What has NOT Changed – Reactor Session: Charles Q. North MD and Q/A Session

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference on Primary Health Care Access:

The following transcription is of the second plenary sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. 

This reactor, question and comment session follows:  “What Has NOT Changed” – A Critique of the Affordable Care Act: John P. Geyman, MD

Charles Q. North, MD, MS, University of New Mexico, Albuquerque: [Dr North is a Senior Fellow of the National Conferences]: Thanks John. It’s always uplifting to hear you criticize the American healthcare system. But the best news is that you’re getting married to Emily next month. I think that’s terrific. And that gives those of us who are just signing up for Medicare hope for the future.

I have a very strong criticism of one of the things you said and that is that I think may be taken as an insult to the civilized world that they would include the United States in that group. I think you might want to consider retracting that statement.

I say that because we have such a high rate of incarceration. We have such a high rate of childhood poverty amidst the wealth in this nation. We have such a high rate of gun violence and death from guns.

Gun deaths are not just suffered by our military as a result of war, but even more from military suicides and guns in our neighborhoods – not rifles used for shooting animals for subsistence living – but for shooting children in schools and shooting gang members in inner cities. I mean to include us in the civilized world is a stretch in some other ways.

That brings me to my favorite topic – the role of the social determinants of health in healthcare. You know the healthcare system itself only accounts for about ten percent of the health status of a population, which you point out in your statistics that really 50% of the people in the country only account for 3% of the problems.

And that’s because they’re well off. That’s because they have access to early childhood education, and a secure home. That’s because they’re food is secure instead of insecure, so they don’t have the problems with starvation and obesity.

That’s because they have safe homes and neighborhoods; so they don’t need to use the emergency room for violence and injury. That’s because they have safe homes that aren’t full of lead, and where they can go out in the neighborhood and exercise.

That’s because there is an emergency response system in their neighborhood that works; they can get an ambulance when they need it. They have a public health infrastructure that can monitor disease and clean air and water and food. And that’s because they have a transportation system that allows them to get work and the ability to find a job.

So I really think that the ACA doesn’t address those issues at all. And those underlying social determinants of health would bring us to maybe being considered the status of civilized nation, like the nations  you referred to that have a social insurance programs that actually work and provide some kind of social opportunity – not equity, but the opportunity to work on equity – at least, in their societies.

And we know that inequity really leads to more health disparities than just poverty itself. Wealthy people are insecure because they’re afraid that poor people are going to go after them, much of the time. And we see that played out in our politics all the time.

The other thing I’d like to say is that we spend a lot of time talking about the federal deficit because of the cost of Medicare. It is really the rising cost of Medicare, not Social Security that is responsible for so much of the deficit.

We don’t talk much about the burden of private insurance premium on households, like we did in 2008 running up to Obama’s election. There was a bit of a  social movement in this country to address bankruptcy from healthcare costs – from not having enough health insurance if you will.

Brill brings that out in his Time article – that it’s people with insurance that are going broke, not just people without insurance. The private insurance premium is a huge burden for working families, and I think it’s going to drive people to Medicaid.

If there’s a choice to go on health insurance exchange and buy a “used car” of an insurance program, or you can sign up for Medicaid. Duh, it’s not much of a choice. If an employer has an opportunity to choose between having his employees getting a county integer program or Medicaid instead of private insurance; they’re going to choose the county integer program or Medicaid rather than private insurance. If they can game that system I think.

So the question becomes how many people are going to sign up for Medicaid? How many states are going to aggressively pursue signing up people for Medicaid? How many community-based organizations are going to work on signing up the members of their communities for Medicaid that are newly eligible?

Then, of course, we have to address the groups that aren’t being included in the PPACA at all. And those are the “undocumented”. Again if you get thrown in prison or you join the military you’ve got access to better healthcare than you do if you’re an undocumented immigrant who follows the rules and tries to get ahead in our society.

I never wanted to be labeled a “reactor”, because it sounds like reactionary. So I’m trying to “out-progress” you.

John Geyman, MD: [Dr Geyman is a Senior Fellow of the National Conferences]:  I agree with everything you said. We certainly do lead the world in those very adverse areas that you mentioned. And we’re not talking enough about the affordability of insurance.

The latest information I saw, for a family of four it willl cost you just nearly 20,000 bucks a year now. The Commonwealth Fund has looked at affordability. They estimate that anything over five percent of your family income is starting to be considered a hardship. Median income is about $50,000 a year for families. And so $20,000 out of $50,000 for a family of four is totally untenable.

We’re getting less and less. Someone has to show me that we’re really reining in the practices of the insurance industry with the ACA. I don’t think we are. They’ll out game us at every turn.

Lead Question: Hector Flores, MD; Wright Memorial Medical Center in Los Angeles [Dr Flores is a Senior Fellow of the National Conferences]; Thank you for the great presentation, John, and to Chuck North for that “nuclear reaction”.

I had a chance to work with the Clinton task force from 1992 to 1994. When Hillary Clinton, who was the chair of that task force sort, was of doing the post mortem, she said that she didn’t realize how much business and politics were ingrained in our healthcare system.

It was actually humbling for me to hear her say that; and that whatever we need to do to change the system has to engage those interests. In part, she said is because America is so unique in its culture that we have a Constitution that is the greater good, but we also have an individual Bill of Rights that protects each individual’s rights. And we have a right to judicial review if we feel that our individual rights have been violated.

We apply these constitutional principles and rights to everything we do, including healthcare. We know we are willing to pay more; we have a good heart to include all Americans, but we don’t want it to mess with our individual insurance.

