If you think we are prepared for a pandemic, think again.

We are in one of the worst flu seasons in recent decades with thousands of Americans dying every week and the Trump Administration is proposing huge cuts to health care access, spending and public health. 

Indeed, Republican efforts to cut access to healthcare -- affordable healthcare -- for every American put us on the path to a deadly global pandemic. 

AS reported by Futurism, The Director of the World Health Organization Tedros Adhanom explained: 
The threat of a global pandemic comes from our apathy, from our staunch refusal to act to save ourselves — a refusal that finds its heart in our indifference and our greed.
“Universal health coverage is the greatest threat to global health,” Tedros proclaimed. As the audience shifted in their seats uncomfortably, he noted that, despite the fact that universal health coverage is “within reach” for almost every nation in the world, 3.5 billion people still lack access to essential health services. Almost 100 million are pushed into extreme poverty because of the cost of paying for care out of their own pockets.
The result? People don’t go to the doctor. They don’t seek treatment. They get sicker. They die. And thus, as Tedros explained, “the earliest signals of an outbreak are missed.”


The Myth of Islands

An Island is a lie.

On my way to work, I drive along Willapa Bay and pass by the two Islands that can be seen from the mainland. Long Island crowds just feet from the highway that hugs the shore. Heavily forested it stretches away to the horizon, appearing as solid shoreline. Long Island holds a grove of ancient forest and in days past was inhabited with settlements. There is a ferry landing just off the road that used to bring trucks back and forth across the narrow thread of water that separates it from the rest of Washington state.

A little farther on is a defiant little islet several hundred yards from where the tourist pass by on their way to the beach.. The US Geographic survey named it Round Island back in 1858. Locals call it Baby Island. Its shoulders’ hunched and spiked with snags and cedar that burl in the winter storms. Only a few acres of brush and trees, it appears a picturesque myth centered in the waters of the bay. Steep rocks rising from the silver gray waters and lonely alone.

We like to think of ourselves as islands, as individuals, as ecosystems wholly within ourselves. We like to believe that our actions affect no one beyond our ragged shore. We like to believe ourselves surrounded by waters isolated from the world outside. We like to think ourselves individuals, the center of our own solar systems -- centered yet separated by time and space from mothers, wives, children and friends who dip into our orbit for time only to swing away again.

It is easy to feel alone.

It is easy to think that our actions do not shatter the mirrored water that flows around us, yet the decisions we make ripple out into the world.

We see it in politics, where the temptation is to live and let live, assuming no responsibility for the community, the state, the nation or the world.

I hear it all the time. I’ll take care of myself, do what I want, and it won’t affect anyone else. If other people make bad choices, can’t access health care or mental health services or run out of money when they are too old to work, that’s their problem. It won’t affect me.

Yet it does.

I work as a nurse in an emergency room. It is the front line of the consequences of bad choices.
I meet a lot of people who until that moment thought that they were islands. Many thought their decisions affected no one but them and them alone.  Some have long suffering loved ones at bedside, others have long since burned those bridges to the mainland. Perhaps they justified this as a way to limit that damage they caused, or perhaps the connection was never very good in the first place.

If not family and friends, there are always the professionals -- the police officers, EMTs, nurses, doctors and socials workers -- who crash in waves trying to make a difference until the last breath.

Every wave recedes taking a little away from the beach and leaving a little of itself behind. Yet, the ocean itself is not unchanged.

I have watched as addiction destroys families and devastates public resources. I have seen suicide shatter communities. I have seen health care professionals struggle to make a difference in the face of increasing needs and decreasing resources.

I have seen doctors and law enforcement officers that I worked with take their own life.

Studies have shown that nurses experience depression at twice the rate of the general population. Doctors have a suicide rate that is at least twice that of the general population and that rate is even greater for female physicians. The stresses come from long hours, increasing work loads and the crushing expectations of health care systems that are always demanding more and paying less. Unfortunately, few seek professional help.

So too some of the stress comes from our own expectations. Physician Pranay Sinha, in a 2014 essay entitled “Why Do Doctors Commit Suicide?”  in the New York Times explained it this way:

“There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel the need to project intellectually, emotional and physical prowess beyond what we truly possess. We masquerade as strong and untroubled professionals even in our darkest and most self doubting moments. How, then, are we supposed to identify colleagues in trouble -- or admit that we need help ourselves?”

Individual strength, resilience  and freedom are cultural virtues in our nation.Yet we achieve most when we come together and recognize our connections and that through those connections our individual decisions have repercussions on the world around us.

This far north the tides are impressive - a dozen feet in sea level change can drastically alter your perspective in a few hours time. When the tide is low, the water drains out of old Shoalwater bay and Round Island is exposed as connected to mainland by mudflats that the unwary may be tempted to walk across.

Drain away the oceans that appear to separate us, and you will find underneath the connections that tie us all together. 

What we do and say and how we act affects those near and far.

How we treat each other and how we take care of ourselves matters.

If you think you are an island, just wait until low tide.


This essay was originally written for the The Daily Astorian and published on 4/29/2016.


