Tag Archives: medicare for all

The Light of the World is in You: It has not been Overcome

When I was 4 years old, I announced to my family that I was going to “be a doctor when I grow up.”  Why?  Because my preschool friend’s father was one, and I thought he was cool.  At age 49, 18 years into practicing pediatrics, my reasons have of course entirely changed.  I may or may not have grown up.


The same thing has happened with my advocacy for single payer.  When I started this, I was (in hindsight) incredibly naïve about the political world and the forces of power at play.  I did not have an inkling of how easy we are to dupe and manipulate—how our emotions can be hijacked by a researched phrase or just a word, and how we can imagine the resulting confabulations are our own.  I had spent decades in school and then working out the intricacies of how to take care of patients in the exam room.  I thought I was keeping up with politics the whole time, but I had only a very superficial grasp.


So when I heard about Medicare for All the first time, having been in practice long enough to be distressed by the strange abuses of economic power in medicine, I felt as if I had “come home”—that this was a beautiful solution to our problems and that all I had to do was make sure everyone understood it well enough to insist we have it.  It felt like a religious conversion must feel.  Everybody in, nobody out!  What could be better?


Don’t panic.  I’m not giving up.  It’s just that my reasons now are entirely different.


The first time I spoke publicly on healthcare reform, I was terrified before standing at the microphone.  I had never been a natural public speaker and used to have a tendency to be shy.  What happened, right as I opened my mouth, seems to have been lasting, because I’ve never been afraid of speaking since.  As I looked out at the audience, I could see who was there supporting the cause, who was uncertain, who was ready to give me what-for—and all of the sudden, I realized I loved them.  Instead of wanting approval or love from them, I felt an deep sense of compassion and affection in my heart, for them.  I thought, “Look how hard we are trying to get this right.”  I wanted to do my best job to pitch my lot in, not with only some of them but with everyone there.


In the years afterwards, I have slowly learned more about politics, power, and human nature.  I’ve given up the Democratic party, many subtle forms of utopianism, the myth of progressive evolution of our species, and the hope that single payer would work here the way it has in other countries.  I’ve given up my school-girl belief that our government is in any way composed of “we the people” and realized that both self-described conservatives and liberals are pawns in a game we will probably never fully understand, both seeing some true problems in each other but neither seeing our own.  At the same time, I know that because I’m human too, I am most certainly under the influence of wrong ideas I also cannot see.


The extent of entwinement of Capital in our governance is now so tight and the wealth and power disparities among us so gaping that I no longer think any of the traditional routes of change, using civilized and orderly processes, will do anything to influence our course.  Even social issues like marriage equality are probably not shifting for the reasons we think.  As we enter into more and farther reaching global trade agreements, it will become progressively less important for Capital to worry about keeping us pacified, and the disconnection of our votes from policy will become more apparent.


In this setting, I have to agree with my conservative friends that handing over health insurance financing to the government sounds suicidal.  We will get single payer, friends—when Capital has worked out how they can do it and still profit.  So it won’t be the same egalitarian and high-functioning system we’ve seen elsewhere.  On the other hand, our health financing is already under the thumb of Capital and Unelected Governance.  And we already all pay for the whole thing.  We are, right now, in it together.  We just can’t see it, and those running the show don’t want us to.


Some of my friends think the order of change needs to be campaign finance reform, a third party, an amendment to remove the personhood of corporations—then Medicare for All.  I toyed with those ideas, but I think now it is impossible. If we got those things, it would be in name only.  Real change of that sort would be too unacceptable to Capital. 


Throughout history, when great wealth and power disparities have become intolerable to the masses, the result has always been revolt.   Disparities are destabilizing.  Utopians for the underdog arise (often highly anti-intellectual), power is overthrown, and the whole cycle starts again.  The problem is that now the tools of battle have changed.  I do not believe the planet can survive the process of another American Revolution or Civil War.   And even if it did, unless we have learned to see each other differently—the way my perspective shifted when I looked out at that first audience—there would be no point in revolution anyway.  It would be palliative care, hospice for humanity.  Eventually we’d wind up right back here.


If there is no escape from malign power, what then?  I support single payer, because I think there is a ghost of a chance that seeing ourselves with a common purpose—a decent healthcare system—might help us also have different eyes for each other.  It is a tremendous long shot.  I don’t expect or want Utopia to result—just a little moderation of the divide between us.  I don’t see that we can pursue entire withdrawal of energies into small communities and let government pretend to drown itself in a bathtub.  That’s just a word game, and we are the losers.  The power won’t release us—it will just change its name.