She added to that to advocate for “single payer”, or single anything will always be opposed by a certain powerful interest – what she called the unusual coalition of about 40% of the electorate being influenced by big business and by people who would rather die than have the government do anything for them.

If that is going to happen, it’s going to require a multigenerational change, before we can get to a new cultural thinking that says the greater good outweighs the individual rights.

In your closing comments, John, you mentioned two very salient points (among many that you did) that were wonderful. First, we need to make the business case for doing the right thing. And second, change will come from a grass roots effort. Could you comment more about that and maybe give us one thing we could do when we go home to start that process?

Dr Geyman: Now that’s interesting. Well first of all, I believe there is popular support for national health insurance.

I am aware of many studies since the 1950’s and 1960’s that show that a majority of Americans, when asked if they would support the equivalent of a national health insurance program, answer that they would.

Often that question is gamed a bit by whoever is asking the question. They add “by the government” or something like that. You know that the wording can be tricky, but there is majority support going back 40 years in this country for single payer financing. That’s the first point.

Second, we can get to thinking change will never happen, that the system is all too big to change. But there are examples where, where cultural changes can happen quite quickly. I think I might say that gay marriage is a rather recent example. That hasn’t taken 100 years. A lot can happen even in a period of ten years or so. I know it  is a big issue, but it can change and has to change.

I think we are building awareness in the business community. Ralph Nader talks about a liberal-conservative convergence. It’s history now, but if you look at General Motors’ cost of building cars, GM paid almost 1500 bucks a car for healthcare. Across the river in Toronto, Canada with its single payer system, the cost was more like $200.

I think if you’re in practice, if you’re in a teaching program, whatever you’re doing, even if you’re retired like I am from practice, you can still be an advocate in your community and inform yourself and see what you can do about it.

For example, in our own community, several of us tried to re-steer the new critical care access hospital that located on San Juan Island in a different direction. But it’s ending up as non-primary care oriented that emphasizes the ER, and emphasizes referral back to the mother hospital instead of the other hospitals where patients used to go to. We know the hospital is not going to be successful.

Over the next year, we’re going to develop a case study of the business plan of our critical access hospital. Patients are going to vote with their feet and their wallets.

We’re going to help them. We have a newspaper on the net that people read more than the weekly print edition. So even in our little community, and wherever else we can, we can lead instead of just following.

Dr North: John’s too polite to say you can join the Physicians for a National Health Program and pay your dues this year. That’s something else you can do I guess.

If you ask people that have Medicare, Medicaid or have served in the military system or in the Indian Health Service system, in the system at community health centers around the country and other examples of federal systems like the prisons (where people don’t have as much choice, of course), I just don’t think you’d find very many people that’d say “Gosh, I wish I could go out and buy private health insurance and be part of that private health system which is so great where they do CT scans and MRI scans and operate on knees nd you know god knows what other unnecessary stuff”.

People suffer from that. They don’t just get bills for trauma like David Sundwall was talking about. They suffer for their life from unnecessary tests and surgery and unnecessary costs. Those costs really keeps them from their other goals, like being able to do other things with their limited resources.

You know medical care is nice when you need it. But your life shouldn’t be centered around medical care unless you’re in the business of it. Your life should be around pursuing your self-actualization through living, loving, working, educating. Those things are more important than being in the medical care system. But we have medicalized American life to the point where money can be made off of just about anything.

Dr Geyman: Wow, well said!

Fred Schwartz, A. T. Still University School of Osteopathic Medicine in Arizona, Mesa. All politics are supposed to be local, but if you look at an electoral map of the country, that shows “red” or “blue” for each county (respectively counties that voted Republican or Democrat in the last election) the red zones are all over the  country.

What I’m having difficulty understanding is not the top 1% in income, who have benefited from a system that allows them to keep all of their money.

What I’m having trouble with are the people who are between 10 and 15% – 15 times the poverty level. These are folks who vote against their own interests – you know “keep your government’s hands off my Medicare” and all of that.

This group actually is in great distress over healthcare issues, yet they elect people who promise to vote in ways that are against this group’s interests. And it happens again and again and again.

Is there anything we can do to actually reverse that trend or is it really bigger than all of us?

Dr Geyman: Well I agree with the absurdity with how that happens. I don’t have any big answers. Do you, Chuck?

Dr North: I think it’s important for us to get together and out who’s behind financing these campaigns. If you look at the NRA, they frankly don’t care about the Second Amendment at all. The Second Amendment has nothing to do with what they’re talking about. What they care about is making money for the guns and ammunition industry. They are their apologists. They’re owned by them.

And if you look at who lobbies for healthcare, you see exactly the same thing – insurance companies who profit from the position. Any good organization has people lobbying to do that or they would fire them if they didn’t, because that’s what they’re all about.

I think it’s really important to have transparency of funding. That’s something we all can participate in as citizens, regardless of our political leanings.

We can also take part in this at the local level because there are city councils, there are community meetings, there are county and state forums for us to discuss these issues. And there are more of us than there are of the people running the organizations. So we just have to do it with sheer numbers and we have the truth.

I think the Internet helps tremendously. It’s leveled the world. Look at the Arab Spring. Now who would have thought Tunisia would lead the worldwide movement for freedom and justice in Democracy a few years ago. So if Tunisia can do it, we can do it, John.

Dr Geyman: I agree with every bit of that including advocating for reversal of Citizens United, which is a big part of the “money in politics” issue.

Dr Bejinez-Eastman (moderator): Just a warning. When doctors start giving you political advice, be careful!

I’ll bring everybody back at 10:14 so we can get started at 10:15 and hear about the impact of PPACA in Hawaii.