Category Archives: Alabama legislative session 2012

We Are Katniss

Yeah, I know—the LA Times is right.  Every group you can think of is latching on to the Hunger Games as an allegory for its own cause.  The archetype of a leader rising from the oppressed masses and inspiring revolution—it’s not new!  On the other hand, retelling it matters—every so often, a particularly resonant retelling changes the world.  Why wouldn’t we expect all players to try and grab the Katniss rights?


I read the trilogy several months ago, starting the first one with my book club (called, very fittingly, The Unruly Women’s Book Club).  Last night, I saw the movie with my husband and two young adult children.  And I can’t help it—I’m going to fall right in the melee scrambling over this metaphor.  I’m claiming that three finger salute for the team.


Driving home, I could not stop thinking “We are Katniss.”  A friend commented on my Facebook page by wondering why I would patronize a movie that glorified children killing each other, and that was my answer—we are Katniss.  Right now, my state, the beautiful state where I grew up and birthed our children and made my home, is doing exactly what the Capitol did.  They are setting out scraps of money in our budget and letting us lose to tear each other to pieces over it. 


They call it cutting the fat out of spending.  They’re the Gamemakers, whom we have somehow put in charge of setting up our playing field.  They tell us with a straight face that we must choose between educating our children, providing their healthcare, treating the mentally ill, or giving the most minimal support to the poorest of the poor.  They say if we don’t choose, they will set loose murderers from our prisons to cut us down and it will be our fault.


I’m not going to go ad nauseum into all the representations in the Hunger Games—how it is like Occupy but better, who the vain and clueless residents of the Capitol are, or why the Capitol is a Wall-Street controlled government and not an indictment against government by the people.  How “may the odds be ever in your favor” is the capitalist version of “let them eat cake.”


I’m just going to say this:  We are Katniss.  Game-makers, right now you may own the field and make the rules.  But you don’t own us.  You cannot turn us into your beasts.  We will not kill each other over your scraps. 


Filed under Alabama legislative session 2012, Politics

Alabama’s Budget and Healthcare: A Plea for Sanity

Alabama, instead of going for a trickle-down economy, has settled on a suck–the-poor-dry scheme.  We have the lowest overall state taxes but the highest income tax on the poor.  While trying to run our state on the backs of the poor and charitable donations from other states through federal funds, we have also cut money to the essential services that keep the poor afloat enough to continue slaving at their low-paying jobs. 


So now, our Governor says, the well is running dry.  Is it because we have sucked all the water out of an already thirsty ground?  Is it because corporations, many based out of state or even out of country, are hoarding that water in their big tanks?  No, he says!  It is because of tornadoes


Well, I’ll be.  In the face of such drivel, one hardly knows how to respond.   


 Our Governor and Legislature have ruled out many potential solutions on principle.  When principles conflict with reality, it’s time to check out those principles again.


They’ve said they absolutely will not raise taxes.   Even a simple $1 a pack tax on cigarettes, which would bring our state tax on tobacco up to average, would net us an estimated 200 million a year.  That’s the kind of tax they usually love, because it would again hit the poor harder than the rest of us.  True, it could ultimately save poor smokers years of life and money if the tax helped encourage them to quit—oh, maybe that’s why they don’t want it.  Without poor people, whatever would those deserving tobacco companies do?


We could, without raising taxes, end the so-called “incentives” and tax breaks we spend to bring business into the state—especially the ones that pay our workers minimally, provide little or no health insurance, use the labor to create profit for themselves, and return nothing to our state.  Maybe the movie corporations will use our labor and money to film us in our falling-down shacks.


I’ve had a dream for years that when things finally got bad enough, even the most conservative states would have a moment of epiphany—they would say “Oh!  You know, if we had Medicare for All, we could balance our budgets!”  Suddenly, they would find wonderful conservative reasons and manage to make it all look like their idea—fine by me.


I’ve looked at some of the numbers to see if I could get a rough ball-park idea of Alabama’s potential savings under Medicare for All.  First, we appropriated about 1.3 billion dollars of state money to Medicaid in 2011.  This was supplemented heavily with federal matching funds.   For teacher health insurance, we allocated about 899 million dollars total. State employee health insurance (not including teachers) cost us about 359 million dollars.   


If we replaced the teacher health insurance with Medicare for All, at an estimated employer matching (Alabama) cost of 4.75% of payroll, a rough estimate of the cost is 222 million for teachers—this is 25% of what we are paying now.  (See this link for a description of Medicare for All funding sources). That’s a savings of 677 million off current teacher insurance.  I can estimate this because the report lists average teacher salary.  For the other state employees, those numbers are probably out there somewhere, but if I use a cost even as high as half the current private insurance (it is likely far less), Medicare for All’s cost to the state would be 180 million dollars.