What else?  Insurance reform, even single payer, can’t possibly be a whole response to the brutality of our healthcare system.  Not knowing how on earth to make a difference in this mess, I keep coming back to the one thing I can do, immediately and every day—practice love.  Love is the ultimate subversion to power and Capital.  Power has no idea what the hell to do with Love—it has no weapons or means of control against it.  If you want to love, no one on earth can stop you.  It isn’t real love, though, if it only applies to those who accept your particular ideology.  Love means, in whatever circumstance you find yourself, whether that’s on Facebook or facing a room of the “enemy”, that you refuse to play by the rules of labels and stereotypes.  For us, right now, we can say “everybody in, nobody out.”


Some of my friends in religions believe in a Utopia where the powers of good triumph over evil, finally and definitively.  I don’t.  Neither do I believe in the converse.  I’m not a supernaturalist, and if I use the word God I am speaking metaphorically.  The most resonant words in the Bible for me are “The light shines in the darkness, and the darkness has not overcome it.”  Not the light burning up the darkness.  Just shining on in spite of it. At the end of the world, even if we annihilate ourselves, in our last breath and heartbeat, we can keep that light of love, our stubborn kingdom of heaven, on fire. Amen.


Filed under citizen responsibility, Healthcare reform

Truth Hearing: Your Help Needed!

Now that I’ve finally done worrying with and studying for my every 10 year board recertification, it’s time to get busy for a more important project: Truth Hearing.  On July 31, the day after Medicare’s birthday, I have reserved the big room in the Huntsville Main Library from 6 to 8 pm.  I will invite local and state leaders to sit on a panel of listeners, while members of our community testify about their personal experiences and difficulties accessing healthcare.


Healthcare Now came up with this idea several years ago.  I only learned about it recently and thought it sounded just right as a project for North Alabama Healthcare for All (NAHA, our chapter of Physicians for a National Health Program).  In this Truth Hearing, leaders will be asked only to listen—not to question us or respond with canned speeches.  Of course, I expect many of them will want to hang around afterwards for conversation, and that’s fine.  But I don’t want any of them using this as a chance to push their own agendas.  There will be no PowerPoint presentations or speeches.


Just us, telling our stories and listening to each other.


There is an onslaught of propaganda from every direction, and not only from Fox and MSNBC or other media avenues.  We have let ideologies, stereotypes and sound bites invade us on our Facebook pages and in everyday conversation.  Reminds me of wearing designer clothing labels and paying to advertise someone else’s product on our rear ends.  It’s high time to unplug our ears, rip off the labels, and find out what is really happening, in the homes of those we share our weather with.  Not only that—we need to do it repeatedly, at least once a year, to learn what the corporate press and the politicians are not going to tell us.  As the ACA rolls out, we should be sure to learn the real effects of turning our health over to the unelected governance of private insurers.


I know it won’t be a random sample.  Sometimes it seems ridiculous that we respond so intensely to stories, statistics be damned.  But maybe we can put our story-loving selves to good purpose.  A story of injustice, with a face and a voice, can be a tipping point—if not for social change, it can change us on the heart level, and that’s where real healthcare reform needs to begin.


To do this right, I need some help.  Our core membership for NAHA is very small, and I am not a great organizer.  I hope some of you can pitch in for this event.  I want to fill up those 200 seats.


This week I am going to send out invitations to listening leaders.  I’d like your feedback on the composition of the panel, which I think should be no more than 10 to 15 people.  Each invitee will be allowed to send a suitable proxy if unable to attend—failure to appoint a proxy will result in an empty chair with a name card.  Here’s my working list:  2 members of the Madison County Legislative Delegation (one from each party); 1 member of City Council; 1 member of the Madison County Commission; the Mayor; Mo Brooks; our two Senators; our Governor; our regional Health and Human Services director Pamela Roshell (because our Exchange will be run by the fed).


I need two people to help with coordinating audio services with the library.  I have paid the fee out of my pocket to reserve the room and will also pay to rent the microphones/ speakers, but I do not have a free day between now and July 31 to get trained in using the library equipment.  I think two people willing to commit to that would be safer than one.


I need helpers to sit up front, to be ready to stand with those who want to testify but are anxious about standing alone.  Needs to be folks who are comfortable holding hands with strangers if asked.  I need greeters at the door to welcome attendees.


