From a conservative position and prior to the ACA nationally we were at 85% of people insured and that was when illegal immigration was at its height which is not a bad number. The issue was there was always that gap of people that made too much to qualify for government aid but weren’t able to pay for medical insurance if it wasnt offered through their employer. Nevertheless, since universal healthcare is now the direction we’ve taken as a nation these are my thoughts on how it should be implemented to keep costs affordable and to make sure that everyone is covered. This is going to likely be the only political issue I will take an Authoritarian position on.
Obama Legacy ACA
The Affordable Care Act was no different than the Republican version of anti Hillary Care of ’94 or the Bob Dole plan of ’96. Ms Clinton sought a single payer program that almost mimicked that of Canada but the Republicans of that era, real republicans that I was a part of and didn’t believe in drinking tea and putting a clamp on systemic legislation in the name of ‘Liberty’, wanted to keep some pressure on the system to keep it more streamlined. So in reality the ACA is essentially the GOP healthcare of act of ’94 where the idea was to introduce a healthy risk pool of people into the insurance system. Unfortunately, this has failed because health insurers care about healthy people as much as they care about unhealthy people. Post the fall of the Soviet Union the closest you can get to the devil is today’s Health Insurers.
I frankly don’t care how it gets funded but I do care that it gets fixed and that if we’re going to do it we do it right. Saying ‘Medicare for all’ is hardly a solution, we have to go after the intrinsic reasoning of why the same services, tests, procedures and operations in our country are so much more costly than they are in other first world nations. I believe we can have a mix of government with some private single payer care to keep pressure in the system but we need to return the management of health to the Doctor with the medical degree & license and not let health care be run by the monstrosity of an HMO’s employees; most of whom are governing your healthcare with no medical training. Behind every $200 doctor visit is likely 2-3 people at the doctors office and 2-3 plus more at the insurance company; if you’re really sick then you can add a random multiplier to that number. It’s obvious that this machine of fraud drives medical costs through the roof and it needs to be stopped in its tracks. If we are to stick with managed care then we have to regulate it on an immense scale including limiting employees on the insurance side like medical review officers, case managers, utilization review and even limit the types of claims that can go to utilization review, make forms universal nation or state wide, increase the amount of acceptable medical loss currently at 80% and regulate costs in every form right down to a pill of aspirin. To expect public and ‘non-profit’ insurance companies that pay their executives million plus dollar salaries and bonuses to Physicians who save monies by not properly treating their patients to police themselves is akin to letting a fox run a hen house. If the insurers aren’t interested in staying in the business then there’s always another that will.
Examples of ‘Non-Profit’ CEO pay:
Aetna – Mark Bertolini – 2015 – $17.3 million dollars
Sutter Health – Patrick Fry – 2015 – $7.5 million dollars
Kaiser Permanente – Bernard Tyson – 2015 – $5.9 million dollars (likely much higher now that he has assumed chairman’s position)
Mayo Clinic – John Noseworthy MD – 2016 $3.5 million dollars
It is important that Pharma companies get repaid on their investments on next generation life saving drugs but being able to jack prices through the roof is not acceptable either and neither is continually raising prices on effective drugs where the patent has been expired for 40-50 years just because they can without a legitimate basis. There has to be some kind of risk and return ratio that’s acceptable and legislated or else our only option is infringing on employers ability to pay for employee benefits and driving them out of business as well as the insured being unable to use their insurance without going broke if they need to see a Doctor.
The Opioid Epidemic
The Chronic Pain Sufferer ~ formerly known as ‘The Patient’
There’s a common and disturbing misconception that a) there is an ‘Opioid Crisis’ and b) that it starts in a Physicians office. What we currently have is a drug problem. The chemically dependent want to get high to fill a hole in their heart. The patient doesn’t want to get high, he or she wants to get out of bed. It is no more complicated than that. A Physician doesn’t just hand out prescriptions and never has. There is no relationship shared between the addicted and the pain patient who is monitored by a medical professional with a license but yet lumped into the same group as the addicted. The current drug problem is with addicts becoming addicted to heroin and fake fentanyl. This is nothing new and just a sign of the times. Now heroin is being replaced by fake pharmaceuticals produced by bathtub chemists who simply look at the patent from a drug that’s 30 – 50 years old, get as many raw materials as they can, synthesize the rest and purchase a tablet press.
30 years ago we used to say an addict started on his journey by smoking a joint and now that pot is legal that is all forgotten. Now we’ve villianized Physicians, the new drug dealer of our day. It’s like we walked down a street and then as you transitioned from your right foot to your left you stepped into a Einsteinian parallel universe and now you’re one street over. Our current part time Oregon incumbent is the poster boy for this kind of absurd thought. Under the CDC prescribing guidelines for treating the chronic pain patient, with the brightest minds in law enforcement and politics involved in medicine where they have no business or expertise, we have Physicians that feel threatened prescribing to their patients. Try to wrap this analogy around your head; the Physician you expect to save your life can also end up in front of a Judge for prescribing you medication to keep you comfortable post saving your life. How does that grab you? This is an absolute American disgrace!
