A Sense of Whiplash About the Affordable Care Act
by Reed Abelson - NYT
More than 100,000 Americans rushed to buy health insurance under the Affordable Care Act on Wednesday, the biggest turnout yet during this year’s sign-up period, the day after the election of Donald J. Trump, who has promised to repeal the law.
The figure, announced by the Obama administration, added to a sense of whiplash about the law, and underscored the magnitude of any change. Despite all the criticisms about the law coming from President-elect Trump and his allies, millions of people now depend on it for coverage.
Even the powerful health care industry, which invested hundreds of millions of dollars in preparing for business under the Affordable Care Act, is disoriented about what to do next — and scrambling for ways to avoid a big financial shock. A repeal of the act would mean the loss of millions of customers for insurance companies and an onslaught of uninsured people to hospital emergency rooms for basic care.
Industry executives say their first priority is to persuade Mr. Trump and the new Congress to replace the law with some way for people to continue getting coverage.
The problem is that, until now, top executives from the biggest insurers have not heard from Mr. Trump or his close advisers about his plans. In fact, the industry as a whole made no contingency plans for a Trump victory and does not yet appear to have developed a strategy. In the last few days, executives have huddled hurriedly with their boards and advisers to discuss how to react.
In mapping out various election situations, “this wasn’t on the sheet,” said Mark Bertolini, the chief executive of Aetna. “We had no idea how to approach it.”
The consequences are urgent. About 22 million Americans would be without insurance if the law were repealed. The new state marketplaces, where about 10 million of those people buy insurance, would no longer exist. The millions of others who were newly eligible for Medicaid would also lose coverage.
“I’m concerned about the fear factor of what is going on,” said Bernard J. Tyson, the chief executive of Kaiser Permanente, the California system that includes hospitals, doctors and an insurance plan. He said the company was already getting calls from people worried about whether they would still be able to get coverage.
Both federal officials and insurance executives say people should not hesitate to sign up during the current open enrollment period.
Yet Republicans have seized on some areas where the law is struggling and in the government-run insurance marketplaces in particular. Early this month, for example, Republicans highlighted the sharp rise in the average price of an insurance plan on the marketplace — 25 percent — as proof that the law was fatally flawed. Mr. Bertolini warned that rates could go even higher next year.
Without a 60-vote supermajority in the Senate, Republicans will probably be unable to repeal the entire Affordable Care Act. But they can eliminate several consequential provisions through a special budgetary process called reconciliation.
Last year, the Senate passed a reconciliation bill that undid large portions of the health bill. The House passed it. And President Obama vetoed it.
The bill would have eliminated the expansion of Medicaid coverage for Americans near or below the poverty line. It would have eliminated subsidies to help middle-income Americans buy their own insurance on new marketplaces. It would have eliminated tax penalties for the uninsured, meant to urge everyone to obtain health insurance. And it would have eliminated a number of taxes created by the law to help fund those programs. (It was written to kick in after two years, meaning the programs would not disappear immediately.)
Many parts of the law cannot be repealed through reconciliation. Among them: reforms to the Medicare program, a provision that requires insurers to cover young adults on their parents’ policies, and requirements that health insurers sell policies to anyone regardless of their health history. Those parts of the law are very likely to remain law.
Crucial aspects of the bill can be undone in a number of other ways, too. The administration could simply halt efforts to sign people up for the state marketplace plans. Or Congress could eliminate the federal subsidies that help millions of people afford a plan. Either one of those moves would most likely cause far fewer people to sign up for insurance, leading to instability or collapse of the insurance marketplaces.
“There are a lot of different triggers that can be pulled,” said Benjamin Isgur, the leader of the PwC Health Research Institute.
For the insurers and hospitals, the challenge is to persuade President-elect Trump that an alternative to the online marketplaces is necessary.
Insurers will feel the loss of customers both in the individual market and under state Medicaid programs. While most are well diversified into other areas of insurance, the Affordable Care Act was seen as a way to forestall the steady erosion in employer-based insurance. The companies spent years and millions investing in being able to sell new policies through the state marketplaces, operating under an entirely new model.
Hospitals, however, are likely to be the biggest losers. Under the law, they agreed to get less money from the government, essentially in exchange for having to cover fewer uninsured people.
“If repeal happens, are there voices in the industry loud enough to replace it?” said Sam Glick, a partner at Oliver Wyman, a consulting firm.
Executives insist that the proposals that have been discussed before, including by Paul D. Ryan, the speaker of the House and a Republican, laid out how to replace the coverage and would allow people to transition to different options.