I need help with getting the word out.  I will have a flyer ready by the beginning of July (although if any of you are good with catchy artwork, your help is very much welcome), and I need people who will commit to sending it out by email, posting it around town, and pestering their friends to come.  I need help making contact with press, so we can get coverage.  I know a fellow who has recently started working with Story Corps at NPR and will ask him if he might want to attend, in case he would like a follow-up interview with a family. When I have the flyer ready, I will also put an event page on FB and ask you to share invitations with friends.


I need 2 camera people (with equipment) to video the event, so we can put coverage on YouTube afterwards.  Those testifying will be asked to sign a release, although we will have an option for those who desire not to be recorded to have either only their voices heard or to be omitted from the video completely.


I need people willing to tell their healthcare access stories—not their political solutions or problems but the stories of what actually happened to them because of difficulty getting healthcare.  It would be ideal to have at least 12 committed in advance, since each person will have 3 to 5 minutes to speak. I know talking about personal health and financial matters in public can be difficult. Heck, public speaking on anything at all can be scary!  We are ready to stand with you.  We need a few brave souls to tell the truth—the whole point of a Truth Hearing.  You are certainly welcome to omit the specific details of your medical diagnosis and focus only on how your life has been affected.


I know I’m asking a lot, and all of you have other work to do.  If I don’t get sufficient help, I will play Little Red Hen and do what I can—but if you want a meaningful, effective event, please step up! Email me at pabston@aol.com and tell me what you can contribute.


I have been listening to healthcare stories for my whole career.  Families in my office who have suffered the ill effects of being uncared for and rejected by our profit-driven medical system tell me on a daily basis what it is like.  More than anything else, their stories have made me determined to stick with advocacy for Improved, Expanded Medicare for All—everybody in, nobody out.  I have the numbers and knowledge of experience in other countries to back the concept up, but at the end of the day, it is always real people that keep me in the fight.  Will others in our audience and on our panel be similarly moved?  Let’s listen to each other and see what happens.


Filed under citizen responsibility, Healthcare reform

Alabama Medicaid: a Sandcastle by the Pink Pony Pub

In a little over 6 months, adults in most states who qualify for Medicaid under the ACA Expansion will suddenly have Medicaid cards.  We’ve made no moves towards that in Alabama.  We’ve said to our minimum wage workers, “What’s in your wallet?  Oops, nothing! Hate it for you.”  If you’ve listened to Governor Bentley closely, he has been mighty careful with his phrasing—instead of saying an absolute no, he says he will not agree to expand Medicaid as it is currently structured


The legislation to do that was passed and signed, but it will not be fully in effect until October 1, 2016.   However, with the Expansion fully funded by federal money for the first 3 years, the timeline for restructuring would allow Alabama to have the new program in place before we have to foot any of the bill for newly covered persons.  That means we should jump right in at the earliest possible time for the Expansion.  Don’t let Governor Bentley off the hook—he is getting what he asked for.


I agree our current structure is a sandcastle by the Pink Pony on the Redneck Riviera, waiting for a hurricane.  It is oddly dependent on overuse of ER and hospital services to draw down extra federal matching money.  Instead of just a 2:1 federal match, we were getting an effective 9:1 match once the money had been recycled in various legal but bewildering ways—and an effort to decrease excess hospital use would have removed funding needed for outpatient services.  So, yes, it had to be revamped.


There are some good things in the new design, mainly the flexibility to use funding for nonmedical items that would improve health and keep patients out of the hospitals, like the air conditioner example.   There are also enormous potholes—no, make those sinkholes—in the new proposed design.  I’m not even going to count the number of times the word incentive is used or try to fix that right now.  The only incentive is a perverse incentive, unless it relates to satisfaction in doing good work. But pay for performance is the zeitgeist. 


Here’s the big rub: the legislature intends to “transfer risk” to providers and away from the state.  The Medicaid budget is a hot potato they want to throw somewhere else, anywhere else.  So instead of dealing with this risk by increasing revenue, what did they do?  Decide that providers would have to worry about making ends meet, not the state.


The law sets up RCOs—Regional Care Organizations—to manage patients within regions.  Each RCO would be given a set amount of money per covered patient – capitation—and then required to cover any needed care.  If medical expenses in that region unexpectedly are higher than the budgeted amount, the RCO has to cover the costs.  The RCO must have a reserve of $ 2.5 million of provider front money in order to be given the contract, so we are not talking about a group of pediatricians and family doctors.  From what I am hearing, mainly hospitals will be the “at-risk” providers.