This issue deserves not just a spot on a page about Healthcare it deserves its own book. It’s a prime example of how politics got involved with Medicine where it wasn’t needed and how it went horribly wrong with no conceivable, reasonable or rational plan on how to solve it. The current problem is nothing more than a 100 year old redux of the the consequences post the Harrison Narcotics Tax Act of 1914 which made narcotics illegal without a prescription. Shortly after its inception narcotic addicts then turned to Physicians in droves to continue with their addiction ‘legally’. The prescribing guidelines of that day were likely not much different than those of today. Ever since the need for a prescription legislation started US Medicine has gone through many ups and downs throughout its current history with regard to prescribing narcotics without ever coming to a real solid conclusion on how these drugs should be provided. The only reason opiates have continued to prevail over time is because they work. Although there have been next generation drugs and some have become extremely popular for abuse in the most contemporary times like Oxycontin the old staples Meperidine, Codeine, Morphine, Demerol, Dilaudid et al have been with us in their current or close to current forms for 100 years plus. Physicians aren’t prescribing these drugs because they make money off of them they prescribe them because people hurt and the last thing someone that’s hurting wants to become is chemically dependant.
How did we get here?
Congress in its infinite wisdom after becoming aware of over prescribing, intense marketing of new drugs and the ease of ‘Doctor shopping’, visiting multiple Physicians to acquire multiple prescriptions, started enacting federal oversight in the early 2000s and required states to use Prescription Drug Monitoring Programs which are a good thing. When a patient obtains a narcotic prescription the prescribing Physician should look at the patients history in the state oversight system and be able to see all the prescriptions for the previous 12 months that are included as schedule’d medications required under each state’s guidelines. This gives the Physician the clarity he needs to consider whether the patient is telling him the truth about his previous prescription history and that the patient is within the CDC guidelines for prescribing. If the patient has a long term relationship with their Physician then there really shouldn’t be an issue especially if the prescribing is kept within the CDC guidelines. Where the legislature went haywire was when they and law enforcement got involved and started putting Physicians in fear of prosecution because they were believed to be possible perpetrators in the grand scheme. Once again we see Congress getting involved in things where they have no business belonging and deciding how Medicine in America needs to be practiced rather than leaving it up to the Physician and their medical license.
Where did this grand thinking get us? Well it ultimately put us into fast forward and the position we’re in now with medical pain addiction being a managed by a professional ‘problem’ to an all out unmanaged epidemic. Most family practice Physicians and some heavy duty operational Surgeons now feel threatened into not prescribing at all. They push off their long term patients to Pain Management Physicians thinking they’re doing the right thing for themselves and their patients. Now many legitimate patients have to cry and beg and see a doctor every 30 days to keep their prescriptions, sometimes even at a fraction of their original dosages. The likelihood that the doctor sees them long enough to even look them in the face is marginal at best. For many Pain Management Physicians, aka clinical Anesthesiologists, this has become their own personal pot of gold and they try to persuade their new patients into procedures that they’ve most likely already had, if their pain history is prolific, costing them time and money. Many times monies for payment that come from the Government via Medicare, Medicaid or Social Security Disability. The unluckiest of patients have their original prescribing doses decimated or are given alternative medications like NSAIDS or other non narcotics that simply don’t work and force legitimate patients out into the streets into the arms of welcoming sellers of products that currently are synthetic, shorter acting and stronger than the street drugs of the past. The patient of yesterday who was once monitored by a professional is now nothing more than the addict of today.
Now that we have a huge newly addicted segment of the population how do we face the debacle and find our way out of it as a nation? If we are Dr Greg Walden, the peoples new addiction expert, we just simply throw money at the problem and pretend that it will go away. Unfortunately it’s not that simple. An influx of monies into addiction treatment and prevention, other than another costly expenditure of public funds, guarantees nothing. An addict can only start to recover if they have some willingness, throwing a book at someone that doesn’t have willingness will only result in a bump on the head. With the strength of street drugs and their affordable costs in mind coupled with how fast people are exchanging normal lives for the path of addiction it is unlikely that there’s been enough of a period of time, in the cycle so to speak, for these folks to truly find their bottom and experience all the negatives to be had from addiction. Without question the new addicts find their way to the bottom very quickly but I find it unlikely that a short history of abuse will lead to success if we throw them into recovery en masse.
What we are seeing in profound numbers is the newly addicted meeting the 3 promises of addiction: hospitals, institutions and death and death is coming faster than it, addiction wise, previously has. This is not the manifestation of an epidemic but more of a public example of a diabolical disease. How are we going to save these people’s lives? Ask 20 different professionals and you’ll get 20 different answers. I believe number 1 we have to restore faith in the physician. These drugs can easily be prescribed at the level of the primary family physician or clinician for chronic pain. There is no need to see a pain management physician ‘specialist’ for moderate chronic pain prescribing unless there’s a need for surgical or procedural interventions. Basic pharmacology and continuing education is all the primary physician needs and they know their patient better than anyone. Getting the former patient back into a medical setting is the first place to start. With the exposure to street drugs that most of these folks have had makes this task to separate them from the insidious side of drug use exponentially harder but the Physician’s office is the first place to start to see evidence of life saving resolve. From the Physician’s office then we can start to access the extent of the addiction process and use correct drugs and the Science of Medicine to treat addiction and any other disorders of the mind the patient may have and then get them on track to recovery. Number 2, we have to get law enforcement and politics out of medicine. Every time I watch a hearing on this issue I’m subjected to a high level DEA agent telling a subcommittee how they ‘believe’ that opiates are over prescribed and they need more new laws to watch over the medical community than they already have. Frankly, I don’t care what a law enforcement official ‘believes’ when it comes to public policy especially with regard to medicine. This is the exact reason we give Doctors a medical license so they can use their intellectual knowledge that has taken them upwards of ten years of education to determine proper prescribing guidelines for every individual in need. I see no issue with the drug distribution industry or the Physician community to police themselves when it comes to prescribing and making them out to have some kind of inclusion in a make believe crime only hurts the patient. Additionally we probably need more training for Physicians to assess the likelihood of their patients to become abusers.