The Trump administration and Congress “are not going to pull out the rug from people,” said Dr. J. Mario Molina, the chief executive of Molina Healthcare, a for-profit insurer. He predicted that the earliest the law could be repealed was 2018, and that it would be replaced with something like a modified version of Medicaid, the government insurance for poor people. “The debate is not around the what, but around the how,” he said.
Because Mr. Trump has been short on detailing exactly what he plans to do, though, many in the industry argue they cannot not prepare a strategy in advance. He has said broadly that he wants to repeal the law, for example, and give states more control over Medicaid programs. He has talked about being able to sell insurance across state lines and has recently discussed a return to the state programs that existed to help cover people with serious medical conditions.
“This is Day 1 of figuring out what all of this means,” Mr. Glick of Oliver Wyman said on Wednesday. Of the health industry clients he works with, he said, “I don’t think I can name one that had done scenario planning around Trump being elected.”
Yet several executives said they planned to be very much involved in the talks. Karen Ignagni, the chief executive of EmblemHealth, a nonprofit insurer in New York, and the former chief executive of the insurance trade group, America’s Health Insurance Plans, said she expected Emblem and others to be involved in many of the same discussions about how to make plans affordable and deliver value that took place in 2008 when Mr. Obama began discussing his overhaul. The debate will be the most sweeping health care discussion since then, she said.
“We’ve got a lot to contribute to the discussion,” Ms. Ignagni said.
http://www.nytimes.com/2016/11/12/business/insurers-unprepared-for-obamacare-repeal.html?action=click&pgtype=Homepage&clickSource=story-heading&module=span-abc-region®ion=span-abc-region&WT.nav=span-abc-region&_r=0
Donald Trump Says He May Keep Parts of Obama Health Care Act
by Reed Abelson - NYT
Just days after a national campaign in which he vowed repeatedly to repeal President Obama’s signature health care law, Donald J. Trump is sending signals that his approach to health care is a work in progress.
Mr. Trump even indicated that he would like to keep two of the most popular benefits of the Affordable Care Act, one that forces insurers to cover people with pre-existing health conditions and another that allows parents to cover children under their plan into their mid-20s. He told The Wall Street Journal that he was reconsidering his stance after meeting with Mr. Obama on Thursday.
The comments added to a sense of whiplash about the law and its future. More than 100,000 Americans rushed to buy health insurance under the Affordable Care Act on Wednesday, the biggest turnout yet during this year’s sign-up period, underscoring that millions of people now depend on the law for coverage.
Beyond Mr. Trump’s comments, new plans laid out on his presidential transition website this week deviate from what he had proposed during the campaign, and he added ideas that appeared to more closely align with the mainstream Republican agenda.
The new plans drop all mention of reining in high drug prices, which Mr. Trump had advocated for months, and add new language about modernizing Medicare, a potential nod to congressional efforts to give people vouchers toward buying private health insurance.
“Health care is shaping up as a priority for the Trump administration and Republicans in Congress,” said Larry Levitt, an executive at the Kaiser Family Foundation, which closely tracks health policy. “But we still have very little detail about what that really means.”
The health care industry, which invested hundreds of millions of dollars in preparing for business under the Affordable Care Act, is disoriented about what to do next — and scrambling for ways to avoid a financial shock. A repeal of the act would mean the loss of millions of customers for insurance companies and uninsured people turning to hospital emergency rooms for basic care.
Mr. Trump, in an interview to be broadcast on CBS’s “60 Minutes,” said the guarantee of coverage for people with pre-existing conditions was “one of the strongest assets” of the law. He also said he would try to preserve the measure allowing young adults to remain on their parents’ insurance until age 26.
“We’re going to do it simultaneously — it’ll be just fine,” he said, saying that people would not lose coverage when the law was repealed.
Policy experts say that the part of the law that Mr. Trump is rethinking, that prevents insurers from refusing to cover people with costly medical conditions, only works financially for insurers if there are plenty of healthy people also buying insurance. If only sick people enroll, premiums would soar. To get healthy people covered, the existing law includes generous subsidies to help more people to afford a policy and taxes people who don’t buy insurance.
Industry executives say their first priority is to persuade Mr. Trump and the new Congress to replace the law with some way for people to continue getting coverage.
The problem is that, until now, top executives from the biggest insurers have not heard from Mr. Trump or his close advisers about his plans. In fact, the industry as a whole made no contingency plans for a Trump victory and does not yet appear to have developed a strategy. In the last few days, executives have huddled hurriedly with their boards and advisers to discuss how to react.
In mapping out various election result possibilities, “this wasn’t on the sheet,” said Mark Bertolini, the chief executive of Aetna. “We had no idea how to approach it.”