The law says these RCOs are not to be considered insurance companies.  Come on, folks, give us a break.  That is exactly what they are—they will be insuring Alabama’s Medicaid program.


Why is this a problem?  Let me count the ways.  First, we have a history of providing insufficient per person funding for Medicaid, because we won’t stop our corporate handouts. We have one of the worst funded programs in the country, 3rd from the bottom in per person spending for Medicaid but 10th from the bottom in overall healthcare spending per person.  Don’t believe it if you hear we are spending too much money on our current program.  Dividing those inadequate funds into RCOs will not help.  If you don’t have enough money in the bank to pay rent, writing 5 smaller checks to the landlord is an interesting thought—but sweetie, I’m sorry to tell you, at least one of those checks will bounce.  The state plans to pass the blame on to the providers for not performing magic tricks. Providers won’t put up with that for long.  They will exit the program and leave patients in the hands of a third party payer, in a system with few remaining physicians.


Second, once we turn hospitals into insurers, can we talk conflict of interest?  Faced with a risk sinkhole, our hospital-insurers will be forced to limit services.  I have already heard talk that in one region, children may not be allowed to go to the Children’s Hospital in Birmingham but could be sent to Vanderbilt, because the costs to the RCO will be lower.  I don’t have any problem at all with Vanderbilt and send patients there regularly, but the choice of Children’s Hospitals should not be made on the basis of cost.  It should be based on the skills of the particular specialists.


Let’s say that against all odds, we do fund the program fully.  If our hospital-insurers come in under budget, they get to keep the surplus.  Anyone can be corrupted with a carrot like that.  I would far rather have my local hospital put in that position than one of the out of state third party payers like Centene.  But we are all human, and every one of us is vulnerable to perverse incentives.


I knew, while this bill was in progress, that there was no way to interfere with the intention to transfer risk.  The legislature was hell bent to do it.  I think now is the correct time for some effort at damage control, because the state has to get a waiver approved before the restructuring can happen.


I admire and respect the people running the Medicaid program in Alabama, especially Don Williamson, who has always been a friend to children.  He has taken a bad piece of legislation and is trying to make the best of it.  I think we should help by asking the feds to fix what our legislators would not.  No matter how much they try to wiggle out of the risk, the truth is that all of us who live here share the risk.  A failed Medicaid program will come down on our heads, in failed hospital systems and loss of shared medical services.  So let’s make this work! We need a restructured Medicaid to do the Expansion.


 Here is the link to the concept paper submitted to CMS (Centers for Medicare and Medicaid Services).  When the final application is submitted, we will have a 30 day comment period with CMS on their public site.  I don’t know that date yet but expect it soon.  I thought I’d let you know now, so you can study this a little and be working on your comments.


Here are mine, so far.  If you have suggestions, please comment.  There may be a better way to design the capitation floor in my first element.  I’m setting the bar at what might sound low to you, the 25th % tile, but it would be higher than our current rate.


Dear CMS,


As a pediatrician in Alabama who helps care for the poorest children on Medicaid, I am concerned about Alabama’s 1115 Medicaid Waiver application for RCOs.  It is very important for the plan to be approved expeditiously, because the possibility of our state accepting the Medicaid Expansion hinges upon restructure.  However, the plan as it stands will put our hospitals in the position of insuring the state against high medical costs in an environment of historically inadequate funding.  In addition, if adequate funding is provided, the plan creates a perverse incentive for RCO providers (whom we anticipate will be primarily hospital systems) to cut needed patient services in order to retain surplus funds.  I believe these problems can be mitigated by the following:


1) Require the state to maintain a capitation payment rate that is never lower than the 25th percentile of per patient cost in the southeast region, to guard against insufficient funding of the program.  A floor on capitation payments is critical to prevent collapse of Alabama Medicaid.


2) Require that any surplus funding an RCO does not spend be used for patient-related improvements to services in the regions (not for construction) OR be returned to the state general fund.  This avoids the risk of perverse incentives for hospitals to cut patient services in order to increase their income and allows the state to receive the benefit of any cost-saving.




