Trumpcareless Insurance Sparks Guerrilla Health Revolution!

Cartoon courtesy of Gustavo Rodriguez http://www.garrinchatoonz.com

Appeal and Repeal. We played that game with Obamacare. Now we are playing the Repeal and Replace game. Let’s face it, no amount of fiddling is going to fix the broken medical system in America. The doctors know that. The patients know it too. The legislators are living in a fantasy bubble of their own, luxuriously insured for life. With the passage of the American Health Care Act, hereafter referred to as Trumpcareless Insurance, in the United States House of Representatives earlier this month, I dare say we have entered the eye of a perfect storm which carries the potential to bring the fiddlers’ roof down. IF WE take the opportunity for a guerrilla revolution in medical care, and health. I offer Five Steps to Guerrilla Health below. But first a few facts.

The non-partisan Congressional Budget Office (CBO) released its most recent analysis of the Trumpcareless Insurance bill on 24 May 2017.  If the Senate passes the bill as it stands an estimated 14 million people will lose medical insurance coverage by 2018, 19 million by 2020, and 23 million by 2026 in comparison with the coverage offered by the current law, the Patient Protection and Affordable Care Act (ACA), commonly known as Obamacare.

Trumpcareless has serious problems beyond just dropping insurance coverage for up to 10% of the U.S. population over time. Experts are critical of the plan, including even the president of the traditionally conservative leaning American Medical Association. The stingier tax credits proposed in the bill are not only based on income, but also on age, and are insufficient for many to be able to pay for individual insurance.  Retirees, self-employed, and low-income people will pay significantly more for insurance. Phasing out Medicaid puts people already near poverty at risk of financially devastating medical bills. Oh yes, while they are at it, they are getting rid of many of the Essential Health Benefits provided under Obamacare. Of these, mental illness care, maternity care, addiction treatment, rehabilitation services are all on the chopping block. The protections Obamacare offered for those with pre-existing conditions will also be eliminated in the current version of Trumpcareless Insurance. If you have a history of any of the conditions on the list of pre-existing conditions, you will be offered the option to pay more for your insurance premiums. The list is long. Very long. Misogynistic. Unjust. People are going to drop out, raising the insurance costs for everyone else. It’s a vicious circle. Unless we take care of everyone we can’t take care of anyone.

Notably, much of the concern expressed is in terms of how many people will exit the “health care market” or the “health insurance market”, not as much in terms of the impact on the actual care of illnesses and injuries, or health for that matter. Everything is not always all about the market. Our health is not for sale.

Anyone with a heart, or a pre-existing condition, or a uterus, can recognize Trumpcareless Insurance as useless. Now, we are not relegated to just sit around in the waiting room, flipping through outdated copies of People, Time, Better Homes and Gardens, Men’s Health, and Cosmopolitan, holding our collective breath in anxious anticipation of the Senate’s re-draft of the bill. If their re-drafted version passes the Senate the new bill will go back to the House. Ping. Pong. It’s a game. So, don’t sit around. Don’t pace back and forth. Don’t just watch and wonder. Yes, write the letters to your Senators, call your Representatives, sign the petitions, march in the streets, raise your voices. Here’s 9 ways to hustle and bustle on this. Do not sit home and cower in fear. No. Your medical insurance is in the balance. But not necessarily your health.

I have devoted nearly my entire medical career to serving the uninsured, under-insured, government insured, homeless, and medically indigent. I have witnessed the impact of not being adequately insured against the financial costs of caring for an illness or injury. Not having access to affordable medical care when you are ill is simply not healthy. Without insurance your care is relegated to already strained government institutions and struggling community clinics. Patients cannot get timely care without resorting to overloaded urgent care clinics and emergency rooms. Access to specialists, specialized diagnostic tests, and procedures is limited. These clinics and hospitals generally don’t hire the number of physicians required to handle the load. The current situation is actually unacceptable. Obamacare was a step in the right direction. The Trumpcareless Insurance bill promises to make things worse.

In my opinion, the first remedy is to bolster and fortify the government medical institutions and community clinics. Make it possible to hire the number of clinicians and staff necessary to take care of the population we serve. It’s pretty simple. The most efficient road to that is a single payer national medical insurance plan.