The Avalanche of Death: This is just the start of US healthcare's collapse

The tax plan passed by the GOP last night is mostly a sop to their donors with some ultra-conservative red meat thrown in to win a few senators who may have once pretended to care about fiscal responsibility.

However, one thing included in the bill is essentially a repeal of the individual mandate to have health insurance -- a key component of the Affordable Care Act.

With this mandate gone, millions are expected to lose access to health insurance, and those of us that still have health insurance can expect it to get more expensive.

The reason is simple -- and the basis for all insurance programs. If something is expensive, you spread the cost out over a large group of people so they can pay small amounts. The problem with health insurance is that not enough younger people sign up for it.

That leaves only older, sicker people paying in to the system. The individual mandate sought to increase number of people paying into insurance pools so as to spread out the costs. Moreover, younger people get sick too -- not as often perhaps -- but they get in accidents, get sick, have sick kids. There is good reason to have insurance even if you are relatively healthy, and the more people with insurance, the lower the costs for each individual.

However, drop the mandate and many of those people will likely leave the pool. That means increased insurance premiums for the people who are left.

As premiums go up, fewer people can afford to buy health insurance and more drop out.

Wash, rinse, repeat.

Meanwhile, the Trump White House and Republicans are already planning to pay for their big tax cut with "entitlement reform." That is the GOP's expression for cutting Medicare, Medicaid and Social Security.

It is something they've wanted to do for a long time. Now they've created an excuse - the tax cuts could trigger forced spending reductions in Medicare starting as early as next year. 

Cuts to those programs will lead to more uncompensated care, which will make healthcare more expensive for insurance programs, which will lead to higher premiums.

More sick people not getting the care they need.
More medical bankruptcies.
Fewer providers.


Vox: Tax Bill is Just the Start of the Obamacare Collapse.
WAPO: GOP Eyes Post Tax Cut Changes to Medicare, Social Security
LA Times: After Giving Tax Cuts to the Rich, GOP Will Cut Social Security, Medicare
Forbes: How the GOP Tax Bill Will Blow Up Medicare
NYT: The Tax Bill's Automatic Spending Cuts

Own it and Learn

As a nurse, I hate making mistakes.
I try not to make them, but they sneak up on you despite your best efforts.

Usually, they come when you feel like you're on top of things, like you have it all under control.

Let your guard down.
Fail to do the one thing you always do.
Fail to catch that vital bit of information at that crucial time.
Trust, when you know you shouldn't.

When I do make mistakes, I've learned that there is a professional -- and healthy -- way to cope.

1) Own it. (Admit it to team quickly and openly) Covering up a mistake, or spending time the the denial phase only makes things worse. Errors are compounded by obfuscation and willful ignorance. Admitting it to your team lets them know you made a mistake and gets them on board with helping you correct it. Moreover, it let's them know that you are aware of the error and not a incompetent idiot who can't be trusted.
2) Figure out how I can avoid repeating it. Every error is an opportunity. Figure out how you got fooled, or why you got complacent, and never let it happen again.

3) Share with peers - so they can learn from my mistakes. This is the other half of owning it publicly and will help when confessing your sins. "Man, I learned the hard way, I'll never get burned like that again."

Mistakes haunt me, they make for a long ride home and a hard time sleeping, especially when they have a negative outcome on the patient. Mistakes make me question my place in this profession and all the time I spend teaching others.

I played cornerback in high school football. Playing defensive back is tough because you will get burned for a big play eventually. The receiver knows the route, you don't. The quarterback knows it is a fake, you don't. You are at a disadvantage of knowledge. When you get burned, there's no time to get down on yourself. Pick your jock up off the turf and get back to the line, the next down is coming fast.

I learned to yearn for the next down after getting beaten by a big play. Getting it right was the only way to get the taste of getting it wrong out of my mouth.

Experience builds confidence if you learn along the way. Each experience is a piece of armor as we go into battle against the unknown. You get tougher. You get smarter, faster - you catch some little thing that you overlooked before.

The most important play is the next one - because that's an opportunity to get it right.

We can't be perfect.

But we can get better.



The GOP Plan to Kill Employer-Based Health Insurance

Mabel Goodwin, forty-five, is examined by a woman doctor at the employment office of the Bell Aircraft plant.  Our Employer based health insurance has its roots in World War II. Library of Congress photo.

I don't know what worries me more, the fact that after eight years, Republicans don't have any single plan as they rush to replace the Affordable Care Act, or the plans that they DO have all involve higher out of pocket costs for healthcare and more people losing their insurance.
Trump's pick for Health and Human Services is Rep. Tom Price. Like all of Trump picks, he is an extreme conservative who hates the agency that he is being asked to lead.

Rep Tom Price has wanted to get rid of the Affordable Care Act more than anyone.

He also has a plan to get rid of employer based health insurance.

As noted in this morning's Talking Points Memo, there has long been an idea in Republican circles that providing healthcare to employees is a drag on the American economy. Even liberals like me think that our way of providing health care is inefficient, an accident of history that created a convoluted system.