Pippa Abston, MD, PhD, FAAP

Huntsville, AL


As always, I want to remind you that we can more effectively cope with the Medicaid funding woes by changing to a much larger risk pool—all of us.  We all share the real risk, so let’s design our system to reflect that.  Improved, Expanded Medicare for All, not Medicaid, is what we need.


Filed under Medicaid, SCOTUS Ruling on ACA

Cruelty or Care? The Choice is Yours

Well.  From the beginning, I have been telling you all that the so called “Patient Protection and Affordable Care Act” is neither protective nor affordable to patients.  We can keep the same PPACA abbreviation and call it what it is:  The Profiteering Protection and Affordable Cruelty Act.  Although I read the whole darn thing, I lack a background in law or politics.  As the specific corporate protections emerge from this convoluted mess, I have to say I didn’t foresee some of them.  I knew it would be bad, just not all the details of said badness.


The latest in our story of woe?  Insurers and some employers have discovered an irresistible loophole that allows skimpy policies covering only a few outpatient services.  The key phrase is “minimal essential coverage”, previously defined in federal law under the IRS Act of 1986.  I noticed some folks had conflated that term with “essential health benefits”, but EHB are mandated items on state Exchange policies starting in 2014.  No plan will be allowed to put lifetime or annual dollar limits on coverage, but outside of the Exchanges, other details of minimal essential coverage are minimally described.


I think I was fooled by the ACA’s opening paragraphs allowing insurers to temporarily restrict annual limits on essential health benefits until 2014.  I missed the absence of any requirement to offer those benefits at all, at any date, except on the Exchanges.  Insurer can’t restrict annual dollar amounts of those benefits if they are offered.  In a stunning twist on catastrophic coverage, it is possible for insurers to cover only the required preventive services and omit the catastrophes.  You can get your colonoscopy “free” if you have a non-grandfathered plan, but any follow-up surgery is entirely on you.     


The most minor effect is that employers who offer bare-bones policies and employees who get them are exempt from the ACA penalties.  I see some reference to this loophole only applying to large employers, but I don’t know how that was determined.  I don’t see it in the IRS code that I found, which includes as minimal essential coverage “B) any other plan or coverage offered in the small or large group market within a State.”—it may be elsewhere.  It seems to me it would apply to any size group policy offered outside of the Exchanges. If one of you can find me the relevant law making this only applicable to large employers, I’d be grateful.


The worst effect is that employees who have minimal essential coverage are not eligible for premium subsidies on the Exchanges, as far as I can tell.  This also seems to be the IRS’s interpretation: “A month is not a coverage month for an individual, and thus no premium tax credit is allowable for the individual’s coverage, if the individual is eligible for minimum essential coverage other than coverage offered in the individual market for that month.” If you can show me in the law itself or in administrative policy how it can be read otherwise, please post a link.  Maybe the IRS can do some creative adjusting.  Generally their creativity seems to apply only to corporations.


How many employers will use these plans to avoid penalties and thus apply this affordable cruelty to their employees in the process?  You know it will start with those who already pay poor wages.  As healthcare costs rise, don’t be surprised if you get this offer you can’t refuse in your own benefits package.   


Do I have grounds to put the word “cruelty” in place of “care” in the ACA?  The law is no longer new.  It is now part of our healthcare system.  I don’t know what else to call a system that not only allows but entrenches the abuses I see in my office.  Children who desperately need skilled child psychiatrists but whose insurance does not have a single child psychiatrist, skilled or unskilled, on the panel.  Children who don’t get the care they need because their parents delay over co-pays and deductibles.  Parents who work long, hard hours at low pay, producing goods and services we use without gratitude or notice, whose “non-emergency” pain goes untreated because of money.   Who try to smile at me in front of their kids, as if it doesn’t hurt, but cry when I take them in another room.  I refuse to make excuses for this awfulness or play around with euphemisms.  Cruelty, brutality, callousness—many words apply, and none of them is “care.”


I can hear the defensive talk already, from people who won’t be able to believe their beloved party would intentionally expose us to this treatment.  It was an oversight, right?  The law is complicated.  We missed this problem, and they did too.  We have a bumbling, well-meaning but hapless government, like a dog that’s so ugly it’s almost cute.  Don’t buy it.  Somebody had better ask what the President and insurers knew and when they knew it.  Remember the industry was mighty cozy with our Executive Branch during construction of the law.  Is it just now that this minimalist option has been discovered?  Or is this a convenient time for discovery, well into the second term?  Will we allow the President to wash his hands of the disaster and pretend he never imagined anyone would behave so?