So if we just take our 2011 Medicaid appropriations at 1.3 billion, our teacher insurance savings of 677 million, and our underestimated state employee savings of 180 million, we have a savings of 2.15 billion dollars.  That’s still an underestimate, because we should remove the current Medicare employer tax, much of the Department of Mental Health expense, the state contribution to All Kids, and some of public health.


Two billion dollars at a minimum.  Read that again—TWO BILLION DOLLARS.  Woo-hoo!!  We’re in the money!  How many tornado shelters would that buy?


I am not including some peripheral savings that might add up to a lot more.  For instance, I know many people on disability who applied ONLY to get health insurance.  But many want to work—they want to feel part of things and contribute.  How many might be able to do just that (and pay state taxes) without the fear of un-insurance hanging over them? The disability money is federal, but the regained productivity and associated taxes would benefit our state.


We could save money we are now spending to regulate health insurers.  And we would remove the number one cause of bankruptcy and foreclosure—health care costs.


Now, doesn’t that sound like a plan?  First fix our current taxes to get ourselves out of the immediate hole, and then advocate Medicare for All?


Here’s the problem, though.  The people in charge are impervious to evidence and reason.  It will not matter how much money we show them.  They will just keep pushing non-solutions like selling off our cost-effective Medicaid to out-of-state swindlers (yes, it’s on the horizon again), making it easier to carry guns everywhere, chasing immigrants around and torturing women who try to get abortions.  A friend told me if it doesn’t have GGIA in it—God, Guns, Immigration and Abortion—our legislators aren’t interested.  I think he’s right.


If we could prove to our Governor and Legislature that in 2 months, without raising taxes or removing tax breaks, we would have a massive earthquake and all of Alabama would fall into the ocean, even they believed us beyond a shadow of a doubt, here’s what would happen.  They would shrug their shoulders.  They would say it must be because of abortions, gun control, Mexicans or God’s will.  They might even jump into the sea themselves before they would admit they were wrong.


Alabama, listen up.  The well is dry.  We cannot afford these people we have voted upon ourselves. 





Appendix—the numbers


Follow along in this report and tell me if I’m wrong. 


Page 18 History of employer cost for teachers’ and state employees’ health insurance (“employer” here is the state of Alabama)


899 million for PEEHIP (teachers) and 359 million for SEHIP (other state employees)


Page 7, Estimated cost of a teacher unit:  average salary for 2011, $ 46,914


4.75 % estimated employer (Alabama) contribution for Medicare for All–  46,914 X 0.0475 = $2228 per teacher


To estimate the total cost of Medicare for All employer contribution, I used the PEEHIP cost of 9024 per teacher, divided by the 899,261,904 total PEEHIP employer cost, which should be proportional to 2228 per teacher divided by the total Medicare for All employer cost.  This is 222,025,213. 


222 million is about 25% of 899 million. 


I underestimated the other employee Medicare for All cost at 50% of current employer cost to be safe—180 million.


See Medicaid Appropriations on page 68.  Notice how little we contribute from state funds, versus Federal and Local.


Other sad stuff in this report—look at the Rainy Day money, the absent COLA for teachers, the absent funding of teacher supplies.  Look at how much we are sustained by federal money, overall.


Filed under Alabama legislative session 2012, Healthcare reform

Rally Against the War on Women, Huntsville, Alabama

Great rally today at Big Spring Park in Huntsville– speakers of every age, beautiful pear trees, music– here’s the text of my speech.  The YouTube is at

This is what Spring in Alabama looks like!

This winter, some of our state legislators came down with a bad virus—let’s call it chicken farmer flu.  The symptoms are breaking out in a rash of bad bills and having delusions that we won’t notice.  Guess what?  We noticed!


We know the truth about these bills. 


We know that personhood has nothing to do with making fetuses persons—it is about trying to take away the personhood of women.


We know that putting women in jail for testing positive for drugs during pregnancy has nothing to do with stopping chemical endangerment of children- – it is about criminalizing addiction and controlling women.   If they wanted to stop chemical endangerment, they would spend more money on treatment centers and less on prisons.


We know that requiring drug testing for people who need Medicaid and denying coverage if the test is positive—including for pregnant women– is not about reducing drug use or saving money—it is about throwing these women and men and babies under the bus.   If they really wanted healthy babies, they would fund Medicaid and All Kids and our Department of Mental Health.


We know that prohibiting insurers from offering abortion coverage or making them charge extra has nothing to do with being pro-life—it is about being pro-Power and anti-Woman.


