The war of words over health reform is increasingly focused on how the legislation will impact small business and employment. The day before the House voted—in a meaningless act of political theater—to repeal the “job-killing” health law, the White House hastily organized a conference call for reporters to speak with Karen Mills, administrator of the Small Business Administration and acting Deputy Commerce Secretary Rebecca Blank. During the call, the goal of which was to highlight how a repeal of health reform would negatively impact U.S. businesses, Mills announced that there’s already been a rise in the number of small businesses offering health coverage to their employees thanks to a new tax credit and other provisions of the law.

As evidence, Mills cited a survey conducted by the Kaiser Family Foundation that found that 59% of firms with three to nine employees offered health benefits in 2010, up from 46% the year before—a rise of 13%.

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In an Opinion column on CNN, Dr. H. Gilbert Welch, M.P.H., a professor of medicine at the Dartmouth Institute of Health Policy & Clinical Practice and the author of Overdiagnosed: Making People Sick in the Pursuit of Health" (Beacon Press 2011), raises questions about a new simple blood test that is
“able to detect minute quantities of cancer cells that might be circulating in your bloodstream.”
Below just a few lines from the column that I found particularly provocative.  You can find the entire op-ed here.
(Thanks to Dr.Val and Gary Schwitzer for spotlighting this column.)  
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“The conventional wisdom is people either have a disease or they do not. But, in fact, there are a lot of people somewhere in between. . .

“I don't know whether this test will help some patients. It might, but it will take years to figure that out…"

“Ironically, what this test might actually teach us is that it's not that unusual for healthy people to have an occasional cancer cell in their blood.”

Hackles rise and fur flies. As Maude Beelman, Deputy Managing Editor at the Dallas Morning News, explains in an essay cross-posted below, local newspapers have good reason to be wary of investigating their community’s most prestigious medical centers:

“Every place has its sacred cows,” she writes in a piece published on the Nieman Watchdog website, “individuals or institutions so prominent and respected that over time they become part of a community’s identity and culture. Questioning them is an affront to civic pride, and investigating them can be a high-stakes gamble.

“The University of Texas Southwestern Medical Center and Parkland Memorial Hospital are two such icons of Dallas,” she continues. “They have enjoyed largely positive press, some of it by design. Their leaders cultivated national profiles and courted some of the wealthiest and most influential Dallas residents, including media leaders, as advisers and donors.”  (Many thanks to Gary Schwitzer at HealthNewsReview Blog, for calling attention to this story.)

So when the Dallas Morning News decided to follow up on insider tips alleging that patient safety was being compromised at these venerable  institutions, the newspaper “faced a community backlash, including cancellation of advertising by UT Southwestern,” Beelman reports.  “Many of Dallas’ wealthiest and most powerful residents are longtime donors and supporters of the medical center and hospital. Some key players have sought to delay, if not derail, the investigation. They have recruited key opinion leaders in Dallas and nationwide to try to discredit us.”

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The individual mandate to buy health insurance is clearly the most contentious aspect of health reform. More than two-dozen states have joined federal lawsuits seeking to have health reform repealed on the grounds that the mandate is unconstitutional. Most recently, just hours after being sworn in as Wisconsin’s new Republican governor, Scott Walker authorized the state's attorney general to join a federal lawsuit in Florida challenging the individual mandate.

Meanwhile, supporters of the Affordable Care Act argue that health reform cannot succeed without the mandate. Their rationale: The legislation prohibits health insurers from discriminating against applicants on the basis of health, either by charging higher premiums for sick people or by refusing to insure those with preexisting conditions. Without the mandate, many young, healthy Americans will opt to go without coverage, the insurance exchanges will be disproportionately utilized by older people, the chronically ill and other heavy users of care. As has happened in states that offer insurance through high risk pools, premiums will be driven higher, and even with government subsidies, all but the well-to-do will be priced out.

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The grotesque slaughter of innocents in Tucson, Arizona over the week-end has led many progressives to focus on the violent rhetoric that pundits on the Right often employ when attacking liberals. No question, this hate-speech has created a toxic atmosphere. Perhaps Jared Lee Loughner was influenced by that language. This might help explain why he shot into a crowd where Rep. Gabrielle Giffords (D-AZ) was addressing supporters, killing six people, including a child.

But if you look at what Loughner has written and said in the past, it seems that, as Alternnet Washington Bureau Chief Adele Stan suggested yesterday, while he was brimming over with “violent impulses” his words lacked any “coherent ideology.” 

That said, I agree with Stan that many of the metaphors that have laced far right commentary in recent years have been ugly. And when the media blindly broadcasts words into the night, that rhetoric has the power to support bloody urges. “It’s too soon to say what, exactly, motivated the man apprehended for the shooting . . .”  Stan writes, “but the Tea Party culture of political intimidation affirmed his violent impulses.” 

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Below , a story by Lawrence Dyche from Pulse: Stories from the Heart of Medicine.  I wish that more people like Dyche observed residents, taught them, and learned from them. I’m sure that most residents would appreciate the encounter.

As regular HealthBeat readers know, Pulse is an online magazine made up of outstanding true stories and poems written by doctors, patients, nurses, medical students and other healthcare professionals recording their personal experiences in our health care system. The quality of the writing is extraordinarily high, and the stories and poems are riveting.

