Adam Smith, the Scottish economist and moral philosopher of the 18th century, in his book An Inquiry into the Nature and Causes of the Wealth of Nations, generally referred to by its shortened title, The Wealth of Nations, introduced the analogy of an invisible hand working within capitalism to promote the social good, by which he meant, according to many sources, a “process by which market competition channels individual greed toward socially desirable ends.” That invisible hand has failed “socially desirable ends” with the current pricing of prescription drugs in the United States.
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Health Reform and Public Service
The world became a lesser place on Friday, August 28. My mother-in-law died. I had known her for 41 years and never once heard her speak a cross word. She died three months short of her birthday. She would have been 90 years old. She worked her entire professional life in public service. Her first position was as a Head Start teacher in the first year of the Head Start Program in Alabama at the time of the Selma march. Her major role, once she returned to Iowa, was as a county home economist, initially in Kossuth County, then for more than 20 years in Crawford County. She added Ida County toward the end of her career. She taught rural families how to survive and thrive in the changing world of the 1960s, ’70s, and into the 1980s. At her retirement dinner, her supervisor said, “In many ways, Norma has been in the vanguard. When you look to see what Norma is doing and, in two or three years, all Iowa counties will be doing it.”
Health Reform and Family Medicine
On Thursday, July 22, I said goodbye to a University of Iowa third-year medical student. The student had been with me for a month.
One of my favorite professors while I was a student at the University of Notre Dame always said that the best way to learn something is to teach it. This was the seventh medical student I have had in my practice in eight years. I have learned so much about my belief in family medicine by teaching these students and sharing my patients with them.
Health Reform and the Letter of the “Court”
June 25, 2015, was a banner day for many reasons. The U.S Supreme Court decision in King v. Burwell allowing 6 million Americans (more than 40,000 in Iowa) to maintain federal subsidies to help pay for individual health-insurance premiums that were purchased under the Affordable Care Act (ACA) federal Exchange was uplifting. The decision will allow the ACA to become a permanent part of our lives and our culture. In Iowa, Republican Governor Terry Branstad responded to the decision saying the ACA was “unaffordable” and “unsustainable.” I would respond to his comments here, but Paul Krugman’s commentary in The New York Times published same day as the decision is a far better response than anything I could write.
In concluding his commentary, Krugman wrote, “Put all these things together and what you have is a portrait of policy triumph — a law that, despite everything its opponents have done to undermine it, is achieving its goals, costing less than expected, and making the lives of millions of Americans better and more secure. … And it’s a beautiful thing.”
Health Reform and Quid Pro Quo
This week, a high-ranking politician left a phone message for me at my clinic. He asked that I call him. The purpose of his call, according to the note from my receptionist, was “politics.” I did return his call and left a message. He called me back while I was out at a movie. Stepping out of the movie to look at my phone, I found that the purpose of his call was direct and to the point: He asked for money for his political campaign fund. Another politician currently running for office has called me at various times during my work hours. He called once just as I prepared to do a knee injection for a patient and again while I was making rounds at the hospital. During each call, this politician asked for campaign money.
Health Reform and Numbers
60. I start and end this blog post with selected lines from poems. Dylan Thomas began his Poem in October with: It was my thirtieth year to heaven. Today marks my sixtieth year to heaven (I hope), and, instead of Dylan Thomas describing the beauty of Wales in October on his birthday, I am witnessing six months and thirty birthdays later the beauty of Iowa in April. April brings the brightest green grass of the year, the snow-white blossoms of the pear tree in my back yard, and the soon-to-be-red blossoms of my crabapple tree in the front yard. Colors seem to explode from every flower and bush.
Birthdays also mark time in relationship to other events, including the anniversary of the Oklahoma City bombing. Albert Einstein died 60 years ago yesterday. Sixty years ago this month, Churchill left office as the prime minister of Great Britain. The American Revolution started 240 years ago on this date. For me, dates give a sense of one’s location in both the positive and negative swings of history. Correspondingly, numbers can give us perspective and relative significance of the people, events, and details of our lives. Today, I review some numbers that I have heard over the past several months, numbers that cause me to reflect on health reform, both positively and negatively.
Health Reform and Medicaid Managed Care
I keep lists. While I do not believe there is a name for someone who keeps lists as there is for one who collects stamps — a philatelist, or a keeper of postcards, known as a deltiologist — I am simply a keeper of lists. One list is of names that are actually what the name says the object or geographic location is. For example, in the South Island of New Zealand, southeast of Queenstown, there is a range of mountains called the Remarkables. They are pristine, beautiful and truly remarkable. Another example is a swamp in northern North Carolina and Virginia called the Great Dismal Swamp, the largest remnant of a swamp habitat that once covered more than a million acres. A final example is the Trail of Tears. It was the route that more than 16,000 Cherokee Indians took from their homelands in the southern United States to Oklahoma. It is estimated that more than a third of those Cherokee people died on the Trail of Tears. Another list I keep is names that do not signify what the name indicates, such as the Big Ten Conference in collegiate sports, which has 14 teams, or the Fox News Network, whose motto is “fair and balanced.”
Iowa is currently undertaking a new program to turn its Medicaid program from a state-government-managed program of medical help for poor and disabled populations to a for-profit, private managed-care approach to administer the medical needs for these populations. The title of this program is the Iowa High Quality Health Care Initiative. I am holding judgment as to which list this program with the ambiguous name would more likely be appropriately added.
Health Reform and Patient-Centered Health Goals
Every other Wednesday morning, I attend our hospice interdisciplinary team meeting. This meeting is one of the highlights of my week. Four years ago, we began introducing each discussion of new and current patients with that patient’s stated goals. I always make notes directly on the printed list of patient names provided at this meeting when certain facts and information about a patient catch my interest. Often, it is the patient’s goals that I write down. The goals are many and varied. A common goal is for patients to stay in their own homes. Other goals include family events, such as attending a wedding or awaiting an upcoming birth in the family. I have heard goals including finishing a scrapbook, continuing to work on a classic car, taking a grandson to a basketball game, or traveling to see relatives. The personal nature of this way of starting the discussion of a patient’s status at the hospice-team meeting places the focus precisely where it should be — on the patient.
Health Reform and Aligned Incentives
In further discussing the now-dissolved CoOportunity Health, as well as Governor Branstad’s proposed plan to turn over the Iowa Medicaid program to a private managed-care company or set of companies, I was going to title this blog entry Health Reform and the Need for Nonprofit Entities, which may, in the end, be what the readers of the blog may feel is my conclusion. Instead, I chose the current title to reflect a refinement of my views over the years. To understand this refinement, I want to start this post by going back to 1993.
Health Reform and CoOportunity Health
It is with sadness that I acknowledge the takeover of the cooperative health-insurance company, CoOportunity Health, by the Iowa insurance commissioner. I have touted CoOportunity Health many times in this blog, and I have strongly felt it was a critical part of the current health-reform efforts in Iowa. My sadness is even greater for the 100,000 individuals who had insurance with CoOportunity Health. These individuals’ confidence and coverage are jeopardized because of this action. The health and peace of mind of friends, family, and patients who I know are insured by CoOportunity Health are a major concern for me at this time.