We know that the Health Care Provider Conscience bill has nothing to do with protecting doctor and pharmacist rights or preventing abortions—it is about preventing women from getting prescription birth control and reproductive healthcare.  It is about punishing women, and women only, for sex between women and MEN.   If they really wanted to cut down abortions, they would make it easy to get birth control.  But let’s talk conscience—it is against my conscience to practice bad medicine.


We know that making rules about exactly how physicians can provide abortions with prescriptions instead of surgery is not about making those darn doctors do it right.  It is about forcing doctors, at risk of prison, to use FDA protocols that are outdated as soon as they are published—it is about denying doctors and women the right to evidence-based, science-based medicine.  It makes malpractice on women not just legal but mandatory.  If they really wanted doctors to do it right, they would give us the freedom to use our training and our brains.


We know that the forced vaginal ultrasound bills have nothing to do with the right to see and know.  They are about using a woman’s own doctor as a hired gun and forcing doctors to rape, assault, shame, emotionally torture and defraud their patients or go to prison. These are hate crimes!


 Make no mistake—doctors do not want to rape our patients.  We do not hate our patients.   But apparently some legislators do.   I don’t know about you, but I don’t want the Alabama Legislature all up in my vagina.  As a doctor, I don’t want them in the privacy of my exam room.


The state-mandated hate crime bills have nothing to do with preventing abortion.   I will never believe these legislators want to prevent abortion until they do the things that are PROVEN to reduce abortion—real sex education in schools and easy access to effective contraception.  I will never believe they care about life until they make our state a place where families can afford to feed their children, get medical care for them, and educate them.


But I’m glad they put the rape and torture bills out there.  I’m glad because now we can all see what kind of people they really are, so we can get them out of Montgomery as quickly as possible.  I’m glad because now we know the truth, and now we can do something about it.


We’ve been embarrassed enough by our state.  This, right here, is the Alabama I’m proud of.


These bills are not grassroots.  They were written by out-of-state special interest groups.   But we do have a grassroots bill now!


It’s called the Right to Professional Medical Judgment Act, SB 413.  It’s so grassroots that the main body was written by an ordinary Alabama citizen—me—and proofread on Facebook by you!  Real women write bills.  Senator Linda Coleman, the bill sponsor, actually read it, unlike Clay Scofield.   Real women read their bills.  She got 9 co-sponsors, unlike Scofield who got none.  Real women and men work together.   This is not the Abston Bill or the Coleman Bill—it is OUR bill.


Let me read you the main text of our bill:


“No physician or health care provider licensed to practice in the State of Alabama shall be forced by state or local regulatory authority to perform any medical service or component of medical service if the service or component of service is not medically necessary or would be harmful to the patient AND the patient does not desire the medical service.  The right to practice within the scope of a medical license supersedes any existing or future legislative act.”


We shouldn’t have to explain to our legislature that they can’t practice medicine without a license.  We shouldn’t have to explain to them that they can’t legislate science anymore than they can change the law of gravity.  We already have the Alabama Board of Medical Examiners, a Board with medical training, to supervise the quality of care by doctors.  It looks like we need this bill to remind them of that.


Take a minute and look around you.  You can be proud to be part of this group of women AND men.  You can be proud to say you live in Alabama.  The winter of bad bills and the War against Women will end, right here.  This is Spring in Alabama.


Filed under Alabama legislative session 2012, women's healthcare

Talking Points for Madison County in Response to Alabama Department of Mental Health (DMH) plan 2012

Talking Points for Madison County in Response to Alabama Department of Mental Health (DMH) plan 2012

 (Please add to this for your county by working with your local NAMI Chapter)


The DMH is planning to close 4 large regional psychiatric hospitals and transition care to local communities, in order to meet severe budget shortfalls for the 2013 fiscal year.  Here are some key points citizens need to address:


1.  In order to fulfill the court-ordered treatment of patients who are committed, we will need crisis stabilization units.  Local hospitals are not prepared to accept these patients and do not have the capacity—their beds are already over-full with acute care patients.  Our MHC has applied for a 16 bed unit.  If nearby county mental health centers (MHC’s) also get the units they have applied for, we can meet or exceed our current capacity at North Alabama Regional Hospital (NARH).


2.  Money and time is needed to prepare the crisis units.  The closure of NARH is planned for September 2012, but NARH plans no new commitment admissions after July 1, 2012. There will be no time or money to build a new facility.  That leaves less than 4 months to locate, purchase and convert an existing facility. DMH does not plan to provide these capital funds, so our MHC will have to apply for a loan once they find a suitable location.  The MHC has requested a budget to operate the units but has not received a figure for what our county will receive.


