Everybody knows the old saw about how the legislative process resembles a sausage factory: even if you like the product, it may turn your stomach to see how it is made. I have been thinking about that metaphor a lot lately as I have watched the Republican caucus in the US House of Representatives slap together their plan to “repeal and replace Obamacare.”
As the House lurches toward a critical vote today, I offer a few personal observations:
- The Republicans have long complained bitterly about how the Democrats “rammed through” the ACA in 2009. This, despite the fact that there were months of negotiations and the bill incorporated many previously mainstream Republican principles (including the individual mandate, which now seems anathema), and the Republicans deliberately walked away as part of their obstructionist strategy to deny President Obama a legislative victory of any sort. It is therefore particularly disturbing to see them scramble to bring this dog of a bill to a vote on some arbitrary self-imposed deadline. What is the rush?
- Speaking of a dog of a bill (with apologies to dogs everywhere), the only “principle” or “goal” that it advances is checking a box that says “repeal Obamacare.” The challenges facing our health care system are pretty easy to categorize. We need to assure access to care, we need to improve care, and we need to control costs. This bill does none of those things and stands to reverse the progress made by the ACA in providing coverage for millions of Americans.
- Don’t be fooled by claims of “lower costs.” The only thing this bill would lower is coverage, mostly by throwing millions off of Medicaid, and by stripping covered services from ACA plans. Any accrued “savings” are achieved by just providing less care for those who are in need.
- The targeting of Planned Parenthood and of reproductive health services, in general, is a shameful demonstration of the deep hypocrisy in the Republican party that has stood for individual choice and limited government (well, at least back when the party stood for anything at all) until it comes to dictating women’s health choices.
- The proposal is demonstrably, clearly, unambiguously and completely at odds with the President’s stated goal of “repealing Obamacare and replacing it with something beautiful” that “covers everybody.”
- Mostly, I am saddened by this rush to do harm, driven by political expediency, facilitated by ignorance, and leavened by a callous disregard for the health and wellbeing of our fellow citizens
What do you think?
Last year I pointed out that Memorial Day was slipping in our collective consciousness from a day of solemn remembrance of those who died in the service of our country to just another “vacation Monday” or the marker of the start of the Summer season.
A recent experience reinforced for me just how important it is for us to make sure we never lose the deeper meaning of the day.
My wife and I traveled to Washington, DC a couple of weeks ago to witness the “arsenal of democracy” flyover. The event included over 50 WWII warplanes, and coincided with the 70th anniversary of “V-E (Victory in Europe) Day” – the defeat of Germany by Allied Forces. As an airplane buff, I found the flyover stirring. It was an historic opportunity to see the “warbirds” aloft, flying in formation, instead of on the pages of history books or on static display in a museum.
Continue reading Memorial Day
I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR’s reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:
It turns out that the top part of the fence that he climbed over was broken, and it didn’t have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn’t know the radio couldn’t override other normal radio traffic. Other officers said they didn’t see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn’t have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn’t fire because they didn’t think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would’ve alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.
The explanation rang true. Of course it was no “one thing” that went wrong; it was a series of events, no one of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “swiss cheese” conceptual model of patient safety.
Continue reading Patient Safety, Swiss Cheese and the Secret Service
With the first – and probably not the last – documented case of Ebola in New York last week, the reaction of State and local governments was big news, and the preparations of the North Shore-LIJ Health System kicked into a higher gear.
New York City Mayor Bill DeBlasio, flanked by the President of the city’s Health and Hospital Corporation, Dr. Ram Raju, and the city Health Commissioner, Dr. Mary Travis Bassett, gave a news conference. I thought they struck just the right balance of information and reassurance, and grounded their responses in what is known about the disease. In discussing the movements of the patient, a physician who had been working in West Africa with Doctors without Borders, prior to his admission to Bellevue, they repeatedly stated that he had posed no threat to the general public. Indeed, they cited the case of the man who died of Ebola in Texas, who had spent days living with family members at a much more advanced stage of his illness, and did not transmit the disease to any of them. Of course, 2 nurses who later cared for him did, but he was far sicker by then (which means he had a much higher viral load, and was correspondingly more infectious), and we now know they likely had inadequate training and personal protective equipment.
Continue reading More on Ebola
Here are a few things that have happened since Ebola arrived in the United States:
- CNN and other cable news outlets seem to have become “all Ebola all the time” with breathless reports about the latest twists and turns
- A grade school banned a teacher from the classroom because she had visited Dallas
- A photojournalist who had travelled to the affected area (and was well) was denied the opportunity to give a talk to a University audience
Parents in Mississippi kept their children home from school because the principal had visited Zambia
People all across the country seem to be in a growing frenzy about the virus. On one hand, I get it. The disease is awful, the CDC seems to have fumbled in its management of the situation and in its messaging, and the disease rages on in a few countries in West Africa. On the other hand, a lot of this is just, well, nuts.
Continue reading Keep Calm and Carry On
The New York Times reported last week on a ballot initiative in California that would mandate random routine drug and alcohol testing of physicians, and targeted testing after major adverse patient events. The full text of the proposal is available here.
Proponents of the measure (Proposition 46) highlight the danger posed by impaired physicians and the ubiquity of drug testing for other professionals such as airline pilots and public safety officers. Continue reading Physician Drug Testing
I am a big believer in celebrating success and recognizing excellence. I find that doing so motivates people to achieve even more, and it helps maintain a healthy sense of organizational optimism. I also believe that one of the keys to making this work is to set high standards, so that only truly high performers get the accolades. Continue reading Recognizing Excellence
What do you associate with Memorial Day? The unofficial start of Summer? Traffic heading east on the LIE? Barbeques? The Indianapolis 500? Sales at your favorite retail store? How many of us think first of what the day is named for – honoring the memory of those who fell in the service of our country? Continue reading Memorial Day
I have long been a fan of the “Case Records of the Massachusetts General Hospital,” which is published weekly in the New England Journal of Medicine. For many years, I made a point of recommending them to medical students and internal medicine residents as a model of concise yet comprehensive case presentations.No wasted words, no missing information, and none of the filler that trainees often added when they presented cases, such as “on heart exam….” or “the sodium was high at….” As I always reminded them (often not as gently as I should have), if they were reporting a heart murmur, I knew it part of their examination of the heart, and if the sodium was 149, I knew that was high. Continue reading Case of Caring
I really do not understand how Congress “works.” While it busied itself with passing a law that fails to fix the clearly broken “sustainable growth rate” formula for Medicare physician payments, it added in a surprise for the entire healthcare industry: a provision that mandates a delay in the adoption of ICD-10 by CMS. Continue reading Now What?