What will it be, folks?  Do you want to keep trying to pass legislation to close loopholes, even though the insurers are always one step ahead?  How long will you continue to support and vote for people who cater to them?  When will you finally say “don’t let the door hit your butt on the way out”—and insist on real insurance and real representation?


Improved, expanded Medicare for All is a simple, achievable, affordable, practical next step.  It doesn’t require revolution, utopia or socialism.  Even conservatives can embrace it.  We have the structure in place.  We are only waiting for you.  Will you speak up?


Filed under citizen responsibility, Exchanges, Healthcare reform

The Dismantling of Justice and Rise of the Medical-Police State

As Alabama continues its slide into financial ruin, many of you may be unaware how severely curtailed some of our necessary state functions already are.  We continue to pile on the tax incentives to corporations without demanding proof of economic effectiveness, and at the same time we add new crimes at a fast clip.  Increased demands on law enforcement and prisons are oddly excused from state requirements to locate funding for the effects of legislation.


Drug possession is arrested heavily in Alabama, without regard to whether the possession results from addiction and/or other illnesses, like chronic pain with inadequate treatment or mental illness.  The great majority of arrests have nothing to do with sales—less than 10% in our state.  It is illegal to have the active illness of addiction, and extra illegal to be addicted and black.  If you are a woman and happen to become pregnant while addicted, you can be additionally prosecuted for the “chemical endangerment” of a child.  This is a gender-specific crime—there’s no penalty to the man who contributed to initiating pregnancy within the body of an addicted woman. The only sure-fire way for a woman to avoid those additional charges is to abort.


Who will pay the cost of our medical police state?  Just as with sales tax, the burden of funding will fall increasingly on the shoulders of those least able to pay.  We already have multiple “pre-trial diversion” programs in Alabama that allow arrested persons to enter various treatment programs, at their cost, instead of going through the court system, at our cost.  I’ve talked with attorneys who are glad to have these options for their clients, but they admit the programs are mismanaged in many cases and that addicts are placed in them often without regard to likelihood of ability to complete such a program.  Upon failure, they enter prison according to their pre-signed guilty admission and still owe the costs of the diversion program.


One lawyer told me he has clients do a dry run of treatment, not supervised by the court, in the time leading up to a decision on diversion.  Because our system has such a backlog, he may have as long as a year to see if his client can succeed.  He will only advise his client to enter formal diversion if the person has done well on the practice effort.  But with low pay for court appointed attorneys, there are unfortunately those with far too heavy a caseload who don’t even meet their clients ahead of time.


The quality of the programs is borderline in many areas of the state.  I have a friend whose significant other, a man with bipolar illness and addiction, was sent to one of the “faith-based” programs locally.  When he told the supervisors about his mental illness diagnosis, did they do the correct thing and request psychiatric treatment?  No.  They called in a couple of preachers to pray away the demon of bipolar.


Arrest and exorcism as a treatment tool in the war against drugs makes about as much sense as arresting tobacco addicts in the war against cancer.


Twelve step groups can be critical for recovery of the whole person, more than just treatment of the addiction itself, and I’ve spoken to many addicts in recovery who say the groups saved their lives.  They tell me there is a tremendous difference between being sober as a “dry drunk” and being in meaningful recovery as part of a community.  But “intention to treat” success rates in twelve step recovery are not substantially better than other methods, meaning that when you take a random group of addicts and send them to walk the twelve steps, it “works if you work it.”  Many addicts will benefit from such groups as an adjunct to additional medical and professional psychological treatment but will fail without ongoing professional help.  There are evidence-based treatments available, including for dual diagnosis of addiction and mental illness, but they cost money—Alabama has none left after the corporate vig.


SB 285 is up (again) this year.  This bill would expand the use of pre-trial diversion at the unregulated discretion of the local DA, without need for local legislation or approval.  It specifically allows the use of “certified” faith-based programs.  The administrative fees paid by arrestees would go into the DA’s funds, instead of being used to fund good treatment programs or legitimate fair trial in drug courts.  Although there are provisions to waive the fees for indigent clients, there is no provision against causing a minimally self-supporting person in recovery to become indigent as a consequence of the fees.  I am told by treatment providers this creates a significantly higher risk of relapse during early recovery.  Advocates for those with addiction and mental illness need to vigorously oppose “pay to play” programs that financially burden sick people without giving them a fair trial.