Employee based healthcare came about during World War II. With workers in high demand, offering health benefits became a way for companies to attract and keep employees. In 1943, the government decided that the costs of companies providing this health insurance to employees should be ta deductible.  This was good for companies -- in that they could write off the cost of their contribution to employee health insurance. It was good for employees too as health care became increasingly expensive with new technology.

They problem with that system is that if you lose your job, you lose your health insurance.

The Affordable Care Act tried to offer an alternative, allowing individuals sign up for health insurance even if they didn't have a job. Some found that plans on the individual market where better than what was offered by their employer.

That said, seven times as many people get their health insurance through work than through the Affordable Care Act -- half the living US population gets health insurance that way.

Price's idea make it much more expensive for the employee and the employer to do so, thereby pushing more people out into the individual marketplace to buy insurance.

Employers would lose tax incentives to provide health insurance to their employees -- the amount of taxes they could write off would be capped. That would mean either passing more of the cost of health insurance to the employee contribution -- making it more expensive -- or vouchering a set amount to the employees to go buy their own insurance. Eventually, the idea would be to drive employees out into the individual marketplaces.

This aligns with Rep Paul Ryan's plan to privatize Medicare too. Ryan wants to turn Medicare from an insurance program to a voucher program which relies on individuals to choose their own plans in the open marketplace. Price's bill would allow people to opt out of Medicare and buy individual insurance plans that likely would be attractive because they cost less, but would also likely not cover as much of the healthcare costs.

The problems with that are several:

1) Republicans also want to repeal the individual mandate - the requirement that people buy health insurance. That means young and healthy people won't buy insurance, which makes insurance much more expensive for those who need it.

2) Republicans want to repeal the requirements that health insurance plans have a basic set of things that are covered. That means you would have to choose from a huge menu of confusing plans, pay in for years and never really be sure if your insurance is actually going to cover you when you get sick.

The idea is that, by having more people choosing their own plans -- and by having insurers freed of many of the ACA's regulations -- younger and healthier people will be able to get cheaper, but skimpier plans.
However, that approach comes with its downsides. With younger and healthier people shifting to more meager plans, the risk pools for people who need more comprehensive care -- the older and the sicker -- decrease in size while growing in average cost. For them, Price proposes a high-risk pool set-up by the states, though the amount of federal money he's willing to invest in them is dwarfed by what it's expected they'd cost.
"There's a lot here that is oriented towards separating the cost of people who have health issues from people who don't," Blumberg said.

Employer based health insurance was a way to share the costs of healthcare. The young and healthy pay in, but use less, reducing the cost for the older patients who need more expensive healthcare.

This is all about how the GOP views health insurance. They feel it is an individual responsibility to pay up or suffer. Moreover, their corporatist leanings have them working to reduce the burdens on employers to provide health insurance -- pushing that burden onto the individual. They emphasize "access" and "choice" to indicate that anyone will be able to buy health insurance if they have enough money.

If you don't have the money, you'll get what you pay for. 

You are going to see a lot more high deductible and catastrophic health insurance options on the marketplace and these options are going to be attractive because they will cheap. Yet they won't cover most health care. Indeed, under most Republican plans you and I are going to pay a lot more out of pocket for our health expenses. 

Where as the ACA tried to broaden the risk pools, which reduced the costs for everyone, the GOP plans want to segment the types of insured so insurance companies can charge much higher premiums to the elderly and sick. This at a time when medical bills are already the biggest source of debt -- even for people with health insurance.

"What this does is it helps you when you are young, when you are perfectly healthy. But we don't stay that way," Health Policy Analyst Linda Blumberg told TPM. "The costs go up tremendously and access decreases tremendously when you have health care needs."

That seems to be a theme among all the Republican health care proposals -- put more responsibility on the individual both for the cost of the premiums and the bills when they come due. They all involve the hope that somehow insurance companies become more efficient and less profit driven, which is unlikely to happen. 

Finally, there is the problem of responsibility. What happens if someone doesn't buy health insurance - or if the bargain basement plan purchased by someone with limited or fixed income doesn't cover unforeseen healthcare costs.  

Aside from the return of medical bill bankruptcies -- which decline under the first years of the ACA -- Republicans propose decreasing support for medicaid and medicare with few backstops for the poor, sick and uninsured. 

As I said earlier, I think employer-based healthcare is a drag on the economy, but I differ from Republicans in thinking we should put even more burden on the American people. 

That's because I believe putting individuals deep into debt or bankruptcy to pay for healthcare is a burden on our nation as whole -- a drag on the economy. 

Other industrialized nations don't have medical bankruptcies.

However, that is because other industrialized nations have public healthcare options. 


Required Reading:
The Accidental History That Created the US Healthcare System NPR
Sara Kliff Read All the Republican Health Care Plans, Here is What She Found, VOX
Price's Bill HR 2300
Obamacare seems to be reducing medical debt NYT
Even the Insured Can Face Crushing Medical Debt The Upshot
Why Americans are Drowning in Medical Debt. The Atlantic