What's Going to Happen to Obamacare?

Republicans have been elected on a single promise over the past few elections -- repeal Obamacare.

Most people have heard the name, but don't know what it means. If you ask them about the benefits of individual provisions of the law, they are in favor of it. If you call it Obamacare -- they hate it.

The problem all along has been that there is no  Republican alternative -- that's because the private insurance based ACA WAS the Republican alternative to expansion of medicare and medicaid.

And just repealing the law would leave 22 million people without insurance -- not surprising then that Trump has softened his stance since the election. 

Five Thirty Eight untangles the thread of what "repealing Obamacare" might actually mean:

The law is built on interlocking provisions; removing one puts pressure on others. That’s what happened when the Supreme Court made the Medicaid expansion optional for states, leaving 2.5 million people in states that chose not to expand in what has been called the Medicaid gap: too poor to be eligible for the marketplace subsidies but ineligible for Medicaid. Leaving in place the mandate for insurance companies to cover people with pre-existing conditions, as Trump said he’s considering, while getting rid of either the individual mandate — the requirement that people get insured — or the subsidies that motivate low-income healthy people to join the insurance rolls could also create instability in the insurance market. Without the necessary mix of healthy people in a plan to offset the costs of insuring people with pre-existing conditions, premiums rise, becoming unaffordable for everyone.
So far there is no prescription of replacing Obamacare that won't result in increasing costs and decreasing coverage. That's the problem with governing -- people feel the effect of what you do and you actually have to follow through with your promises.

Forbes details a lot of things that are going to be bad for health and healthcare on the Republican agenda. If you want a dozen more things to be scared of it is worth reading --  The anti-science crackpots he has in line have all kinds of bad news.


Required Reading:
What the Republicans are going to do to your health.
What Will Trump Do to Obamacare  538
What will Happen to Obama Care


You Can Only Do What You Can Do

full steam a head
Triage is all about sorting out the sick from the un-sick prior to the application of limited resources.

It is a vital part of the job we do.

There are times when it feels like bailing water with a teacup on a sinking ship.

A well designed Emergency Department will have enough nurses and doctors to handle the daily expected volumes of bellyaches and runny noses as well as the chest pains and traumas. It will also have a good triage system where a nurse puts eyes on a patient on arrival and determines whether they are sick or not sick.

Yet there are always time when you will get fooled. Patients lie -- often because they don't know the truth. They don't know the important information, or their presentation is unusual, their story is vague. The medical team goes down the wrong path -- prioritizes the labs before the head CT or vice versa.

There will always be times when a department gets overwhelmed and resources just aren't available. Things get missed or miscommunicated, computers go down. Things go wrong.

I've just been through a week of these brutal days: Of restrained psych patients tipping over their gurneys and ambulances coming through the door of our little ED two at a time. Six 12 hour shifts of waves crashing against one doc, two nurses and a tech.

On my last night, I knew I was in for another 12 hours of pounding surf.

When the day shift nurse gives you a hug because they are so glad to see you come on, you know they've had a brutal 12. It took us a while to figure out that the misery to acuity ratio was out of control. Once we sorted the drama from the trauma, we took care of the sick people first and finally got thing restored to baseline chaos.

We spent most of the night, feeling like we were underwater and no amount of swimming was going to bring us to the surface.

I could see it in dayshift's eyes as they were leaving. The next shift finally comes in to clean up the mess and you kick yourself as you go home. It is tempting to blame others, or blame yourself for what went wrong.

Yet, blame doesn't fix anything ... and doesn't make anyone feel better or work better.

When other team members make a mistake how we respond can be the determining factor in helping that person recover and get better. As author Justin Bariso writes:

"leaders are in a unique position to help individuals recover from mistakes. When a leader keeps his or her own failures in mind, it's easier to use words to encourage and build up than to dishearten and tear down. By choosing to focus on the positive, skillfully sharing your own personal experience, or simply reminding the person that everyone has a bad day, you do everything in your power to help that person recover."

Of course we need to review the breakdowns in the system to make it better, to innovate to better allocate resources if possible. When the heat of battle has died away, we need to talk to our team to discuss what could have gone better. We need to learn whether we got it right or got it wrong. That's why experience in emergency medicine is the most precious resource.

However, internalizing our mistakes can take the form of self-abuse, battering our confidence and diminishing our ability to make decisions that have to be made.

It is times like this when I find myself consoling my coworkers with a mantra I've picked up over the years.

"You can only do, what you can do."

As a human being and as a system, resources are finite. We cannot see or know everything, we cannot be everywhere at once. We must triage and prioritize our tasks, triage the demands on our minds and on our souls. We are not superhuman and we cannot bear all the burdens of the world.