Before I proceed any further, I would like to clarify the way I prefer to use certain terminology. The current medical care system is primarily an illness care system. I prefer to not refer to it as a health care system. Most doctors, nurses, clinics, and hospitals are focused on diagnosing and treating illnesses. The bulk of our efforts in the medical system are geared towards tertiary prevention, essentially delaying death. Since the advent of vaccinations, screening tests for early detection of disease, and early prenatal care,  secondary prevention has become part of the practice of primary care medicine. The wellness movement has brought some attention to encouraging individuals to adopt Therapeutic Lifestyle Changes (TLC) to modify individual risk factors for disease. But even if a medical professional encourages these changes, the bulk of that responsibility lies with the patient.  And that is a very good thing, in my opinion, if the most efficient and effective means of staying healthy, primary prevention, rests in the hands of the people. More power to the people.

Another term, health insurance, should, again, more accurately be termed illness and injury insurance. Health insurance is something we have to practice as individuals and communities to protect ourselves from becoming ill. Illness insurance is what we pay for in the, hopefully, off-chance event we become afflicted. Insurance is not something that determines whether we are healthy or not.

Access to medical care is also not the primary determinant of health status. The World Health Organization (WHO) lists the primary determinants of health status of an individual.  Medical services and individual behaviors are only small parts of the picture. Tender loving care (TLC) from your doctor, and therapeutic lifestyle changes (TLC) will only take you so far. Yet, that’s where the bulk of our health attention is spent. Our health is also determined by our income, social, and educational status, the environment we live in, employment and working conditions, social relationships, genetics, culture, and gender. There is good evidence of the impact on health of transportation systems, food and agriculture, housing, waste management, energy sources, industrial behavior, and urbanization. These are called the social determinants of health. According to data from the University of Wisconsin Population Health Institute, access to medical care contributes to 10% of health status, and quality of that care another 10%.  A 2010 report from the WHO Department of Ethics states, “Health services that do not consciously address social determinants exacerbate health inequities. If a revitalised primary health care is to be the key approach to organise society to minimise health inequities, action on social determinants has to be a major constituent strategy.”  We need to think Beyond Holistic.

In addition to a single payer national illness care insurance strategy that includes all residents of the United States, and addresses the other primary determinants of health, we still must control the spiraling costs of illness and injury care.  Just because the government is paying, doesn’t mean the gouging should continue. In fact, because the taxpayer will be paying, all the more reason to make actual costs reflect actual value.

The huge profits being made off the suffering of people in their most vulnerable moments is unconscionable. Illness insurance is the primary culprit for costs spiraling out of control. Costs mushroom when nobody feels like they are paying. When you carry illness and injury insurance with a low deductible, you feel like someone else is covering your costs, so you spend freely. When the doctor or hospital feels like the patient isn’t paying, but rather the insurance company is paying, and isn’t going to pay in full, then it doesn’t harm anyone to jack up the bill and hope for a partial payment. That leaves the folks running around with no insurance, or high deductibles, staring at some figures with many more trailing zeros than they can manage. Then we start playing games with managed care, and that turns into skimping on care. In the final analysis there are way too many parties vying for a slice of the pie. The deal needs to be straight up between the doctor and the patient. Cut out the insurance companies. Cut out the massive administrations. Keep it simple. And lower the costs.

We have heard it all before; the U.S. medical care system is the most expensive in the world, and yet we rank last among eleven “developed” nations in most dimensions measured (access, equity, health outcomes, quality, and efficiency). That’s old news now. We need a different system, from top to bottom. I doubt any meaningful change will happen within the system. Not in the House. Not in the Senate. Not from the AMA. Forget the Appeal, Repeal, and Replace Game. Forget the Tinker, Tweak, Twitch, and Turn Dance. It is time to take health into your own hands. What we need now is radical revolutionary change. Now is the time. What would civil disobedience in this regard look like? Get healthy. Stay healthy. Spend your time and energy on being healthy. Invest your hard-earned money into primary prevention. Bypass the insurance-medical-pharmaceutical industrial complex to access higher quality illness care. Yes, drop out of the current market and invest in a better one.

