I had come to take for granted, I was not surprised that changing planes at Chicago's O'Hare, the nation's second busiest airport, was not the least pleasant thing about this trip.

However, as much as I think the airlines, and TSA, and the folks who run the airports could all do things to make air travel less of an ordeal, especially for those of us who are not "preferred" on any airline, this trip made me realize that there are things we can do to make life better for each other.

Repeatedly I found myself wondering whatever happened to civility.

Examples of its disappearance abounded.  There was the fellow who saw that I was taking longer than he would like to get my stuff into those plastic bins at security - and believe me, I'm very efficient, having done it so many times that even someone my former-schoolteacher mother would have called a slow learner could do it with blinding speed.  So he looked at me, heaved a loud sigh of exasperation, and made a great show of barging past me to put his own stuff on the conveyor ahead of mine.

As a result of this, he got to wait for the tram to the gates 30 seconds longer than I did.

Then there is the waiting for the tram.  At the Pittsburgh airport, the people exiting the tram get out first, from the other side, before the doors open for those boarding.  Some inexperienced travelers don't know this, and so they stand back from the doors to allow room for exiting passengers.  I watch in amazement as some who know this isn't necessary slide right in front of them to take positions that will allow them to board the tram first.  The line from the movie "Norma Rae" comes to mind: "You must be from New York."

At the gate, I am not flying Southwest, the only airline that organizes boarding in very small groups, thereby minimizing the rush and confusion attendant upon all other boarding schemes, in which all 14 thousand people in Zone 2 want to be the first of their group to board.  If you fly, you've seen it: some passengers behave as though they are boarding in Zone 1, only to hang back toward the end, then pause - revealing they aren't holding boarding passes for Zone 1 at all - before stepping briskly forward to begin boarding as soon as the gate agent reaches for the microphone to announce Zone 2.  I am convinced there is some prize for being the very first to board in one's zone that I've just not heard about yet.

Why are people so eager to get onto the plane?  Why do they want to sit in seats just large enough for elementary school children any longer than they must?  You see, space in the overhead bins for carry-on luggage is limited.  The sooner one boards, the more likely it is that there will be space available.  Being in a later-boarding zone and finding that the space is all full is quite frustrating, as one tries to work one's way back forward in the plane and hand the bag off to a flight attendant to be checked with all the luggage that people will be waiting for at baggage claim (for one of life's longer versions of eternity).

Walking down the aisle of the plane I happen upon yet another example of incivility.  I see a young man smartly hoist his carry-on bag into a space in the bin directly over row 8, where I am going to sit, and then keep walking down the aisle. I then see that there is no more space left in an overhead bin anywhere near row 8.  So I keep walking, and eventually locate space above row 22.  Guess who's sitting in row 22?  Indeed!  The same fellow whose bag is now above my seat. As I place my bag in the bin above him, I realize I will now have to make my way back forward while the flow of boarding passengers down the aisle, barely wide enough for one person, is moving in the opposite direction.  As I'm doing my impression of a salmon swimming upstream, I wonder why he thought this was a good idea.  Did he really think all the space in the bins closer to his seat would be full?  No, I'm pretty sure he didn't.  I'm pretty sure he didn't think at all, about anything other than grabbing the first space he saw, and that was probably not thought but a reflex, something from our reptilian ancestors.  Yes, that's it.  No thinking at all, because "thoughtless" is the word that best fits his behavior.  And at the end of the flight, I will have to wait for nearly all of the passengers to disembark (I cannot bring myself to use the absurd "deplane") before I can head back to row 22 to retrieve my bag.  Fortunately, I do not have a tight connection at O'Hare.

Did I mention - yes, I think I did - how busy an airport O'Hare is?  I have time enough to grab a bite to eat and a drink.  I'm pretty sure I can find something far better than what will be "available for purchase" on the flight from Chicago to Seattle.  (No complimentary meals nowadays, although thoughts of such things are great when one is in a nostalgic mood.)  But it is early evening, and O'Hare has meal facilities that are adequate for the number of passengers changing planes there at 4 AM, not 5 PM.  After considerable searching for a restaurant with seats, I give up on that idea and notice - joyfully - a place that is selling decent-looking sandwiches with a line short enough that I should get to the cash register before my flight is boarding, with perhaps a nanosecond to spare.

On the flight from Chicago to Seattle, I know I will be in my child-sized seat for about four hours, and I realize I should use the time to get some work done on my notebook computer.  It's a 15-inch MacBook Pro - not the smallest choice, but not overly large, either, and I've paid the extra money for a seat in the part of the plane United calls Economy Plus, which means my knees are not pressing into the back of the seat in front of me.