Nor should we expect that of ourselves or others.


Required reading: A Lesson in Leadership


The Profit-Making Costs On Our Health

photo: Library of Congress
The profit-motivated US healthcare system not only makes our healthcare more expensive than other industrialized nations, it also changes our our culture and our behavior to make us less healthy.

One of the biggest problems with the American healthcare system is that it is a rigged economic game where you don't know the price of what anything costs, and yet the price of the unavoidable healthcare needs could bankrupt you.

This price blindness is a fundamental flaw in our so called free-market system, but it is far from the only flaw tied to profit-driven healthcare.

Since so many people fear the boogeyman of socialised medicine, let's talk about some of the problems with the alternative system we now suffer through.

As an aside, please don't equate Obamacare or the ACA with socialised medicine -- it is not. The ACA simply required people to get health insurance and required private insurance companies to sell it to them. These companies are still profit motivated and opposed to cooperating with each other for the sake of good patient care.

For profit corporations are poor actors in the healthcare business, and yet we continue to place more of our lives in their greedy hands. Drug companies in particular have finally been exposed to the spotlight as they have cranked up prices on life saving medications just to boost the share on Wall Street and the bonus of the top executives. While a few high profile examples have recently gotten attention of the media, this practice is widespread and continuing unabated.

As Fortune Magazine reported:
More than two-thirds of the 20 biggest pharma companies used price hikes to drive revenue growth in the first quarter of 2016, according to an analysis of corporate filings and earnings statements by the Wall Street JournalThe review also found that drugmakers have been relying on this tactic more and more and raising prices by higher amounts than before despite multiple Congressional inquiries into the practice and proposed reforms to tackle drug costs from President Obama, Hillary Clinton, Donald Trump, and others. The findings underscore the enormous power that the biopharmaceutical industry maintains in a system where negotiations over prices and discounts are stratified across a decentralized mix of private insurers, government health programs, and drug benefit managers.
Yet another way that for profit companies negatively influence our healthcare decisions is through twisting science and lobbying government.

A recent episode of Tom Ashbrook's On Point had an excellent sampling of the horrifying impact on our nation's health.

Investigative reporters have recently uncovered evidence that drug makers lied to doctors to push the aggressive prescription of addictive oxycontin as "less addictive" alternative to drugs on the market. Documents show the drug makers knew this was not true. 

Moreover, these same pharmaceutical companies were responsible for lobbying to implement increasing the aggressive treatment of pain with narcotics. This is where the whole "pain is the 5th vital sign" originated.

Thus doctors in the United States are being penalized for creating an epidemic of narcotic addiction while at the same time their compensation is linked to surveys of patients asking if they got enough pain medication. That's why the United States -- which has only 5 percent of the world's population consumes two-thirds of the world's prescription pain medication.

It's not an accident of culture, but a concerted, planned out lobbying effort on multiple fronts designed to increase demand for a product. Millions of dollars are spent each year to boost demand for a product that is detrimental to the nation's well being.

In the same show, Ashbrook interviews researchers who discovered that a few well placed science papers in the 1960s allowed the sugar industry to divert scientific research away from carbohydrates and toward saturated fats as the cause for chronic health problems.

Of course this lead to the marketing of products with reduced fats and greatly increased the consumption of sugars.

On both issues we see the way our health culture has been altered by the pursuit profits at the cost of American lives.

Required reading:

Secret Trove Reveals Bold Crusade to Make Oxy a Blockbuster

The LA Times Series on the Oxycontin

How the Sugar Industry Shifted the Blame to Fat

To Make Big Profits, Drug Companies Use Monopoly Shenanigans

Drug Rep Arrested in Opiod Kickback Scheme

The whole On Point podcast is available and worth listening to.


Healthcare Ain't Hamburgers: Why Bills from the Emergency Room Are so High

A few weeks ago, I was working the night shift in the Emergency Room and I got a call.
"My two year old have a fever of 100.4, that's bad right?"
"Not really," I said. "Kids get sick all the time, the fever is the body's way of fighting an infection."
I got a few more details, made a suggestions for dosing Tylenol and Ibuprofen and to encourage hydration.
"So I don't need to bring him in?"
"You are always welcome to," I said. "We're open 24 hours a day. However, we'd probably just give her some Tylenol. Based on what you've told me, it doesn't sound like an emergency."

What I could have said, but didn't, was that the Tylenol at the hospital would probably cost $500.

That's not really true of course.

 The cost of the medicine we give is not the cost of the service we provide. Staffing an emergency room with highly trained trauma and emergency doctors, nurses and technicians, keeping x-ray and lab technicians on call throughout the night -- costs a lot of money.