The consequences are urgent. About 22 million Americans would be without insurance if the law were repealed. The state marketplaces, where about 10 million of those people buy insurance, would no longer exist. The millions of others who were newly eligible for Medicaid would also lose coverage.
“I’m concerned about the fear factor of what is going on,” said Bernard J. Tyson, the chief executive of Kaiser Permanente, the system based in California that includes hospitals, doctors and an insurance plan. He said the company was already getting calls from people worried about whether they would still be able to get coverage. Both federal officials and insurance executives say people should not hesitate to sign up during the current open enrollment period.
Terri Marsh, 61, in Goose Creek, S.C., did not hesitate to sign up again for a Blue Cross plan as soon as she could. “Insurance is something you have to have,” she said. Before the marketplace plans were available, she had been without coverage for five years, despite having a serious inflammatory disease.
“Because I have a pre-existing disease that is off the wall for them, I could not get insurance,” she said. Without getting the coverage through the law, she said, “I could possibly be dead.”
Yet Republicans have seized on some areas where the law is struggling and in the government-run insurance marketplaces in particular. This month, for example, Republicans highlighted the sharp rise in the average price of an insurance plan on the marketplace — 25 percent — as proof that the law was fatally flawed. Mr. Bertolini warned that rates could go even higher next year.
Without a 60-vote supermajority in the Senate, Republicans will probably be unable to repeal the entire Affordable Care Act. But they can eliminate several consequential provisions through a special budgetary process called reconciliation.
Last year, the Senate passed a reconciliation bill that undid large portions of the health bill. The House passed it. President Obama vetoed it.
The bill would have eliminated the expansion of Medicaid coverage for Americans near or below the poverty line. It would have eliminated subsidies to help middle-income Americans buy their own insurance on new marketplaces. It would have eliminated tax penalties for the uninsured, meant to urge everyone to obtain health insurance. And it would have eliminated a number of taxes created by the law to help fund those programs. (It was written to kick in after two years, meaning the programs would not disappear immediately.)
Many parts of the law cannot be repealed through reconciliation. Among them are reforms to the Medicare program, a provision that requires insurers to cover young adults on their parents’ policies, and requirements that health insurers sell policies to anyone regardless of their health history. Those parts of the law are very likely to remain law.
Crucial aspects of the bill can be undone in a number of other ways, too. The administration could simply halt efforts to sign people up for the state marketplace plans. Or Congress could eliminate the federal subsidies that help millions of people afford a plan. Either one of those moves would most likely cause far fewer people to sign up for insurance, leading to instability or collapse of the insurance marketplaces.
“There are a lot of different triggers that can be pulled,” said Benjamin Isgur, the leader of the PwC Health Research Institute.
For the insurers and hospitals, the challenge is to persuade President-elect Trump that an alternative to the online marketplaces is necessary.
Insurers will feel the loss of customers both in the individual market and under state Medicaid programs. While most are well diversified into other areas of insurance, the Affordable Care Act was seen as a way to forestall the steady erosion in employer-based insurance. The companies spent years and millions investing in being able to sell new policies through the state marketplaces, operating under an entirely new model.
Hospitals, however, are likely to be the biggest losers. Under the law, they agreed to get less money from the government, essentially in exchange for having to cover fewer uninsured people.
“If repeal happens, are there voices in the industry loud enough to replace it?” said Sam Glick, a partner at Oliver Wyman, a consulting firm.
Executives insist that the proposals that have been discussed before, including by Paul D. Ryan, the speaker of the House and a Republican, laid out how to replace the coverage and would allow people to transition to different options.
The Trump administration and Congress “are not going to pull out the rug from people,” said Dr. J. Mario Molina, the chief executive of Molina Healthcare, a for-profit insurer. He predicted that the earliest the law could be repealed was 2018, and that it would be replaced with something like a modified version of Medicaid, the government insurance for poor people. “The debate is not around the what, but around the how,” he said.
Because Mr. Trump has been short on detailing exactly what he plans to do, though, many in the industry argue they cannot prepare a strategy in advance. He has said broadly that he wants to repeal the law, for example, and give states more control over Medicaid programs. He has talked about being able to sell insurance across state lines and has recently discussed a return to the state programs that existed to help cover people with serious medical conditions.
“This is Day 1 of figuring out what all of this means,” Mr. Glick of Oliver Wyman said Wednesday.
Mainers Covered by Obamacare Face Uncertain Future Under Trump Presidency
Mainers Covered by Obamacare Face Uncertain Future Under Trump Presidency
During his campaign for president, Donald Trump vowed that on his first day in office he’ll ask Congress to repeal the Affordable Care Act. That puts insurance coverage for 20 million Americans, including 84,000 Mainers, into question.
