Who Suffers When Medicaid Is Cut?

Each spring we who plant vegetable gardens look forward to getting things a little bit better than the year before; we have a another chance to start fresh and get it right.  The expectation of sharing the bountiful crop nourishes our sense of generosity and caring, nourishes our feeling for others.  With each tiny Burpee seedling that is planted the seed of altruism is also planted, and then fed and watered to get it started.  As the early weeks pass I carefully inspect the garden daily, looking deeply to find and support what is working, and to try to fix what is not.  This concentrated effort causes time to slow down.  In the beginning, walking through the neatly planted rows there is order, no chaos. 

But by mid-summer the prickly cucumber vines twist and punish my fingertips.  But the canopy

Cucumber Vine from "Mother Nature Network"

leaves protect the cucumbers hanging underneath.  Following the vine to the very end there's a surprise.  Some of the cucumbers are straight, as expected, while others have curled up into crooked shapes, not how they are supposed to look at all, impossible to peel.  Transporting these cukes and the few Early-Girl tomatoes that have begun to ripen back to the house cradled and cocooned safely in the bottom of my too-big tee-shirt I feel full, and connected firmly to the Earth.  I sense that this gardening strengthens my compassion for life, for life in all its forms.

As I empty my shirt onto the kitchen counter and marvel at the freshly picked (and still living) vegetables I glance over at "The New York Times" and think to myself, Now what?  What is Congress up to?  Why, it's healthcare insurance again, the latest version.  Cuts in Medicaid.  Who are the people who will be hurt, I wonder?

It didn't take much digging to find out.  Over the next ten years it had been estimated by the non-partisan Congressional Budget Office that 22 million Americans will likely lose coverage but the newest figure is 32 million, as many as 17 million in the next year alone.  Most of these have been relying on Medicaid and the Medicaid Expansion under the Affordable Care Act (ACA).  Who are they?  Let's see. 

According to the "Business Insider" (July 14, 2017 ) Medicaid currently covers 20% all adults 19-65, 30% of all adults with disabilities, 39% of all children, 40% of all poor adults, 60% of all children with disabilities, 64% of all nursing home residents, 76% of all poor children, and 49% of all births.  These are the people in the cross-hairs of the new version of the Senate healthcare proposal. 

Especially to be affected are those in states with high rates of poverty and the working poor who benefited from the Medicaid expansion.  (While Medicaid is far from perfect and does not solve the problems of timely access to affordable medical care-a subject for later-at least it aims to try to address the inequalities in health insurance coverage that have been based solely on income.)

On the other hand, provisions contained in the so-called Better Care Reconciliation Act (wow!) as originaly proposed by the Senate's long-awaited (eight years in the making) plan to "repeal and replace" what they still refer to as "Obamacare" (the ACA) have been designed to help other groups of Americans.  Help them quite a lot.  The big winners were to be households making more than $250,000 a year as two ACA taxes targeting them would be repealed; those whose "passive" income is mostly from investments would have come out particularly well.  But the wrangling continues as factions within the controlling party writing the plan search for agreement, and the details of what finally emerges will certainly be changed (at least a little bit).  We will stay tuned and we will be listening.

Manel Blanco: "Coming Out of the Cocoon"

After writing these few paragraphs and sensing the pain and suffering hidden in the cold calculations I take a deep breath and let it out slowly.  The unborn, young children, new mothers, disabled fathers, and grandparents living their lives out in nursing homes, among others, will be without protection. 
This feels like the direct opposite of a cocoon, the direct opposite of a cocoon of caring.  Is this what we really want?   

I Have the Blues

On Monday of this week, a friend who scours the local Sunday paper sent me an article by email.  I read the title: "The Puzzling High Cost of Delivering a Baby."  For a few seconds I thought, well, okay, someone else has written on the same subject that I had submitted to the paper the preceding week!  Great, I'm not alone!  But when I touched the screen and started to read I saw that what she emailed me was the story that I had sent in.  It was in print already and I was excited to get a personal response so quickly. 

(Most recent post is here.)

Anyway, a few days later I went back to the York Hospital to look again at the old medical artifacts by the library where I had spotted the small bill for the delivery.  As I drove up I noticed the prominent “Valet Parking” sign.  It made me think that I was pulling up to a four-star hotel.  Maybe my room will have a view, maybe the food will be spectacular...No, that's just to make it easier for patients and families, I know.  There was no such welcoming sign 33 years ago when I arrived here from Baltimore.  

As I peered into the display case again I noticed a huge round ashtray.  They were once ubiquitous around the hospital, even seen in patients' rooms.   Maybe the “Valet Parking” sign, a somewhat jarring sign (to me) of our excesses will one day be relegated to the status of such an artifact. Perhaps in 2022?  Or maybe 2030? Or maybe even 2018!