When you get into a car accident, or have chest pain at 2 am, all those resources are put to good use -- we work hard and earn every dime.

However, the Emergency Department (it stopped being a single emergency room years ago) is not really the place you want to take your non-emergencies.

By far the majority of patients I see on a daily basis do NOT need emergency care. A generation ago, few would have thought to go to the ER for a child's fever or abdominal pain after gorging on all-you-can-eat tacos.  Things we would have waited out at home, or just massaged with an ounce of regret, we now rush to the ER for an instant cure.

Not only do we want fast-food medical cures, we also want fast food bills. McDonalds sells $1 hamburgers for that price because they pay their workers nothing and make up for it on buying and selling in huge volumes.

Healthcare is not a hamburger. 

The Emergency Room can't pay teenagers to do our job at minimum wage. We have to pay highly trained people what they are worth. We have to keep the doors open and the trauma team ready to spring into action because real emergencies happen. When you come in needing only and band-aid, we are happy to help. If your 6 year old bumps his head, we are happy to reassure you.

However, you aren't paying for a hamburger, you are paying for our expertise -- education that costs thousands of dollars to establish and maintain. Emergency room doctors and nurses have to be ready for anything, so we study pediatrics, cardiac care, trauma, respiratory care.

Two recent articles illustrate the public confusion over what an emergency department is for and why it appears that visiting the ER is so expensive.

In The Case of the $629 Bandaid, Vox examines what happened when a came in to the ER for a little cut on his child's finger. The doctor (!) washed it off and put on a bandaid - then had the audacity to charge $629 for the service.

The article never questions why the parent didn't wash the cut off and put the bandaid on at home -- like millions of people do every day, instead it focused on how horrible our healthcare system was for charging a lot of money for this misuses of resources.

Going to the ER for a bandaid is like buying a Bugatti Veyron for a 1 mile commute to work.  You could just walk -- and it would be better for you. If you are choosing the wrong tool for the job, don't blame Bugatti for charging $1.3 million.

Part of this is the loss of the intergenerational knowledge that would allow us to turn to an older parent for advice and reassurance. Now we have the internet which deals only in horror and rare catastrophes.

It is also part of our on-demand culture that we expect immediacy and instant gratification from our services. The other side of this issue is from the Kevin MD blog.

In ER Misuse and Our Instant Gratification Society, we learn that many of the people who use the ER have access to other less expensive forms of healthcare, but they choose the ER because it provides the instant gratification that we have come to expect in our service-oriented consumer culture.

I have had patients in the ER at night who tell me they have a doctor's appointment for their complaint first thing the next morning but "I don't want to get up that early."

Where this really comes into conflict is when the ER is actually treating emergencies. The people who are in ER for something minor, often don't comprehend that we prioritize care based on the sickest first -- not on first come first serve.

I have had a 30 year old walk into a patient's room where we were doing CPR on a baby to ask why it was taking so long to get seen for her ear pain. I have turned around from putting a patient having a stroke on a helicopter to care for a 12 year old with belly-button lint.

The split is generational, too.

I see older adults who worry about their bills and avoid going to the doctor or the hospital when really they should. I struggle to reassure them that we just want them to have the best care they can and that the price to protecting their heart or their life is worth it.

On the other hand, I try to warn away people who probably don't need to go. I try to explain that it costs at least $500 just to walk through the door.

This is a fear I hear expressed by providers when there is talk about making healthcare free.

Sure it will help all those people who can't afford their medications, or put off coming in when chest pain because they are fear the bills that will follow, but it will also increase the casual misuse of emergency resources by those who can't be bothered to wait for their doctor's appointment the next day.

Moreover, patient satisfaction surveys now play a big role in how much or whether medical providers will get paid.

Yet they only survey people who use the ER but aren't admitted to the hospital (thus, likely not having an emergency) This pushes hospitals to enable those demanding emergency resources for non-emergent conditions. A doctor may spend three hours in critical care saving a man's life from a septic infection only to see if rating drop because he had to ignore the 25 year old who came in complaining of a sore throat for two days.

In the end, we all need someone to tell us that we're not having an emergency for all the things that likely are not going to kill us or cause permanent damage. We can wait until morning to go to the urgent care or see our doctor.

Until we understand that emergency rooms are for emergencies, we are all going to be less than satisfied.

Required Reading:
ER Misuse and Our Instant Gratification Society
The Case of the $629 Bandaid
The ER and Our Inverted Priorities
The ER is for Emergencies, from the Washington State Hospital Association


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 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.