3.  There will be potential barriers to purchasing a suitable facility.  Our community has a history of “not in my backyard” responses to various forms of subsidized housing and group homes.  It is unknown how much time/ effort this will require to overcome.


4.  Once a facility is purchased, the renovation requirements will be extensive.  For example, all existing glass windows will need to be removed and replaced for patient safety.  Showers will need to be redone so that there are no rods for patients to hang themselves on.  There will need to be “crash bars” installed and safe furnishings purchased.  Doors, both internal and external, will need to be secured and fencing must be erected.  The crisis units will be used to stabilize the very sickest patients—those who are actively trying to kill themselves, are homicidal, or otherwise severely psychotic.  For their own safety and the safety of the community, the facility must be properly prepared.


5.  It is unrealistic to expect the crisis units to be complete in less than 4 months, when a site has not even been located nor a budget amount provided.  The MHC is not to blame, because they have only been informed of the plan within this month.   Our MHC will work as quickly as possible, but there is NO WAY they can have this finished by July 1 in order to accept commitment patients.


6.  Current group home residents who have been stable in their placement are now being “bumped” to less supervised settings in order to make room for those being discharged from NARH.  Many of these bumped patients have a history of multiple relapses and re-commitment.  Without a facility for new admissions, there will be no place for them to go. DMH does not plan to fund expansion of group home beds. 


7.  We appreciate the DMH’s concept of community care and less restrictive settings, along with the “recovery” orientation.  However, national statistics tell us that there is a certain percentage of patients with serious mental illness (SMI) who will always require more intensive support than supervised apartments can provide.   Our MHC’s are NOT failing to provide the care that would cause recovery—there is simply no known cure for these tragic illnesses.


8. Madison County, according to the US Census Bureau, had a population of 334, 811 in 2010, 255,460 of whom were over 18.  According to national statistics, 1.1% of those over 18 will be diagnosed with schizophrenia, usually in the young adult age.  That means we should expect about 2810 of our residents to have this diagnosis.  Of those, national statistics tell us that 8% will have recurrent exacerbations despite treatment, and 35% will have exacerbations with a worsening function over time that never returns to baseline.  After 10 years of illness, 5% are expected to need hospital level care at any given time.  For our county alone, that would be 140 people expected to need residential care in the hospital. If we have only 16 on average, that means we are already well below expected numbers and that our MHC is not underperforming.  Even with current MHC group home beds at 60, we are utilizing less highly supervised care than expected.  And this is only for schizophrenia!  We also have illnesses like bipolar and chronic depression.


9.  Our families are filling the gap now, but we are already overburdened and cannot do more.  We applaud the plan to increase independence and integration into the community for those who can be helped in this way, but we must acknowledge the reality that some with mental illness cannot live this independently.  Our MHC cannot be expected to provide a magic bullet cure when no one in the world has been able to do it.


9.  The consequences of failing to transition safely to community care are grim.  Even with current services, 10 to 13% of those with schizophrenia eventually kill themselves.  Up to 60% of male patients attempt suicide during their illness.  If we set up a revolving door between group homes, the community, and re-commitment, there will be even more suicides when those who are most ill fall through the cracks.  If there is not even time to prepare safe crisis stabilization units, the risk will be even worse.


10.  Most mentally ill patients are more likely to injure or kill themselves than others.  Although violence against others and homicide is rarer, when it does occur, it is overwhelmingly more likely to happen to a caregiving family member than to a stranger.  Nationally, as many as 6% of patients with schizophrenia are in jail at any given time and 6% are homeless.   There is no rational way to bypass our need to provide adequate services—we will pay for it one way or another.


11. Of all the budget shortfalls, a failure to fund treatment for mental illness will be the quickest to show up in tragedy.  Failing to fund education may take years to be seen in a less prepared work-force.  Failure to fund Medicaid may take months to be seen in higher illness and disability burden.  Failure to treat our seriously ill residents, because of their severe fragility, will take DAYS to result in deaths.  We cannot afford to roll these dice.


12.  Please contact your legislators immediately, as well as the Alabama House and Senate committees preparing the budget, the Governor’s office, and any community groups you think might help us speak up.  Time is of the essence. Tell them we MUST fully fund the DMH and we MUST have more time to prepare this transition.


Please see my other blog post for more.