Trump also promised to implement reforms that will make health care more affordable, broaden access and improve quality. But some health advocates in Maine question whether the president-elect’s proposals will actually fulfill those promises.
According to Trump’s website, no one should have to buy health insurance if they don’t want to, so he plans to eliminate the Affordable Care Act’s individual mandate. But that proposal, says Consumer for Affordable Health Care’s Emily Brostek, would only drive up premiums.
“I know Donald Trump has also said that he believes that people should not be excluded from health coverage because of pre-existing conditions, and it’s a little hard to see how those things hang together,” she says, because insurance companies need healthy members to balance the cost of sick members.
Trump also pledges to make insurance more affordable by allowing individuals to deduct premiums on their tax returns. Brostek says that would be a change from the current subsidies that are available when insurance is purchased on the online marketplace.
“Which, you know, we have concerns about, because a lot of people can’t afford to wait till the end of the year, till tax time, to get that money back, which is why the advanced tax credit through healthcare.gov has worked so well,” she says.
The uncertain future of the ACA under Trump also has Maine’s insurance co-op concerned. But Community Health Options director of communications Michael Gendreau says the co-op plans to provide health coverage for the long-term.
“We have had a few people ask us, ‘What does it mean for us?’ And despite all that we’ve heard about repealing the Affordable Care Act, or dismantling it, whatever language one wants to use, that the the legislative process ahead is not something that’s going to be like a faucet where the ACA is simply turned off one day,” he says.
With Republicans in control of both houses of Congress, Trump could have the political power necessary to make major changes to the Affordable Care Act. But independent U.S. Sen. Angus King of Maine says he hopes the direction will be reform versus repeal.
“I would hate to see us just say, ‘Well, to heck with those 20 million people who now have health insurance that didn’t have it before. They’re going to be on their own,’” he says.
Republican U.S. Sen. Susan Collins of Maine says President Barack Obama has been resistant to opening up the health care law to changes, but the Trump presidency offers a new opportunity.
“Of Republicans working with Democrats to try to fix Obamacare, and there’s a lot to fix. And there’s also provisions in the law that enjoy widespread support,” she says.
Those include allowing kids to stay on their parents’ insurance until age 26, says Collins, as well as prohibiting insurance companies from discriminating against those with pre-existing conditions.
But one other area of uncertainty under Trump is Medicaid. He wants to convert it to a block grant, which Robyn Merrill of Maine Equal Justice Partners says would reduce access to health care.
“By block granting Medicaid,” she says, “there’s a certain amount of funding that goes to states. States have more flexibility to put restrictions in place.”
It’s also unclear whether Medicaid expansion will remain an option for states.
Maine Equal Justice Partners is part of a coalition that launched a campaign this fall to put the question of expanding Medicaid on the 2018 ballot in Maine. For now, says Merrill, the option is still in play.
Mainers Covered by Obamacare Face Uncertain Future Under Trump Presidency
Trump Can Kill Obamacare With Or Without Help From Congress
Recently a colleague asked if I would address a small, informal quarterly gathering of hospitalists. We settled on a date, and when she asked me for a title for my remarks, I offered: “Presence.”
From the pause on the other end of the line, it was clear she seemed to think there was more to follow—a subtitle perhaps, without which the word seemed to dangle.
“Just ‘presence’?”
(I’d been doodling on the paper in front of me, trying it out.)
“Yes,” I said. “Presence, period.”
On the paper, the period seemed critical. (I’m reminded of the precocious boy-narrator in an Isaac Babel story who says, “No iron can pierce the human heart as icily as a well-placed period.”) My period asked me, the reader, to stay with the word—to be present. No subtitle. Just: Presence.
The idea of “presence” had its origins for me in a parking lot not far from my office at Stanford University and near one of my favorite spots on campus, the Rodin Sculpture Garden. In walking past Auguste Rodin’s Gates of Hell, a massive pair of bronze doors inspired by Dante’s Inferno, I’m consciously or subconsciously reminded to seize the day. In the past year, I’d watched construction on a unique building in the same vicinity. The signage said it was to be the home for the modern art collection of one family, the Andersons, who were giving the collection to Stanford. From a distance, it looked like a cake box sitting on a narrower and well-lit square pedestal.
It occurred to me that the intent of the university and of the Andersons might be that the collection should not only enhance our lives as viewers but specifically enhance our lives as educators, even in fields far removed from art history. Fields such as my own of internal medicine and infectious diseases. In clinical teaching, I’ve tried when I can to link art and medicine using such iconic paintings as Luke Fildes’s The Doctor. But with modern art, with the abstract, it feels challenging to make such a connection. In truth, modern art has always felt a little intimidating to me.