The plane reaches cruising altitude, and we have been given permission to use our electronic devices - as long as smartphones are in airplane mode, so you can use them only to play games and do other things that don't involve sending and receiving signals.  I don't quite understand this, because I'm pretty sure there are no signals to receive at 30,000 feet, and I'm also pretty sure I cannot use my smartphone to direct the plane to land in Tahiti instead of Seattle.

Now it's time to take out my computer and get to work.  Then I notice that the fellow in the seat in front of me is reclining.  This means I can open my computer just barely far enough to see the screen and have room to get my fingers onto the keyboard to type.  To make the effort more interesting, every so often, he repositions his body in his seat, hurling himself against the seatback, during his flopping-fish imitation, with sufficient force to cause me to snatch my computer off the tray and pull it all the way back against my chest to keep it from being damaged by the shockwave.

This mystifies me.  By "this," I mean two things.  First, why are seats built to recline, when the only thing that does is make the passenger immediately behind even more miserable, while changing the angle of the seatback far too little to make a difference in the ability of the person "reclining" to fall asleep?  Second, why does the person who wants to move the seatback to that useless angle not realize this, and think, "Oh, that won't help me, it will only torture the passenger behind me, so I won't do it."

I have a personal rule.  I rarely think of reclining my seatback, but if it crosses my mind, I do it only if the seat behind me is unoccupied.  If that seat is occupied, I do not look around and ask the occupant if s/he minds if I recline.  Doing that would put my fellow passenger in an awkward position, having two choices.  First would be to lie: "No, I don't mind at all if you put your seat back, reducing my personal space when I hoped it was already at an irreducible minimum."  Second would be to say, "Well, actually I do mind, and I would rather you didn't."  A fellow passenger may not tell the truth and pick option 2 for fear of being perceived as a jerk.  So, my thought on putting the seat back: it is an act of hostility, something one does only because one delights in torturing the person seated directly behind.

I'm trying to soft-pedal this.  Notice I called it an act of hostility, not an act of war. Those familiar with the language of geopolitics will see the difference.  I didn't call it an act of war, nor did I - tempting though it was - call it a war crime.  I did think about calling it that.  You see, I am convinced that, were they evaluating the practice of placing coach passengers in those tiny seats for flights lasting longer than an hour or so, Amnesty International would declare it torture.  And so, a passenger who deliberately makes it worse for the person directly behind may, indeed, be committing a war crime.

By now you know how much I enjoyed my transcontinental adventure.  And I was flying United Airlines - you know, that airline that uses theme music from George Gershwin (who, I am quite certain, would strongly disapprove) and the slogan "Fly the Friendly Skies."  Friendly?  What is the appropriate response to that?  I think a guffaw fits rather nicely, don't you?

But if we want the skies to be friendly, what say we begin with each other?

Turn in Your Drugs? Just Say No!

Tomorrow (October 26, 2013) is National Drug Take-Back Day.  The Drug Enforcement Administration (DEA) says this day "aims to provide a safe, convenient, and responsible means of disposing of prescription drugs, while also educating the general public about the potential for abuse of medications."
This has been a twice-a-year event since October 2010, and tomorrow will be the seventh such specially designated day.

On the last National Drug Take-Back Day this past April, the public turned in nearly three quarters of a million pounds (or 371 tons, if you are among my "tons of friends" who like the word tons better). Press releases from the DEA offer some insight into the rationale underlying the program:

According to the 2011 Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health (NSDUH), twice as many Americans regularly abused prescription drugs than the number of those who regularly used cocaine, hallucinogens, heroin, and inhalants combined.   That same study revealed more than 70 percent of people abusing prescription pain relievers got them through friends or relatives, a statistic that includes raiding the family medicine cabinet.  

Although I am neither a lawyer nor a statistician - nor do I play either of them on TV, nor did I stay at a Holiday Inn Express last night - I love to look at sentences like that and examine what they really mean.

More than 70% of people using prescription drugs got them through "friends or relatives."  I am walking the streets and happen to see my buddy Jim.  "Hey Jim! Ya got any Oxys?"  (For the uninitiated, this is short for oxycodone, a potent prescription analgesic derived from morphine, which in turn was derived from the opium poppy.  These drugs are all generically referred to as opioids.)  Jim says he does.  We settle on a price, and both walk away happy.  Is Jim a drug dealer? You could say that.  But he is also my friend, and he counts in the statistic cited above.