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Filed under Alabama legislative session 2012, citizen responsibility, mental health, specific advocacy ideas

Alabama’s Budget Canary: Funding the Department of Mental Health

As you know, our state is woefully short of the amount it takes to carry out our basic functions, and legislators have been acting like teenagers about it—shrugging their shoulders, rolling their eyes and saying “oh well!”’.  Many of the shortfalls will not show up in immediate damage.  Inadequately funded schools will result in a poorly prepared workforce, and proration to universities will eventually limit quality to the point our students invest tuition money elsewhere.  Loss of support for Medicaid and AllKids could result in poorer child health (and yes, even death from conditions not treated in time), but this could take months to show up.


The delayed nature of these consequences allows legislators to get away with it, for awhile.  One program on their hit list, the Department of Mental Health (DMH), could prove the exception to that rule. 


Our DMH funds three basic divisions—Developmental Disabilities (formerly called mental retardation), Substance Abuse, and Mental Illness.  In the planned budget, mental illnesses will take the entire cut to the department.  I am told that this is likely because the opposition to cuts for developmental disabilities would be too heavy, in the form of service mandates, lobbying groups, and potential lawsuits.  Addiction treatment is so minimally funded that there is nothing left to cut anyway.  So that leaves mental illness.


I would not want to be Zelia Baugh, our state’s mental health commissioner.  She has an impossible task.  The DMH pays out funds two ways, for operations, including at state owned facilities serving those who are committed by probate courts or criminally committed, and for contracted services by county mental health centers (MHCs).  The MHC’s also bring in money from private insurance payments and sliding scale payments by patients, but they are heavily dependent on the DMH money.


Baugh had a choice between cutting payment to the MHCs, already running on less than they need, and cutting payment to the state facilities, also underfunded, or both.  If she had cut MHC money, the centers would have had to let large numbers of staff go.  Patients would have to wait significantly longer than they already do, and for some of the most fragile patients who had barely been managing in the outpatient setting, the loss of access would have caused rapid increase of hospitalization and civil commitment.


The state facilities probably could not have been funded less and still stayed in operation.  So Baugh, under the gun, decided the only option was to close the state facilities almost completely.  The patients formerly at Taylor Hardin, for the criminally committed, will move to the new Bryce.  Mary Starke Harper in Tuscaloosa, the hospital for geriatric patients, will remain open because it is funded with Medicare money.  Everything else will close.


DMH plans to transfer care of committed patients to local facilities, as part of an overall strategy to integrate persons with SMI into their communities.  This could be a great plan for many patients, but for some it is unrealistic—I’ll cover the “philosophy” aspect in a later post.  So where are these local facilities?


Ah, there’s the rub!  There are no such creatures.  All over the state, MHC’s are scrambling to figure out what to do.  I am the secretary of our Huntsville chapter of NAMI (National Alliance on Mental Illness)—NAMI is an advocacy and support organization for families of persons with SMI.  We are not opposed to more community care.  We just want to be sure it gets done correctly.

 I met with Brian Davis, the director of the Madison County MHC, along with several NAMI members and board members, this past Thursday evening.  Brian kindly spent 1.5 hours answering our questions and explaining what our MHC is trying to do.  I’ll cover other community services later, but for patients newly committed to hospital care, he has asked for funding to run a 16 bed crisis unit (more than 16 beds would disqualify them from billing Medicaid).  If the adjacent counties also get the beds they’ve requested, there will be an equal or greater capacity than we previously had at NARH for our area.


He has submitted a budget request to DMH, but unfortunately he will not have any real idea of the planned funding for several weeks.  The state hospital in our area, North Alabama Regional Hospital, is projected to close along with the others at the end of September (because of the fiscal year), and that would be hard enough—but NARH plans to close to new civil commitments as of July 1.  That means he must locate a suitable building, renovate it, staff it, and be ready to go in less than 4 months.  He can’t start until he knows about the money, so make that less than 3 months.


To compound matters, he expects DMH money to only apply to operations for the crisis unit—it won’t cover capital.  So he will have to get a loan for our MHC.  He will have to locate a suitable building (not time to actually do new construction), purchase it in the face of the usual NIMBY outcry, and do extensive renovations.  Patients aren’t committed here unless they are considered a real threat to themselves or others—that means he will have to replace all the window glass and install “crash bars.”  He will have to get safe furnishings.  Even details like the showers have to be right—otherwise patients could hang themselves on the shower bars.


Are you getting the picture?  Do you think there is any way in heck all these tasks can be completed by July 1, or even September 30?  I sure don’t.


I asked Brian what it would take to do this right.  He told us he would need twice the expected money and three times the time.  If he had that, he said, he could do a GOOD job for us, and the outcome would be improved services for persons with SMI.  Money buys time, so that’s our first priority.