One afternoon shortly after the museum opened, on my way back to my car, I impulsively decided to walk in. It was spring. I felt brave. I imagined the punchline: “Physician walks into Modern Art Museum!” After all, this isn’t a place where we routinely find ourselves, or if we do, it’s not related to work. Personally, I felt my visit was related to work and not just by proximity to my place of work: I was here in the true spirit of an educator (so I told myself) trying to climb out of what novelist Walker Percy called the ruts of specialization, the narrow chutes of professional work and our specialized language that can leave us wearing blinders to other forms of knowledge and inquiry.
The building was suffused with natural light. There were no corridors, no rooms that led into rooms, no sense of a labyrinth. Instead it was open—the cake box sans cake. I could and did stroll around the whole thing in fifteen minutes. It was much less intimidating than, say, the Louvre, where a tourist popping in for a few hours (after standing in line for a long time) can come away overwhelmed, feeling the mind has been shrunk instead of expanded. And yet the compact space (by museum standards) held a who’s who of modern art: Jackson Pollock, Mark Rothko, Willem de Kooning, Wayne Thiebaud, and many more. Iconic names. I had a vague cognitive knowledge of that kind of art but no experience. Just as I might know who RuPaul is, or 50 Cent or Amy Winehouse—but don’t ask me to hum a tune.
I was pleased with myself after my visit. Whatever fears I had (about being grilled about my knowledge by docents, or scrutinized by security guards, or finding the art to be opaque and mysterious) were unfounded. The place was inviting and friendly.
From then on, I made it a practice to stop in.
It was in the repeated visits that I began to recognize and relate to certain paintings and sculptures. If I imagined myself to be a crude but sentient probe being sent into orbit around an unknown planet, then in my loop, my antenna received different and discrete stimuli. I was surprised to find I didn’t really care for “funk” art. Even though funk art is “figurative”—featuring recognizable things such as fish and words—I wasn’t drawn to it. Not yet anyway. My reaction was the opposite: to hurry past.
But I found myself seeking out the bench in front of Pollock’s Lucifer and Rothko’s Pink and White over Red. The scientist in me recognizes my bias here: These are well-known artists, their works the jewels of the collection, and the benches strategically placed. Still, I believe it was more than that: I was also responding to the inherent appeal of these paintings, even though the words to explain why didn’t come easily.
On Thursdays I have the great privilege of making afternoon rounds with the three chief residents in internal medicine at Stanford Hospital. They often have a patient in mind for the four of us to see. These sessions are about reading the patient’s body as a text, about bettering our skills at mining the body for all it is saying. But we make all sorts of diversions, and one afternoon, in lieu of the bedside, I took them to the Anderson Collection. I made no claim to knowledge or purpose. I wasn’t the tour guide—I just walked them through a space that was new to them. In doing so, I thought of a connection to our clinical work: I drew an analogy to the phenomenon of “transference” and “countertransference” in patient care. In psychiatry, for example, patients can develop feelings for the therapist; this “transference” is often useful for patient and therapist to dissect. “Countertransference” refers to the feelings the therapist develops for the patient, feelings that range from anger to attraction. Such feelings are normal and important to recognize in oneself, primarily so as not to act on them. Walking among these paintings and observing our responses—both positive and negative—was a means of being self-aware and attentive to a variety of countertransference.
After nearly a dozen visits, alone and with others, even though I wasn’t consciously trying to relate the art to the pedagogy of medicine, I began to make connections. My tool is the medical gaze, the desire to look for pathology and connection, and it would seem there was no opportunity for that within a pigmented square of uniform color or a rectangle of haphazard paint splashes. But in me a profound and inward sort of observation was taking form.
Pollock’s piece, Lucifer, had a manic energy, a seduction—not unlike some hypomanic people I know. (We all know them; they seem more prevalent than they really are, such is their energy.) The force was confined to an elongated rectangle against a white wall. I could imagine the frenzy of an artist standing over the canvas—no easel here—throwing paint at it, using different colors, using anything but a brush (turkey basters, syringes). At times I felt I was looking into a mind—his, or maybe mine—and seeing the neurofibrillary tangle. It was not the mind depicted in the static histology slides of medical school; it was dynamic and alive, like watching thoughts emerge from a substrate of neurons, or a dream evolving. Yet there was order in the midst of that anarchy. From a distance, the random splashes of color looked mostly black and green, and only when you got close could you see thin streaks of vibrant yellow and blue and red, which were nonetheless necessary for the energy perceived from afar. My response to Lucifer was far from constant; it seemed to have a connection with how my day had gone.