I saw that the graduating nurses in the carefully-arranged black-and-white photo were all women.  The ratio of women to men in nursing was 12.7 to 1 in Pennsylvania in 2015 according to "Becker's Hospital Review."  The situation with regard to physicians years ago was, of course, the exact reverse.  In fact, I found only two women physicians in the official photo of the entire medical staff of 1983.  Now?  

Overall, the percentage of physicians who are male is 65% according to a Medscape report of 2016. But women represented 46% of U.S. graduating physicians in 2015.  So, in 1984 there were only two women doctors here, and almost no male nurses.  The change over three decades is striking.  It sometimes takes a long time to see the full story.  You need to stick around, and you need to pay attention.  Maybe the looking back causes us to wince when we see where we are now.  It takes time to get used to new ideas.  Sometimes we get stuck when “we like what we have.”  Sometimes it's better to change.  Sometimes it hurts to care about the world enough to try to improve it.  

My sister-in-law noted that our parents never talked about healthcare costs.  Why didn't they? The idea of health insurance started at the turn of the last century.  In Pennsylvania Blue Cross was a non-profit enterprise run by the Commonwealth.  In the 1930's membership in a Blue Cross plan was practically a civic duty.  Boy Scouts handed out enrollment procedures and preachers urged all members of their congregation to enroll.  

The Blue Cross and Blue Shield plans formed as not-for-profits to give communities access to medical care and protect against financial ruin. All members paid the same amount no matter how old or sick, and no one was turned away. The Blues became one of the trusted brands in America" (Sarah Varney, NPR Morning Edition, March 18, 2010).  In fact, the original Blue Cross of Pennsylvania Insurance started as a charitable mission.  It was affordable for nearly everyone. You went to the hospital and showed them your card, and all was well.  But when the commercial insurance industry took over and the profit motive took precedence over the welfare of the patient things changed.  

And that is how my parents could afford to have four children in the 1950s and not worry about becoming bankrupt and to even allow themselves the dream of sending us to college.  I can imagine my father smoking, with the cigarette dangling precariously from the corner of his mouth, waiting for the next mouth to feed and not being in the least concerned about the hospital bill, only that we were were healthy.  

Maybe the original Blues had the right idea.  Maybe some old things are worth looking at again (but not cigarettes). 

(Click here for the most recent story about one of our York, PA doctors.)

York Hospital and Dispensary Bill For Delivery in 1922

A week ago I was leaving the hospital by way of the old original entrance.  I was a visitor, not a patient.  I had several surgeries there for cancer, and since my daughter was adopted I had not had the experience of the delivery room and the faded crinkled 3" x 6" bill in the historical display case caught my eye.  I was not expecting to be stopped by a slip of paper since I had gone to the hospital on a mission and I was focused on that.

I was there as a collector of colored plastic disks.  My niece, an anesthesiologist in Los Angeles, wondered why the brightly colored caps from the injectibles used in the OR were discarded.  Could they serve another purpose? she thought.  So she created "TheArtOperation.com."  The caps from the vials of medication that were used to put people to "sleep" (actually into a light coma, she corrected me) and then brought back to awareness could do service as art objects.  They could be saved and given to children and even established artists to inspire them to create something of beauty (or whimsy).  But as I carried the bag of these reminders of surgery back to my car I reflected on the simple hospital bill and the stories I've heard about the high cost and the anxiety of carrying and delivering a baby, and I was disturbed.


The carefully-itemized typed and then the hand-annotated bill was for a total of $49.75! Yes, $49.75.  The bill was transparent.  
There were no cryptic billing codes (one for this, another for that, and one for who knows what), only English words and a few straightforward numbers. (The only expense not on the bill might be for the daily two-cent newspaper.)  As I said, I've listened to women's stories and I wondered what today's deliveries cost and how they are billed and how they are paid for, and how this affects the birth experience.

So I googled.  In the US the average total price charged now for pregnancy and newborn care is about $30,000 for a vaginal delivery and $50,000 for a C-section, with insurers paying out an average of $18,329 and $27,866, according to a recent report by Truven Health Analytics.

And the bill itself?  A long list of sometimes carefully-itemized charges including those for the use of the delivery room itself, the recovery room if there's been a C-section, the mother's room and board before and after delivery, the nursery, the anesthesia or epidural charge and the separate anesthesiologist's fee, the specialized neonatal nursing care, the physician's obstetrical bill, the pediatric fee, the lab, medication costs, the imaging and then the radiologist's fee, and the routine hearing screening, among others.  We have come to expect something like this.  

But that might not be all.  We might be shocked to see a charge of $39.35 for a quick "skin-to-skin" baby-to-mother contact after a C-section that was on an actual bill posted on the Internet by a confused but still grateful new father from Utah (as reported by Vox on 10/4/16). And there may be other mysterious charges.