Back to the consequences of failing to be ready for this transition.  It might help to look at other states that cut services.  It is a grim picture.  Most mentally ill patients who kill or hurt people target themselves, not others—we can expect an immediate increase in death by suicide.  For those who do attack others, it is usually a care-giving family member who gets hurt or killed—the same family members struggling desperately to make up the gap in state services.  Speaking as one of these family members, I can tell you I am more afraid of what the state would likely do to my loved one—execution—than I am of dying myself.  But given the high frequency of SMI, we should also anticipate the rarer public violence to increase. 


We will pay, one way or the other—in money or in death.


I know I’ve asked for a lot of action on your part this year.  I hate to constantly have to tell you the sky is about to fall or that the alert level is red!  But it’s just that way.  You, my friends, are holding up our sky. 


Many of our fellow Alabamians with SMI can do well with proper treatment, but their mental health is very, very fragile.  A disruption in service can send an apparently stable person over the edge in a matter of days.  We will see disaster not in years, as for education, or months, as for Medicaid, but DAYS.  I’m not saying we should pass the planned cuts to those other programs—we should not.  We should tell our legislators to do their jobs and come up with the money, no matter what campaign pledges they have to break.  Otherwise Alabama will go down like the Titanic, with our statehouse playing the no-taxes violin on deck while we prepare to drown.


Your efforts so far have been productive.  The sneaky planned privatization of Medicaid, initially termed a “done deal”, has at least for now been slowed down.  The attack on women’s health services in the form of SB 12 has been met with such loud public outcry that the bill sponsor is backing down.  Keep pressure on—it works!  Tell our legislature to give the MHC’s money so they can buy time to do this right.  I’ll post a separate list of talking points for my county—please help NAMI Alabama add to it by investigating plans in your area.


Efforts are already in place by NAMI chapters in our state and NAMI Alabama, but family members burdened with providing in-the-trenches care to their loved ones can’t do it alone.  We are all affected by the mental health of our state.  Get in there and fight with us, shoulder to shoulder! 


Filed under Alabama legislative session 2012, citizen responsibility, mental health

HR 676, Part 7: Women’s Reproductive Health Should NOT Be Managed By Chicken Farmers

Before I get to mental health, which I promise is really coming soon, I’m going to reflect on how the current uproar in Alabama and other states over women’s reproductive rights might call for some careful editing of HR 676, the Expanded and Improved Medicare for All Act.  I’ve reviewed the wonderfully long list of covered services previously.  Is it clear enough to stop a conservative administration from limiting reproductive care?  I fear not—I believe it needs to be substantially strengthened.


Contraception would likely be covered without explicit mention.  The bill covers “all medically necessary services”, and preventive care plus prescription drugs are clearly listed.  There is no way we are going to list every medically necessary service in the bill itself, but other services that have been historically limited by insurers are mentioned outright, such as dental care and mental health services.  To be on the safe side, we should go ahead and specify contraception coverage.  Just as for other medications, there would be no co-pay at the point of service—this health plan is pre-paid entirely.


What about abortion? HR 676 needs to specify coverage, very directly.  Single-payer advocates sometimes avoid mentioning abortion, even though NOW is a supporter of HR 676. It has been an uphill battle to try and get Medicare for All on the table—I am sure the thought is probably just “don’t go there.  Don’t make the job even harder than it is.  If it is legal, we can assume it will be ok.”  That is likely a mistake.


Maybe one day, contraception will be so excellent and free of side effects that abortion will become obsolete.  Maybe one day, an embryo or fetus can be painlessly removed and grown in some high-tech incubator, later to be adopted.  Until that time, we must clearly state that we are going to fund a medical procedure the courts have already said is legal.


The best prevention of abortion, a very sad procedure no woman wants to need, is contraception and an educated public.  The Dutch have the lowest abortion rates in the world— they got there by teaching everyone how to prevent unplanned pregnancy and making contraception easily available.  Sure, contraception isn’t perfect, but it really does help, as opposed to delusional attempts to prevent sex itself.  If those who call themselves “pro-life” would quit behaving so irrationally, teens in the US could be just as well-educated, and all women would have access to contraception.  Instead, these forces reveal themselves to be about not life but power.


In Alabama, if you’ve read my recent posts, we are being besieged with a flurry of bills written by out-of-state special interest groups trying to keep women from accessing both contraception and abortion.  At the same time, the State House may cut funding for a range of services to children, including healthcare, education, enforcement of child support, and foster care.  Pregnant women may be unable to get Medicaid if they test positive for drugs, and there are efforts to imprison them as well.  It is a truly bizarre double-bind.