We need to reform our entire approach to drugs and addiction.  I’d like to suggest Alabama enter a state-wide Twelve Step program, which can be done in a non-religious way.  Our first step as co-dependents is to admit that all our efforts against drugs that treat addiction as criminal have failed, and the second is to look elsewhere for help.  Testing potential Medicaid and foodstamp recipients for drug use and then cutting off benefits or throwing sick people into prison makes as much sense as emptying an addict’s stash into the toilet or tying a drunk man to the bedposts and hitting him with a skillet.


We need to move to the making amends part pretty quickly.  A good start would be to accept the Medicaid Expansion post-haste as well as fully funding addiction and mental health treatment services—good ones, not those involving exorcism. Then we need to seriously consider the benefits of Medicare for All, with full parity for addiction and mental health medical treatment.  Treatment should ideally be provided through evidence-based public programs instead of through faith-based or private programs that rely heavily on funds from high relapse rates.


Please contact your legislators and tell them why you are opposed to these bills.  Speaking as an individual citizen and not in representation of any advocacy group, I am dismayed at the public silence of the Alabama Department of Mental Health.  On behalf of their clients, they ought to be all over the news, calling for a moratorium on criminal prosecution of illness.  Their vision statement reads “lifting life’s possibilities through a system of care and support that is consumer driven, evidence-based, recovery focused, outcome oriented and easily accessible, with a life in the community for everyone.” DMH, where are you? Will you not speak up?


Filed under addiction, Alabama Legislative Session 2013, evidence based medicine

Redefining Affordable: The Future of Health Insurance Premiums under the ACA

In a move that goes beyond redefining the word “is”, the IRS has released its final rule on what will be considered “affordable” premiums for families.  Although you will not be on the hook for a tax penalty if the premiums for your entire family exceed 8 % of your income, an increasingly common problem, you will not be eligible to purchase a subsidized plan on the coming Exchanges as long as your individual premium for your employer plan is 9.5% or less of your household income.


Do you see where this is going?  Let’s say your employer really doesn’t want to pay the wrist-slap penalty for failing to provide you with an “affordable” insurance option.  So she finds a policy that costs exactly 9.5% of your total household income, which includes your spouse’s two part-time jobs.  You have two children, and your spouse’s jobs don’t include benefits because they are part-time.  Could a policy covering all four of you cost 38% of your income?  I used to have an option for individual or family coverage through my employer, but now there are premiums based on number of persons in my family.  Even those of us with decent incomes are going to be hard-pressed to come up with that money, and remember—this is only the premium.  It does not include the “cost-sharing” of co-pays, deductibles, and non-covered services.


For low-paying jobs, where it would be hard to find a policy that meets the criteria of essential health benefits for 9.5% of salary, look to insurers and the feds to get really creative finding loopholes.  Less of your body might be essential than you now imagine.  There are already waivers for so-called “mini-med” insurances until 2014.  Do you really believe the waivers will disappear on schedule?  I’m not holding my breath.  Some sort of redefinition is probably already in the works.


If a state refuses to participate in the Medicaid Expansion, your children might still be covered if you are under the poverty line.  Children in families up to 300% of poverty are generally eligible for the SCHIP programs (ALLKids in Alabama).  But what about you and your spouse?  Oh, well, the IRS says.  You don’t have to buy insurance—we won’t penalize you.  You can “keep the coverage you have”, even if it is no coverage.


Can you hear me now? As long as private insurers are part of our healthcare system, our health is at risk.  The insurers need to keep our care costs high, so they can rake in their allowed percentages, so there will be little effort to make serious improvements to healthcare that would keep us healthy at less cost—steps like eliminating subsidies for producers of toxic and obesity-promoting foods, getting corporate food out of the school lunch program, repairing the broken FDA, reducing our exposure to environmental poisons, or financing our public health system effectively.


Let’s get serious about healthcare reform—we need Medicare for All, now more than ever.  Look at the estimates for taxpayer funding under this system, a pre-paid plan with no co-pays or deductibles.  It’s affordable for ALL of us, no creative re-defining needed.  Medicare for All—everybody in, nobody out.  Look for a chapter of PNHP (Physicians for a National Health Plan), Healthcare Now, or other single payer groups in your area, and find out what you can do to make it happen!  If you are in North Alabama, we’ll be expecting you.


Filed under HHS rules on ACA

Alabama NAACP gets the ball rolling: Speak up for Healthcare Reform next Saturday!