As my visits accrued, I felt much like someone returning to a city over a long time span. Each visit I noticed that I had changed, and what I observed was changing, too.
At first I had studiously avoided reading anything about the art. The rationale was this: In bedside physical exam rounds with my medical students on Wednesdays and chief residents on Thursdays, I ask that if at all possible, the physician or the student who knows the patient, and is bringing us to visit, not tell us anything medical about the patient—especially the diagnosis. This isn’t so we can be clever and deduce this on our own but rather to ensure that on these rounds (which are not about management, but observation) we are not biased by a label. We can read the body as a sacred text being opened for the first time. Labels such as “cirrhosis” or “endocarditis” can blind us to what else is on display. Similarly, with the paintings, I had wanted to experience them without bias. Now that they were becoming familiar, I read about whatever work caught my fancy.
In 1956 Pollock wrote of his work:
“When I am in my painting, I’m not aware of what I’m doing. It is only after a sort of ‘get acquainted’ period that I see what I have been about. I have no fears about making changes, destroying the image, etc., because the painting has a life of its own. I try to let it come through. It is only when I lose contact with the painting that the result is a mess.Otherwise there is pure harmony, an easy give and take, and the painting comes out well.”
The italics are mine. That line resonated with me because it paralleled the dystopia that is prevalent in American health care. It’s the thing that is dragging down the experience of patients and physicians alike: the sense of losing contact. More specifically, it’s the sense that the intermediary of the electronic medical record (EMR) and fulfilling every “Lean” mandate has made us lose contact with our work. The result is a mess, with great unhappiness in the ranks.
Rothko’s Pink and White over Red is a square of a beautiful and vibrant red with a long, horizontal pink rectangular slit at the top, like the slot in the door of a speakeasy as depicted in a noir film—the opening through which the bouncer checks you out. It’s the sort of painting that when I was young and ignorant I might have been tempted to dismiss. (“Big deal, I could’ve done that.” The older me might have replied, “Yes, but you would never have thought of it.”) But having learned to sit with the painting, to be present, I viewed it differently. It seemed to represent my interior space, what I see on the back of my eyelids when I close my eyes, the image still etched with the glow of the window through which I was gazing. It is soothing. It is the womb. It is emotion. It is pre-consciousness.
In the most cursory reading of Rothko, I came across this:
“If you are only moved by color relationships, then you miss the point. I’m interested in expressing the big emotions—tragedy, ecstasy, doom.”
And:
“Art is an adventure into an unknown world, which can be explored only by those willing to take the risks.”
Forgive me if I felt he was speaking to me personally, rewarding me for being brave enough to drop in from the parking lot and engage with his work. There was also pointed instruction here. If we were to substitute the word medicine for art, his aphorism would read:
“Medicine is an adventure into an unknown world, which can be explored only by those willing to take the risks.”
Being with patients, being present and willing to engage directly in the manner they most want is a form of risk. The representation of the patient in the EMR (the iPatient, as I call it) is necessary. But being with the iPatient too long is a guaranteed way of not being present with the actual patient. It can even begin to feel safer and simpler to be present with one of the many “enchanted objects” around us—computer screens, tablets, and smartphones—than with human beings. Perhaps this is what I most want to teach at the bedside: not the causes of low sodium or the latest sepsis protocol. Or not just that (and besides, odds are you can find that online in a flash). I want to teach the art of being present. That, as Rothko says, is an adventure into a risky, unknown world.
I look back and think of patients long gone, particularly patients in the early AIDS era, who were young men for the most part at a time when I too was a young man. Was I present? They were full of the ripening of life, full of desire and longing and ambition, at a time when I too was full of those things. I wanted to “do” for them, to fix what ailed them. I wanted to be busy with them in a medical way, even though in those days we had no effective HIV medications and there was nothing we could do to change the course. I would examine them, because that was what I knew to do, and that ritual, with its laying on of hands, conveyed an important message to the patient that they would not be abandoned. The absence of any treatment also taught us physicians powerful lessons. I learned from my physician assistant, Della, a warm and caring woman who felt less of the pressure to do, and instead could just be. I remember her cajoling me to make more home visits. Once as we walked in to see a patient who was hours from exiting the world, I said, “What are we going to do here, Della?” She said: “We are going to be with him.”
As the German philosopher Martin Heidegger said, sometimes words and speech (and action, I might add) are just a way of forgetting our being or that of the person we are dealing with. I don’t think I got it then. I get it now.