Seeing this dismal script played out has made me re-visit the most common critique of single-payer healthcare—that it would be done poorly, because it is government.  I have said before that our main protection is the requirement for ALL of us to have the insurance, including legislators and administrators.  Will that be enough?  Maybe not.  As long as there are procedures special to women, we are at risk of male legislators attempting to practice medicine without a license.  


In Alabama, we have a chicken farmer—a chicken farmer!—who thinks he knows enough about medicine to tell doctors how to get informed consent for abortion.  I will not come to his farm and try to manage his chickens.  He needs to stay out of our exam rooms.  I mean nothing derogatory about farmers or their chickens.  I would say the same about a nuclear physicist.  These are just very different specialties.


We already have insurers who get away with poor coverage of women’s health needs.  We need to be careful that a national insurance program would not put us at risk for the same problem.  How to do it?  Perhaps we can strengthen the design of the National Board of Universal Quality and Access.  I will go over it again when I get to that section of the bill, but as written it includes a minimum of one health care professional.  This board has many tasks, some of which don’t require significant medical training.  I believe we need to separate out a Board to include both practicing physicians and patients that will oversee the determination of medical necessity.  This board should have a voting majority of physicians and half should be female.  Members should be elected by physicians and patient advocacy groups and should not be employed by potentially conflicting interest corporations (like pharmaceutical and device companies).  They should also not be government employees.


Our nation’s founders attempted to set a balance of powers in place.  I was taught in elementary school this means the legislative, executive and judicial branches.  I’m learning there’s a lot more to it!  There’s the balance of power between citizens and our elected representatives, between states and the federal government, and between private enterprise and the state.  There’s even a balance of power between physicians and patients, one that has evolved markedly for the better in recent decades.  Men and women, adults and children, workers and employers—on and on.  It’s mindless to argue over big and small government—the argument needs to be around the power balance.  Anyone who gets too big, whether that’s government, corporations or a mob, will throw it off.


Power balances can and will get off kilter.  Sometimes the problem can be solved by adding a little more weight to one side or the other.  Sometimes one of the weights must be removed and replaced.  We don’t always know to predict an imbalance until it happens—I doubt if our founders expected Citizens United.  Monarchy might have been just fine if it had always been benevolent.  If we were a different sort of country, ideologically, we might be ok letting a government board determine our health benefits.  I do not trust our current crowd with that job.


Our healthcare balance has been weighted much too heavily in favor of corporate insurers who put their profits ahead of both patients and physicians.   We probably can’t fix the problem without replacing them.  HR 676 replaces them with government—the other side of the scale needs to be firmly weighted with physicians free to practice quality, professional medicine and patients who demand to be treated with respect, as full participants in their medical care.


Filed under Alabama legislative session 2012, HR 676 Analysis, women's healthcare

Alabama SB 12: Against the Rights of Women and Physicians

Have Alabama Legislators finally stepped on a hornet’s nest?  SB 12, the bill that would force physicians to verbally assault women during their required but medically unnecessary ultrasound before legal abortion, has triggered quite a flurry of citizen opposition.  Clay Scofield, the bill sponsor, says he will revise the bill so that it no longer requires intravaginal ultrasounds—the woman can “choose” which probe to have “used on her.”  He also maintains that the section requiring the narration of body parts even for women with ectopic pregnancies or whose babies have died in utero was only poorly worded and will be “clarified.”


So far, the bill appears to still contain a specific requirement to do the narrated ultrasounds even if the doctor determines that the woman might kill or maim herself afterwards, or if she has a “psychological” diagnosis.  This leaves the physician to make a Hobson’s Choice between risking a patient’s death by suicide or death by coat-hanger. 

There is a rumor Scofield may revise the wording that makes any doctor who doesn’t do the narrated ultrasound a Class C Felon, but he didn’t highlight that section in the bill as something to be revised.  As it stands, a physician would be at risk of going to jail and probably losing a license to practice.


The bill says it is severable—this means that if any single provision is struck down by the court, the rest will stand.  We already have a law on the books from 2002 forcing physicians to do ultrasounds—the features this bill would add, as above, are likely to be hacked away in court at expense to Alabama taxpayers.  So it is a waste of our time and money.


The bill should be pulled.  But what about the existing law?  It is a problem—I didn’t know about it before this, since I’m not an OB-Gyn.  This may be an opportunity to end that law as well.  As it stands, it is a violation of women’s rights and physicians’ rights.


In the rest of this post, I’m going to address the angle of physician rights.  Not because those are more important than women’s rights (I’m a woman and wouldn’t do that), but because I don’t think the problem has been addressed from that angle in the legislatures or courts.  If it has and has failed, please let me know.  I believe that protecting physician rights to practice correct medicine, without the legislature stepping in to practice without a license, may put a quash on this type of bill.