A book that gathers some of the best Pulse stories from the magazine’s first year was recently reviewed in the Journal of the American Medical Association  (JAMA) where Perri Klass wrote  “All of the stories in this book . . . are told with a kind of urgency; these encounters change lives and mark memories. This collection is in some sense about writing for one's life."

 You can buy the collection here https://cart.bookmasters.com/marktplc/cart.php?buy=9780984291007M&pub=51900

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 “The Calling”

By Lawrence Dyche

I am a non-physician who teaches physicians. A clinical social worker by training, I help doctors learn to be more compassionate and skilled in their human interactions. I sit in with residents as they see their patients. I help them to become better listeners, I remind them that as they touch the body they also touch the soul. I emphasize the enormity of witnessing. And after two decades of doing this work with innumerable students, I still regard the medical profession with awe–not simply the doctors but the calling, and the extraordinary way I've seen some people answer it.

Back in the Eighties, when I was beginning this work, I shadowed a resident for an entire day on the wards of a city hospital. Despite the years that have passed, my memory of that day remains vivid.

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Anyone who suggests that “we don’t really know where the waste is” in our healthcare system just hasn’t been reading the news. There is so much over-ripe, low hanging fruit waiting to be plucked that the stench of excess has become difficult to ignore.

Even Bloomberg News, which is a business news website, not a health care reform website, pulled no punches in a December 30 story titled “Doctors Getting Rich with Fusion Surgery Debunked by Studies.”   Here Bloomberg focuses on Twin Cities Spine, a Minneapolis group that performs 3,000 spine surgeries a year at Abbott Northwestern, a hospital that boasts performing more spine procedures than any other medical center in the country. Following the money, Bloomberg reporters Peter Waldman and David Armstrong reveal that in the first nine months of 2010, spine surgeons at Twin Cities received $1.75 million in “royalties and consulting fees” from Medtronic, a medical device company which sells Infuse, a bone-growing material widely used in a type of back surgery called “fusion.”

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A lot of thought goes into the naming of new legislation. Calling the health bill the Patient Protection and Affordable Care Act hits on the essential goals of health care reform—medical security and financial savings. So the GOP’s proposed law to repeal the health legislation needed an equally pithy title to rally support: “Repealing the Job-Killing Health Care Law Act” is nothing if not evocative.

With the repeal effort, the GOP is counting on bringing the focus back to the one issue that most of the country is very concerned about; unemployment. By using the words “job-killing,” the implication is that the Affordable Care Act will lead to increased expenses for employers, followed by job losses and a worsening of our country’s financial recession. House leaders have set the date for a vote on repeal (largely symbolic since the effort is sure to stall in the Senate) for January 12, although there are signs it might come even earlier.

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Naomi’s post (below, January 5) says everything that should be said about the administration’s decision to reverse its position on end-of-life planning. She nailed the story (thank you, Naomi).  

I’m tacking on a postscript only to report that tonight (January 5), Boston surgeon and New Yorker writer Dr. Atul Gawande talked about the turnaround, calling it “a tragedy” in an interview with Chris Hayes on MSNBC’s “Countdown with Keith Olbermann.” (This evening Chris Hayes was filling in for Olbermann.) 

As Gawande explained, research shows that when patients have more time with their doctors to discuss end-of-life care, they are less likely to die in a hospital or in an ICU.  

Most of us want to die at home. In a hospital, we are tended by strangers. Many may be kind, but, still, we are subject to the hospital’s schedule and hospital rules. As one physician who worked in an ICU explained when I was writing Money-Driven Medicine: “The patient becomes part of ‘the system.’” When she said that, I couldn’t help but think of criminals entering our prison system. Most of the time, hospital patients, like inmates, are told what will happen next. Rarely are they asked: “What would you like to happen next? Would you like to see your children this evening?”

In an ICU, visits from family and friends are even more limited, and some patients wind up strapped to their beds. Admittedly, this can be necessary. Otherwise, when patients are delirious or in pain, they may try to leap out of bed or tear out the tubes that are keeping them alive. Hospitals cannot station a nurse at the bed of each patient 24/7. And they don’t want to be sued because a patient hurt himself.

 At home, relatives and close friends can take turns being at the patient’s bedside–especially if the family has help from hospice or palliative care workers taking on other tasks.  

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After all the ridiculous fear-mongering by Sarah Palin and her conservative compatriots about government funding of “death panels,” Congress dropped a proposal to encourage end-of-life planning from the health reform legislation passed last March. But early this week, it came to light that the administration had in fact quietly included reimbursing doctors for end-of-life counseling along with a host of new Medicare regulations. The provision, which authorizes payment for “voluntary advance care planning,” went into effect on Jan. 1. 
 
Now, just four days later, there’s been a complete reversal of that decision. According to an unnamed official in the Obama administration, the provision was removed from the new Medicare regulations because of a “mix-up”; “the advance care planning component wasn’t included in a proposed rule offered for public comment last summer,” the official tells the New York Times. Instead, the rule was mistakenly put into the final regulations in November by Donald Berwick, the new head of the Centers for Medicare and Medicaid Services. But despite the administration’s attempts to make Berwick the fall guy and to blame the reversal on a procedural mix-up, it’s more likely that other forces—namely politics—are the real reason for the government’s very public back-down on end-of-life planning.

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