Recently, while on rounds with my students, we visited with a patient whose mother was in the room. They were both so gracious, and as ill as he was, he was generous in allowing us to examine him, to focus on aspects of his illness that had little to do with management but were purely to educate the students. Once we were in the hallway, I asked the students if they had noticed anything special about the mother. They had not. And yet the mother had vitiligo, a condition that strips the skin of pigment, a patchy process at first that eventually results in no pigment anywhere for most people with the disease. While it had no bearing on the son’s condition, it was a striking observation because the son had darker skin and the mother was almost white. Had we entered as true beginners without homing in on the label “patient,” they might have seen it too.
That sense of starting with a blank slate is a feeling I relish. It has become harder to come by. Increasingly, students have a “flipped” patient experience, where a “new” patient is someone they have already met in the computer, having read all their labels before seeing them in the flesh. It is as far from the blank canvas as one can get.
My colleague Alexander Nemerov, an art historian and Stanford professor, recently gave the “First Lecture” at the university—an occasion when all thousand-plus Stanford freshmen gather in Memorial Auditorium on their first academic day to hear from a chosen faculty member. In his lecture, Nemerov spoke of Helen Keller, who at nineteen months experienced a febrile illness and subsequently lost sight, hearing, and therefore speech. She was in darkness until a remarkable teacher, Anne Sullivan, came into her world.
Nemerov described his visit to the Keller home in Alabama, and to the now-famous water pump on the property, as if visiting a shrine. There, after months of struggling to teach Keller language through signing, Sullivan had held the young girl’s hand under the flowing liquid of a hand pump and repeatedly signed out the word “water” in her palm. Suddenly, she broke through. The child understood, as Nemerov says, that the “word and the world could almost magically be the same thing.”
I resonated with the image of Keller at the pump. It seems to me that our efforts as teachers are encapsulated in that moment: Our job is to allow the student to “see” in this way, to open up their world.
What is it I want my students to see? I want them to see the signs of disease, the phenotypic manifestations of disease that get buried by the hype around genotype. I want them to see that the outline of a cigarette packet in the shirt pocket of a male patient tells us much more about the patient’s risk of sudden death than anything in his genome. So much of diagnosis is to be found in the history and the physical, which in turn guides us to order tests more judiciously. Those visits to the bedside with my students every Wednesday and Thursday—guiding hands to feel spleens and eyes to observe neck veins—are like putting their palms under the water pump, allowing them to feel and connect.
Beyond that, there is another kind of seeing that is even more important. Disease is easier to recognize than the individual with the disease, but recognition of the individual whose care is entrusted to us is vital to both parties. There are some simple rules: First, we must go to the bedside, for that is where the patient is. It’s a vital and simple step, but harder than it looks. It simply isn’t possible for the patient to feel recognized and cared for when they feel unattended; the fact that their data is getting a lot of attention in a room full of computer monitors where doctors sit does not satisfy. The gravitational forces of the hospital are always pulling us away from the patient to a screen, and it is not our doing. We are chained to the medical record, and every added keystroke adds another link in the chain. We must be unchained.
Second, when we go to the patient, it follows that we must listen, and we must examine with skill. The patient’s disease is not located on an image in the computer, nor on a histology slide, nor in numbers of body chemicals—it is located in or on their body. To touch the place that hurts, to examine the body, is to affirm the locus of their illness.
Third, one must revisit and revisit, as few things are completely revealed at the first encounter.
The crisis in health care—spiraling costs; inequities of care; the abysmal incentives for primary care; the paucity of geriatric care when our population is aging; physician depression, dissatisfaction, and attrition—offer no easy solutions. There are a few things that are timeless in medicine, unchanged since antiquity, which we can keep front and center as we bring about reform. One is the simple truth that patients want us to be more present. We as physicians want to be more present with the patient, as well, because without that contact, our professional life loses much of its meaning.
It is a one-word rallying cry for patients and physicians, the common ground we share, the one thing we should not compromise, the starting place to begin reform, the single word to put on the placard as we rally for the cause.
Presence.
Period.
ColoradoCare measure Amendment 69 defeated soundly
ColoradoCare’s $36 billion budget would dwarf state government’s spending
by John Infold - Denver Post
Amendment 69, the ballot measure known as ColoradoCare that would have created a universal health care system in Colorado, was soundly defeated Tuesday night.
At 8:30 p.m., with nearly 1.8 million votes counted across the state, the amendment was trailing 79.6 percent to 20.4 percent, according to preliminary state figures. Updated vote totals at 7 a.m., with 86 percent of the vote counted, the measure continued trailing at roughly the same percentage or 1,833,879 to 467,424. Throughout the campaign, the measure had polled better with Democrats than Republicans. But even in left-leaning Denver, the amendment was losing 2-to-1, according to early returns.