I am a doctor and for most of my adult life I have only carried catastrophic medical insurance with a high deductible. This means I pay out-of-pocket for everything. This impacts other choices I make in my life, for the better, in my opinion. It means I prioritize my well-being above most everything else. I do my best to avoid falling prey to the modern-day definitions of success. I live as simply as I possibly can. Quality of Life trumps Standard of Living. Sleep beats status. Slow whole food wins over packaged processed convenience meals. Meditation is my medication. Creative expression and joy crushes career advancement. Family and friends are the riches money can’t buy me. Knowing the invoice is coming to me means I invest upfront and engage in ongoing maintenance before problems set in and become chronic and irreversible. At the risk of employing a mechanistic analogy, regular oil changes make your car run more smoothly and much longer too. I avoid giving my money to the pharmaceutical industry as much as possible. When needed I use the herbal remedies recommended by my acupuncturist or Ayurveda practitioner. I avoid the allopathic medical system like the plague, unless absolutely unavoidable. And I’m not the only doc floating about without a plush insurance plan. I refer you to my series on Doctors without Medical Insurance.

Quite some time ago I conducted a thought experiment for myself. It suddenly flashed upon me as I was examining the belly of a patient: as long as I was standing there, or someone else in my place, to rescue this man, he would never take responsibility for his health. I did my best for the homeless gentleman. And I pondered for myself, what would my life look like if I had nobody to turn to for help. No doctor, nurse, chiropractor, acupuncturist, herbalist, counselor, therapist, shaman, or quack. Nobody. What if there were no medicines, vaccines, or surgeries I could turn to. I realized in a flash I would live my life completely differently.

I would throw away my alarm clock. I would protect myself from as many chemicals as possible, including artificial flavors and colors. I would drive more slowly, and ride my bicycle less recklessly. I would cultivate an attitude of gratitude. I would practice pre-emptive forgiveness. I have enough experience with life to know, despite all precautions, death lurks around any corner. It’s inevitable, for each of us. So I would appreciate every moment more fully. I would dance more, sing louder, and take deeper rest. I would see my friends more often, and laugh more fully. I would choose work I enjoyed. Or, if my job wasn’t my favorite pastime, I’d minimize my time commitment to it. I would stay home when I wasn’t feeling well, rather than pushing myself over the brink into an illness. My primary duty and responsibility would not be to the office, but to care for myself. I would quiet myself sufficiently and frequently to attune myself to the subtle signals of my mind/body. I would attend to what I hear. I would harmonize my relationships. I would engage in my civic duties with a greater sense of responsibility to protect myself and all of my community. All this takes time. Not money. Time. Contrary to popular (American) belief, Time Is Not Money. Time is only Now. Now is always entirely in my hands.

Five Steps to Guerrilla Health

  1. Trust your Clinician.
    • a. Clinicians come in many forms: physicians, physician assistants, nurse practitioners, nurses, midwives,

      Poorly Drawn Lines by Reza Farazmand

      acupuncturists, herbalists, psychologists, counselors, therapists, manual medicine practitioners, etc. In any of these fields, not all clinicians are equally skillful, kind, experienced, or wise. Be choosy. Find a clinician practicing independently who you trust. Ask your family, friends, colleagues for recommendations.