It’s been a busy winter already—flu season is in full force, and that means I have a little less time to get to blogging.  I do want you to know about an important upcoming event.

Our state NAACP chapter is having a rally next week, Saturday January 12, from 12 to 2 pm on the steps of our Capitol building in Montgomery, to support healthcare reform.  I understand there are plans for an ongoing effort to move our state forward, especially around the Medicaid Expansion—let’s ALL show up next Saturday.  The bigger the crowd, the more press and legislative impact we can make!  I’m supposed to be in a marathon all-day board meeting in Prattville, but I’m going to slip out for a bit to participate as one of the speakers.  Maybe someone will write me a doctor’s excuse?

I’ve written previously about the Expansion—in a nutshell, it would extend Medicaid benefits to adults below 133% of the federal poverty level.  There is nothing in the ACA to help them otherwise—over 100% of poverty, they are eligible for subsidies on the Exchange, but they may not be able to afford the premiums and cost-sharing required.  I tried looking up the exact amounts on the Kaiser calculator but it automatically puts anyone under 133% of poverty on Medicaid.  I guess the people at Kaiser are so reasonable that they couldn’t imagine a state refusing the funds.  When I enter a 27 year old single person making 16K pre-tax a year, 139% of poverty, it tells me he would pay $537 over a year for premiums—not too bad.  But cost-sharing (co-pays and deductibles) is capped at $2083, in addition to the premiums.   I doubt that 27 year old has 2K in a savings account.  He might have an insurance card he can’t afford to use.

If you are at 100% of poverty or below, you will have NO access to subsidies on the Exchange.  So it is the Medicaid Expansion or nothing.  Let’s say you are a 27 year old single mother of 3.  Or, for those who will get caught up worrying about whether a 27 year old single woman with low income “should” have 3 children, let’s make it easier and say you are a 27 year old widowed mother of 3.  You could work more than 60 hrs a week at minimum wage and still be below the 100% poverty level!  You could get Medicaid for your children, but for you—nothing.  I see this in my office every day.  Hardworking parents or even grandparents raising children, who can’t get health insurance.  Many of them know they have untreated high blood pressure, untreated asthma, untreated diabetes—all their resources go into doing everything they can for the children.  Wouldn’t you do the same? Sadly, many will die early from the long-term effects of these illnesses.

Governor Bentley says we can’t afford to do right by them, but he is wrong.  Ask him why we can afford to hand out subsidy after subsidy to big businesses as “incentives” to employ people at wages or hours too low to get insurance.  They are increasing our healthcare costs, but somehow we can still afford to give them welfare.

By now, he must have read UAB’s research showing how the Medicaid Expansion would boost our whole state economy.  I haven’t heard him comment on it yet.

Medicaid should not be the end of our work—we need badly to proceed with efforts to get Medicare for All.  But it’s the least we can do for people who are currently without any other option.  There is no deadline on accepting the Expansion.  The earliest we can start is January 2014, only a year from now.  If we wait, we can still do it but would miss some of the 3 year period of 100% federal funding.  Why should our fellow Alabamians have to wait a single day longer than needed to get healthcare?  Why should Alabama miss out on any of that money?  I’ve heard through the grapevine our Governor is worried about doing the Expansion before the 2014 primaries—let’s show him that if he doesn’t do it on time, he shouldn’t even bother entering the primaries at all.  If we can’t convince him not to put his political ambitions ahead of human life, maybe we can at least make our lives fit his ambitions.

I asked Benard Simelton, President of Alabama’s NAACP, to give me a few words.  He said, “When it comes to affordable healthcare, we must do all that we can to provide health care to everyone.  It should not be just for those who have a certain income but for every human being regardless of circumstances… You would think that the Governor, being a physician himself, would appeal to the Hippocratic Oath he took when he became a doctor. There is a passage in the modern version of the oath that states ‘I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.’  Where is the warmth and sympathy and understanding in the Governor’s refusal to provide health care for people in Alabama, especially since the Federal Government will pay for the vast majority of it? There is another passage that states, ‘I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.’  Governor Bentley, show that special obligation to all your fellow human beings so that those who are infirm because either they can’t afford or don’t have a job can have access to affordable health care…live up to your oath.”

I agree.  Please let’s show folks in Montgomery we stand up for each other.  Get your carpools together—I hope to see you there!


Filed under Healthcare reform, Medicaid