We Deserve a Better Healthcare System, We Deserve Medicare For All

Recently, I was taking care of a gentleman in his sixties with high blood pressure and diabetes. My goal, I explained to him, was to prevent a heart attack or stroke which are too frequently the  consequence of these diseases. I will closely monitor his kidney function and blood sugar levels so that I can recommend the safest and most effective medications for him so that he can live as long and symptom-free as possible. This medical care is based on the latest medical evidence and guidelines, and I am proud to provide it. 

If I am to truly be a steward of his health, however, it is not enough to focus on his medical care. I must also carefully consider the greater social context of his life. Reducing consumption of refined carbohydrates and sugar is crucial to blood sugar management in patients with diabetes. Are fresh fruits and vegetables still affordable to him or is he mostly eating cheap processed foods to stretch his grocery budget? For this patient, insulin was necessary to prevent painful neuropathy in his hands and feet. How much are the copayments on his insulin? Is he taking the full recommended dose, or is he cutting back because of expense? 

Understanding these social determinants of health is a core competency of high-quality medical care in the twenty-first century. Given that the majority of premature death is attributable to factors other than medical care, I would be remiss as a primary care provider if I didn’t engage with the social and environmental factors that bring illness into my patients’ lives.

One harmful social condition that I must engage with every day is the commercial health insurance system which mediates access to medical services. In this system, insurance companies collect enormous amounts of money through premiums in exchange for limited access to doctors and medications only after you additionally pay co-pays and meet your deductible. 

The expense of co-pays and deductibles all too often push those with chronic illnesses into poverty. Nearly half of the people diagnosed with cancer end up with negative net worth in the subsequent two years. Every year in America 530,000 people file for bankruptcy in part due to medical debt. Many find themselves being sued by hospitals when they struggle to keep up with their bills. 

I see this damage done by our current commercial insurance system every single day. I see how poverty leads to disease which requires medical treatment which then exacerbates poverty and the cycle begins anew. It’s enough to drive you to despondency. 

But let me tell you, I’m not despondent at all. In fact, I’m quite hopeful.

I’m hopeful because there is a presidential candidate who is working to break this cycle of illness and poverty. There is a candidate who believes that health care is a human right. There is a candidate who believes that no one should be impoverished by illness or made ill by the deprivations of poverty. There is a candidate who is fighting for my patients, for me, and for you.

That candidate is Bernie Sanders and his plan for Medicare For All will put an end to the financial destructiveness of our current health care system. By providing a universal, comprehensive health care benefit that is free at point of service for all Americans, we can finally have the health care system we deserve in this country.

As a primary care doctor, I can think of no better advocate for health and well being of my patients than Bernie Sanders and I am proud to join Doctors For Bernie in endorsing him for the democratic nomination.

Care Of Vulnerable Adults: Balancing Independence and Safety

Last night, I watched ProPublica and Frontline’s excellent documentary, Right to Fail, about New York’s struggle to find the balance between independence and safety in the care of people with disabling mental illness.

Finding this balance between independence and safety is something that I struggle with in primary care frequently. Most of the time, you can find a balance by bringing family members into the conversation and focusing on harm reduction and quality of life. But sometimes it’s not enough.

I took care of a gentleman in the emergency department the other day whose blood oxygen was dangerously low because of a condition called aspiration pneumonitis that he got because he was choking on the food that he was eating. He had neck surgery a couple months prior and the muscles that coordinated his swallowing reflex had not fully recovered. I advised him to come into the hospital until his lungs recovered enough that he wouldn’t need supplementary oxygen or we could arrange to have an oxygen tank delivered to his home. I told him I was worried that with prolonged low oxygen levels, his brain, heart, and kidneys may start to be damaged or fail. He declined admission, but couldn’t really repeat back to me an understanding of the risk he was taking by leaving against medical advice. I offered to call a family member on his behalf, but he didn’t want to worry them. I was stuck…

As someone with a strong professional and emotional drive to protect people from physical harm, it hurts me to see people suffering because of a limited capacity to take care of themselves. I often feel the impulse to say, “well let’s just have someone else take care of you.” I’m not alone in that. I think most people, when they seem someone on the street who is clearly unwell and in distress, feel suffering on that person’t behalf.