    • Establish a trusting relationship with your clinician. Most doctors studied medicine with the motivation to serve people and relieve suffering. Doctors practicing within corporate and government medical institutions often do not have the autonomy required to practice as they would like to. Creativity is not encouraged. Standardized algorithms and protocols are the norm. But your body doesn’t function by protocol. Your life is not an algorithm. Your human being is a spontaneous improvised phenomenon. Find a clinician who thinks outside the box.
    • Some clinicians are exiting the medical-insurance-pharmaceutical industrial complex. Find them, support them. Make it possible for them to practice and thrive independently. Don’t use your insurance policy to pay them. Insurance companies ream the patient with premiums, and underpay the clinicians. You can request reimbursement from your insurance policy. Often there are so many restrictions, and bureaucratic hoops to jump through it isn’t worth it, unless the bill is big. If you can’t afford the clinician’s fees, discuss your concerns and negotiate something mutually beneficial. Independent practitioners have this flexibility, and enjoy exercising it.
    • Allow the trust in the doctor-patient relationship to strengthen over time. Be sure there is sufficient time allowed in each appointment to address your concerns to your satisfaction. Don’t overload your clinician with every concern on your list in every appointment. Be willing to be cared for over time. This is easier in an independent private practice. The panel size for the doctor is much smaller. In the large medical institutions primary care doctors are caring for 3,000 to 5,000 patients, so appointment slots come open after many months. In that scenario it is understandable you would want your concerns addressed when you get the opportunity. But they often only give you 10-15 minutes. Go to an independent practitioner who has the time to care for you.
    • Do not be looking for every and any opportunity to sue your clinician. That’s like trying to build trust with your spouse while looking for every and any reason to separate. If you want affordable medical care, then reducing the costs of malpractice insurance, and all the aspects of that industry, is vital. Trust is essential. Do your part to cultivate it.
    • Be truthful with your clinician. Honesty is the only way to build trust.
  2. Trust Yourself
    • Your health is in your hands. Take full responsibility for it. Take stock of your physical, psychological, emotional, and spiritual assets. Cultivate your strengths. Fortify the areas where you need growth. Be willing to learn. Be willing to change your lifestyle and habits. Be willing to be honest about your values, priorities, and goals. Be willing to take the actions that reflect your priorities.
    • Most of the time you know what to do. You don’t need a doctor to tell you. All the power for nurturing your health rests with you. Turn to the experts, the clinicians, when you need guidance but do not rely on them to fix you. Do not depend solely on information gleaned from the internet. When educating yourself turn to reliable sources of information.
    • When you need medical interventions, such as medications, herbal remedies, supplements, procedures, tests, surgeries then do not try to practice medicine on yourself. Refer yourself to the trusted practitioner(s) you’ve identified above. Do not hesitate to discuss your intuition and gut feelings about your medical care needs with your physician/clinician. Share what works and doesn’t work for you. Be honest about what is comfortable and uncomfortable for you.
  3. Trust Time
    • Time is good medicine. Healing takes time. Be patient when you are a patient. Allow time for healing to happen. Don’t expect quick fixes. Often the hurry is occupational obligations and productivity expectations. That’s when to remember your priorities, and act accordingly. No matter what your personal or professional priorities are, you simply can’t rush Mother Nature.
    • Caring for yourself takes time. Take time to sleep. Take time to cook. Take time to eat. Take time to exercise. Take time to relax. Take time to connect with people. Take time to learn. Take time to be quiet. This may actually may mean work less. Negotiate with your employer, or change your employer. They need you just as much as you need them. Do high quality work so that is true.
    • Being cared for takes time. Clinicians and patients both need to allow for sufficient time to understand the symptoms and context, observe the signs, think through the possibilities, and consider the options going forward. Allow sufficient time for the treatment(s) to work. Don’t rush any aspect of it. (Unless, of course, you are exsanguinating, in cardiac arrest, having a stroke, have suffered a gunshot wound, etc.)
  4. Trust Life
    • We are not born with a contract that says, “Life will be Fair, Life will be Easy, Life will be Salubrious, Always.”
    • The contract actually says, “Life will be Full, Life will be Rich, Life will have its Ups and Downs, Life will consist of Pleasure and Pain, Life will offer Gains and Losses, Life will require you to Learn and Grow and Change, Always.”
    • Trust what Life brings your way. You just never know what’s going to happen next. Work with it.
    • There is no insurance policy to protect you from Life.
  5. Trust Death
    1. Each of us will make it all the way to the end. Trust that you will also make it all the way to the finish line.
    2. None of us knows when our end will arrive. It’s a surprise. Just like your birthday!
    3. We are all on a one-way street together. And it is definitely not a race.
    4. Dying is perfectly safe. Have no fear.
    5. There is no insurance policy on earth that will prevent your death.

Then bust our arse off for a single payer national medical insurance plan that includes strict regulation of pricing.

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Jayshree Chander

Doctor Chander