At a downtown Denver watch party for supporters of the measure, the mood was quiet but not yet resigned to defeat.
“The early returns, I hope, are not reflective of Colorado,” said state Sen. Irene Aguilar, a Denver Democrat who is one of the amendment’s leading backers.
But supporters also acknowledged it was unlikely the measure would recover and vowed they would try again another year.
“We learned a lot,” said T.R. Reid, an author who is another of the amendment’s most prominent supporters. “And we’ll definitely be better next time.”
Opponents declared victory.
“We’re grateful to the people of Colorado for carefully considering Amendment 69 and voting overwhelmingly against a measure that was clearly risky, untested, and fiscally irresponsible,” Kelly Brough, president and CEO of the Denver Metro Chamber of Commerce and chair of opposition group Coloradans for Coloradans, said in a statement.
Amendment 69 would have eliminated most private health insurance in the state and replace it with a taxpayer-funded cooperative known as ColoradoCare, which would have provided coverage to every single Colorado resident. It would have been paid for, largely, through a 10 percent payroll tax — workers at businesses would have been responsible for a third of the tax, while their employers would have picked up the rest; the self-employed would have paid the full 10 percent. The cooperative’s budget, at about $36 billion a year when fully implemented, would have dwarfed the state government’s budget.
Soda Taxes Sweep to Victories, Despite Facing Big Spending
By Margot Sanger-Katz - NYT
The beverage industry spent a lot of money to defeat soda taxes in four American cities Tuesday, but it lost in every one of them.
The victories for soda-tax advocates — in San Francisco, Oakland and Albany, Calif., and Boulder, Colo. — were decisive. Those communities now join Berkeley, Calif., and Philadelphia in embracing plans to tax sugary beverages.
The pro-tax forces had the help of their own deep pockets. The billionaires Michael Bloomberg and John and Laura Arnold donated heavily to the pro-tax campaigns. They didn’t match industry spending, but they got close. Altogether, the Bay Area campaigns cost about $50 million, more than was spent on the state’s Senate race, medical marijuana initiative and gun control measures combined.
The spending may have made a difference. Big donors stayed out of early soda-tax fights, but the beverage industry always fought hard against them, and 40 such measures failed. Mr. Bloomberg, the former New York mayor, donated in the late days of the Berkeley campaign, and he has spent more heavily in the more recent fights.
Howard Wolfson, one of Mr. Bloomberg’s senior advisers, said the victories would encourage Mr. Bloomberg to invest in soda tax initiatives in more cities. He has already put $1 million into television commercials in Cook County, Illinois, where county officials will vote on a soda tax Thursday to help fund spending on public safety.
“The tide has clearly turned on this issue, and momentum has swung in our favor,” Mr. Wolfson said. “I am confident in the months ahead more municipalities will seek to implement soda taxes to help their citizens, and we will be willing to help them as they do.”
Soda taxes, originally dreamed up in academic journals, were once dismissed as a fringe idea, possible only in a place as liberal as Berkeley. They are now the law in major American cities.
The measures have been advanced by economists and public health experts looking for methods that might combat obesity, diabetes and tooth decay — maladies all linked to soft drink consumption.
But soda taxes are new enough that the evidence that they have much impact on health is still unclear. Early research from Berkeley and Mexico, which passed a national tax in 2014, suggests that such taxes can increase prices and reduce purchases of sugary drinks. Measuring their health effects will take longer.
In the Bay Area communities, advocates used health arguments to sell the measures, focusing on childhood obesity as a particular public health risk. But that has not been the strategy everywhere. In Philadelphia, Mayor Jim Kenney sold the tax as a way to fund popular prekindergarten expansion. In Cook County, the tax is being described as a way to pay for police in the Chicago area. Future initiatives are likely to be tied to local political preferences and needs.
The American Beverage Association, an industry group, has vowed to fight soda taxes wherever they appear. The group’s president, Susan Neely, has described the communities that voted this week as unusually liberal and health-conscious. Wins there, the group argues, are not predictive of sentiment in the rest of the country. She said the industry shared health advocates’ goals of reducing obesity, but not the means.
But public sentiment on sodas may already be shifting. Though the public remains divided on taxes, often seen as a nanny-state intrusion, more and more Americans are turning away from the beverages. Sales are down, and many people say they are actively avoiding the products. Anti-soft drink advertising is likely to appear in major American cities. The declining public image of the beverages will create new challenges for the industry, even if it doesn’t keep losing soda tax fights.
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