But when you finally receive the bills the fun begins.  What does your insurance "allow" and what is the deductible? And is there now another deductible, one for the new family member?  And what does "copay" really mean?  And is anyone responsible for the full "price" as listed, and if not, what meaning does "price" have?  And will there be a denial of coverage because you didn't tell your insurance agent (if you can get them on the phone) that you were headed to the hospital ahead of schedule?  And what if the on-call doctor covering for your own doctor isn't in the network?  And then the bills come from different zip codes and from unrecognizable billing services.  Can you still find the "Queen of Hearts" in this Three-Card Monte?  What's a woman to do?

It is likely that as she is blindsided by this confusing financial and book-keeping burden her vitally-important oxytocin levels begin to wane and her potentially-damaging cortisol levels creep up.  Is this the right way, the just way, to usher in a new life?  Is this the way to honor new parents?  I believe we deserve something better.

HAPPY MOTHERS' DAY  
                                                       

Doing The Right Thing

"The challenge is to do the right thing, to the right person, to the right extent, at the right time, with the right motive, and in the right way" (Aristotle).

Changes in American Medicine are immanent and we need the right motive, the right values. Our emotional concern and compassion for others vary, and how we respond to the needs of others is, in turn, influenced by externals. By avoiding missteps of the past we can have a shared vision that benefits all.

Some care narrowly, as with their hands, palms facing each other, carefully separated by only inches. They say, "Let's first take care of this group, these few things." Others spread their arms wide and say, "Let's take care of as many we can now, no waiting." still others place their hands somewhere in the middle.

The three approaches are complementary, providing depth, breadth, and patience to the project. And this inclusiveness of vision provides the combination of forces most likely to result in effective meaningful change. When we listen (really listen) to one another we discover that we are not as divided as we thought.

The next decisions in healthcare are not without potential danger. American Medicine has at times taken shocking turns. It is a story, unfortunately, of persistent and endemic inequalities and inequities. Racial, ethnic, and economic factors have often influenced and tainted major policy decisions. Decisions such as: Who shall receive comprehensive preventive health care, and who shall not? Who shall benefit from the best we can offer, and who will be left out? Who shall simply be ignored and allowed to die quietly, and who shall be given another chance to live? Who shall gain easy access to the emergency room and beyond, and who shall be routinely turned away once the urgent situation has passed? And who will pay for it all?

Doctors in the 19th century had few tools. They could work to alleviate pain with morphine, surgery was crude and dangerous, and infectious diseases caused the bulk of morbidity and mortality. This changed with anesthesia in 1840 and then with penicillin in 1928. Progress has been steadily accelerating as we now cope mostly with chronic illness and "degenerative" diseases. For those with access to the most well-equipped hospitals admission raises the anticipation of miraculous medical and surgical cure. Minimally-invasive surgery should leave no scar. Perfection is anticipated when a baby is born. Death is seen as a failure. But through each era, medical resources have been distributed inequitably.

Missteps are recognized in retrospect and often after the weakest are hurt. Corrective efforts follow but may miss their mark.

For example, Roy Porter in "The Greatest Benefit to Mankind" (Norton Publishers 1997) writes:

"By 1900 (in the US) the management of health was...a tangle of voluntary, religious and charitable initiatives, as was primary care for the needy, while medicine for those who could afford to pay was essentially a private transaction” (Porter; p. 631).

In the early part of the twentieth century:

"War and the threat of war did not merely expose the ill health of people in modern industrial society; they provoked grave anxiety generally about the nation's health. Many...became incensed at the thought of sickly soldiers and an enfeebled national stock...The response...was the eugenics movement, which directed the health debate to the problem of fitness, understood in national and racial terms (emphasis added)...Unemployment and poverty were (therefore seen as) results, not the causes, of social incapacity" (Porter; p. 639).

The answer? In 1930 eugenists championed stricter immigration laws and secured the first compulsory sterilization measures; 15,000 Americans were sterilized by 1930" (Porter, p. 640). But: "Public health advocates...opposed eugenic policies (and)...demanded a comprehensive health system, administered by local health authorities and funded by taxation." (Porter, p. 640). Universal (or nearly-universal) health coverage has been the goal of several Presidential administrations in modern times including those of Truman, Kennedy, Johnson, Nixon, Carter, Clinton, and, of course, Obama.

"According to the CDC...for the first three months of 2016 the uninsured rate was 8.6% down from 9.2% (the year before), and from 15.7% before the Affordable Care Act was signed into law. For just the 18-64 demographic the same study shows the uninsured rate at 11.9% down from 22.3% in 2010 when the ACA was signed into law. These (figures) represent the lowest uninsured rates in over 50 years according to the studies (emphasis added)" (obamacarefacts.com/uninsured-rates/)

The uninsured rate for those over 65? Essentially zero. Why is that not the statistic for all age groups?

How can we come together as informed citizens of the wealthiest society in history to provide compassionate and equitable healthcare for all Americans? Let's share our ideas and make this happen. Let's do the right thing.

Anita