I encourage those of you fighting the bill to contact your physicians and other medical providers, not just those who do abortions but all of them.  Please be patient and understanding.  The doctors I have talked to, even those who are very opposed to this bill, get a look of visceral fear on their faces when I ask if they will speak up publicly.  They are literally afraid of being shot and killed.  Many have young children that they don’t want to put at risk.  So some may have to support you anonymously, but you can still keep a count.  I will do my part by sending this post to the Madison County Medical Society,  the Medical Association of the State of Alabama (MASA) and doctors I know.


I have sent an email to Vivian Figures asking her to introduce a bill called the Right to Medically Necessary Practice Act, worded as follows:


“No physician or healthcare provider licensed to practice in the State of Alabama shall be forced to perform any medical service or component of medical service by state or local regulatory authority, if the service or component of service is not medically necessary or would be harmful to the patient, and the patient does not desire it. This right to practice within the scope of a medical license supersedes any existing or future legislative act.”


Please call or email Senator Figures and ask her to do this. She is a good legislator and I believe she will go to bat for us or refer it to someone else if she believes another sponsor would be successful.


Here is a sample letter you could give your physician or other healthcare provider—please reword to make it personal.


Dear Doctor,


As you may know, SB 12 is in the Health Committee of the Alabama Legislature.  This bill would require physicians to narrate an ultrasound in detail, showing fetal body parts, to a woman before she can consent to a legal abortion.  It would allow the father (and the grandparents) to sue the woman if she doesn’t have the ultrasound, even if he is her rapist.  It would force the physician to do this even if the woman is diagnosed with a psychological disorder making such a procedure dangerous and even if the physician determines she will maim or kill herself if the ultrasound is done.


Initially the bill contained a requirement for the physician to do a trans-vaginal ultrasound if the image was better, even if the woman objected.  It also required the procedure for women with ectopic pregnancy or fetal demise.  Senator Scofield says these sections will be revised, but the fact that this was included should tell you that the bill’s intention was to inflict harm on women.


If the physician does not comply, he or she would be guilty of a Class C felony and would go to jail.


The existing law requires the physician to do an ultrasound already.  It does not require narration during the ultrasound, encourage lawsuits, or put doctors in jail.  We believe those elements may be struck down in court, so this bill needs to be pulled before we waste any more taxpayer money.


Even the existing law is a problem, however.  Physicians are being manipulated from every direction and not being allowed to practice medicine according to their training.  Current medical evidence says that in most abortions, no ultrasound is medically necessary before the procedure.  The only published data, from a study of 350 women, showed that not one woman changed her mind about a planned abortion after viewing an ultrasound.  This means that the procedure is not necessary for informed consent.  Our state law forces doctors to do a medically unnecessary procedure before they are allowed to do a legal one.


We believe this legislation of medical practice needs to end, once and for all.  Science changes too rapidly to be bound by law.  If the legislature can force doctors to do this particular procedure, where will it end?  Doing medically unnecessary services, against the patient’s wishes, is a type of fraud and is against professional ethics.  It wastes precious medical resources and money.  The Alabama Code clearly states that it is the opinion of the Alabama Board of Medical Examiners that physicians should not do “more or less than the medical problem requires.”


We believe a bill is needed to stop the inappropriate practice of medicine by government, to be worded thus:


“No physician or healthcare provider licensed to practice in the State of Alabama shall be forced to perform any medical service or component of medical service by state or local regulatory authority, if the service or component of service is not medically necessary or would be harmful to the patient, and the patient does not desire it. This right to practice within the scope of a medical license supersedes any existing or future legislative act.”


If you agree and want to protect your right to practice good medicine, please contact your legislator and ask for the bill to be introduced during this session. 


There is a bill already introduced, intended to prevent women from accessing birth control and other reproductive services, called the Health Care Provider Conscience Act.  It is a badly worded bill that could lead to malpractice.  But there is no law to protect the right of physicians to practice freely within the standard of care.


We know many physicians may be uneasy about speaking out and fear retribution from political extremists.  We are asking you to do two things which are low-risk:


1) Contact your legislature, County Medical Society, and MASA to say that SB12 is unnecessary, a required ultrasound already being part of Alabama law.


2) Contact these same people to promote the new bill as above, protecting your freedom to practice good medicine.


As your patients, we need you to have the right to care for us using your best medical judgment.  We will speak up for you.  Will you speak up for us?




Your Patient

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Filed under Alabama legislative session 2012