Many people with disabilities are glad to have assistance when that assistance is provided with compassion not condescension and supports of positive sense of self. I strongly believes that we need much better programs to support people with disabilities to maximize their capacity to live independently. But for those who who expose themselves to significant harm by rejecting assistance while having a questionable capacity to understand the risks and benefits of that decision, it gets difficult.

Institutionalizing someone against their will can be traumatic and harmful and must be a last resort. That being said, I do think it is sometimes the right thing to do, and it needs to be an option on the table.

In summary, 1) watch Right To Fail, 2) support programs that help people with disabilities live independently with dignity, and 3) consider that there are (rare) situations where loss of agency can be a net benefit to an individual with severe mental illness.

Anti-Racism Reading Group #4: White Fragility

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here, part two here, and part three here.

For the third reading of the anti-racism reading group we focused on White Fragility. Our reading was the article White Fragility from the International Journal of Critical Pedagogy which you can download here. Supplementary materials were Dr. DiAngelo’s White Fragility and Rules of Engagement and this comedic White Fragility Workplace Training Video.

What is White Fragility? In Dr. DiAngelo’s words:

White Fragility is a state in which even a minimum amount of racial stress be- comes intolerable, triggering a range of defensive moves. These moves include the outward display of emotions such as anger, fear, and guilt, and behaviors such as argumentation, silence, and leaving the stress-inducing situation. These behaviors, in turn, function to reinstate white racial equilibrium.

Continue reading “Anti-Racism Reading Group #4: White Fragility”

Securing Housing For All

As a family doctor in Seattle, I take care of numerous patients experiencing homelessness. The toll this takes on their bodies is impossible to ignore. Sleep deprivation, chronic stress, physical and sexual assault, temperature extremes, and malnutrition all weather the body rapidly. As a physician sworn to preserve and prolong life, it is profoundly disturbing to come up against such profane and preventable degradation on a daily basis.

For this reason, I joined the Housing For All Coalition last night as they put forth a call to action to a packed hall at the Seattle Labor Temple. Speakers from the Transit Rider’s Union, Socialist Alternative Seattle, Nickelsville, SHARE/WHEEL, and DESC each spoke to the urgency of ending Seattle’s housing crisis. While each speaker brought a unique perspective, including the perspective of the formerly and currently homeless, they all emphasized the importance of increasing access to both affordable permanent housing and safe temporary shelter.  Continue reading “Securing Housing For All”

Anti-Racism Reading Group #3: Perinatal Mortality

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here and part two here.

For the third meeting of the anti-racism reading group, we focused on increased rates of perinatal death (i.e. death around the time of birth) for black women with this excellent piece of reporting by NPR and Propublica. NPR’s Code Switch team produced an excellent podcast on this same story which you can listen to here or read the write-up here.

This is an especially timely reading given Erica Garner’s recent death at age 27 from a heart attack just three months after giving birth. Erica was the daughter of Eric Garner who was murdered by the New York City Police. Since his death, she had risen up to be a prominent and effective activist against police violence.   Continue reading “Anti-Racism Reading Group #3: Perinatal Mortality”

Innovations in Primary Care: Moving Beyond Fee-For-Service

The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.

In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.

Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure.   Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”

Anti-Racism Reading Group #2: Theft of Black Wealth

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here. 

For the second meeting of the anti-racism reading group, we read part one of Ta-Nehisi Coates’ The Case For Reparations. In our first meeting, we discussed big-picture theory of race, so we followed that up by focusing in on particular racial project called redlining which had been a major contributor to both racial housing segregation and wealth inequality in America today. Continue reading “Anti-Racism Reading Group #2: Theft of Black Wealth”