So what are we really worried about here?  Mama is going out to get the mail. She slips on wet grass and falls, resulting in a rather nasty fracture of her ankle. She goes to the hospital and gets operated on by an orthopedic surgeon.  When she is discharged, the orthopedist estimates how much pain medicine she'll need for how long and writes a prescription for that.  As it turns out, she doesn't use anywhere near all of it, and it sits in the medicine cabinet.  Her teenage son or daughter or friends of theirs visiting the house discover the pills, and you know what might happen from there.

So what should you do?  Well, first, before you open the medicine cabinet, look in the mirror on the outside of it.  Ask yourself if you are the sort of person who might get addicted to opioids.  This requires a bit of introspection.  When you were taking the pills prescribed for some painful condition, did you always take them solely because you were in pain?  Or did you ever take them partly because you liked the way they made you feel?  Because they seemed to make the day go better?  Because when you took them your mood was better, you were less likely to get into an argument with your spouse, less likely to yell at the kids when they didn't really deserve that?  All of those other reasons for taking the pain pills - reasons other than straightforward pain relief - suggest you may have a propensity for getting addicted.  And maybe once you no longer need the pills for the problem they were prescribed to help with, it would be better to get rid of them.

As you might guess, though, that propensity toward addiction is more - much more - of a problem for people with chronic pain, who can't just get rid of the pills any more than they can just get rid of the source of chronic pain.  So those unfortunate folks have to ask themselves those questions about why they're taking the pills frequently, if they want to make sure they aren't slipping from seeking pain relief into seeking escape from life's annoyances or seeking mood elevation.

If, however, you are confident that you are not inclined toward addiction - maybe the pills just don't really do anything for your mood (not everyone experiences euphoria from opioids), or maybe you just don't have those kinds of at-risk personality traits - you probably don't see any good reason to get rid of your pain pills.  After all, you never know when you might need them for something else, and as long as they're still "good," why throw them away?  That's just wasteful. (By the way, most prescription drugs have a shelf life that goes far beyond the expiration date on the bottle.)

If you're not worried about yourself, and you have no irresponsible people living in your household, then why would you turn in your drugs?

You wouldn't.  No, you would, instead, respond to this program by asking, "What? Have these people lost their minds?"  And you might make a list of the reasons why this is a dumb idea.  (1) It's wasteful to throw away perfectly good medicine. (2) If I need a strong pain reliever in the future, I can just go to the medicine cabinet instead of bothering my doctor.  (3) If I had turned in my drugs and had to go see my doctor for an evaluation resulting in the issuance of a new prescription, his records would reflect the old prescription and the new one, and he might get the wrong idea about how much pain medicine I'm using, unless I remembered to tell him I used only half of what he gave me the last time and turned in the rest. (4) My primary care doctor never likes to give anyone more than ten pills of a controlled substance, because he always feels like Big Brother at the DEA is watching him, and any time I ask him for pain medicine, I get the uneasy feeling that he thinks maybe I'm a whiner who should just "walk it off."  So if I hold on to the extra pills left over from the orthopedist who operated on my broken ankle, I can avoid all that.

I'm sure you could come up with some more reasons of your own to add to this list.

You probably know, if you're a regular reader - and especially if you read my essay on New York City Mayor Michael Bloomberg's anti-Big Gulp campaign - that I am an avowed skeptic regarding any government programs based on what folks in government think is good for us.

Just in case you thought I was going to overlook an opportunity to skewer Big Pharma, there is funding for a public education campaign about this program from a company than makes opioids.  Turn in your drugs, and we get to sell more of them when you need them later.  Yes, I know, I'm just a cynic.

So, do I think you should turn in your drugs?  If you're like most people, Just Say No (credit to Nancy Reagan, although she was looking at a different aspect of the drug problem when that tag line was developed).  But there is a certain value in this program.  I hope it will get people to think about whether their own use of prescription opioids might not be solely for pain relief, that maybe they like the mood elevating effect, and that could suggest they're at risk for getting addicted. And I hope it will get people to think about whether prescription opioids in the home might be found and abused by teenagers or other irresponsible persons, in which case taking steps to secure potentially dangerous drugs is the logical solution.  This might mean turning them in, or it might mean locking them up.  If you have a potentially irresponsible person in your household, you should no more leave a dangerous drug unsecured than you would leave a firearm unsecured.

So, tomorrow ... have a nice day.  And hold on to your drugs, unless you're taking them just to have a nice day, or you have another good reason to turn them in.