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[Originally posted at SFGate: http://www.sfgate.com/cgi-bin/blogs/rchoi/detail?entry_id=89596]

 Ok, I confess. I have contributed to the $2.3 trillion that our country spends on health care every year. As a patient I want the best possible care for my family and me. As a physician I am the gatekeeper to expensive procedures, medications, and diagnostic tests. However, by several indices including life expectancy, infant mortality rate, and satisfaction with the health care system, we are not getting our money’s worth.

As discussed ad nauseum during the health reform debate, we can point the finger at any number of parties for the high cost of care: hospitals, the pharmaceutical industry, insurance companies, and patients. I would also add to that list health care providers.

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[Cross Posted from SFGate: http://www.sfgate.com/cgi-bin/blogs/rchoi/detail?entry_id=89117]

A few weeks after the release of Governor Brown’s January budget I attended a Senate Subcommittee hearing on Health and Human Services in Sacramento. The Governor’s proposal included increases in co-pays and premiums for beneficiaries of Healthy Families (SCHIP) and Medi-Cal as well as taking $1 billion dollars from First 5, a vital program for young children in my clinic and many other communities across the state. I was there to describe the impact these program cuts would have on children and families.

While I was prepared to give my testimony I was completely unprepared for the heartbreaking testimony given by others who pleaded with the Committee members to spare their programs. The proceeding four hours were some of the most difficult I had ever experienced. As the Senators worked through pages of proposed cuts, lines of foster mothers, chronically ill seniors, advocates, and agency representatives formed to describe the harsh reality of the cuts to lives of real people.

More than once did someone say that people were going to die from these cuts. To be fair, the Senators were sympathetic but only responded with “our hands our tied” rhetoric. The entire morning was brought into focus by one comment: we must recognize the “cumulative impact” these cuts will have for some populations.

As a community health center physician, the communities I take care of are the first to be laid off when a business has to downsize. They are the least able to accommodate a rise in food prices or a hike in college tuition. They are the least likely to have a connection to a legislator or official who can help. They are also more likely to be sick and on multiple medications. They are among the ones who need the threatened services the most, particularly in difficult times such as these.

But it is not just them. Many formally middle class and upper class families are getting pulled down as well. In a private clinic where I work part-time, I see parents who lost a job bringing in their children for one last check up before their health insurance coverage terminates. The next day in my community health center, I will see new patients who formally had private health insurance coming in for urgent problems. In fact, the influx of the newly uninsured is stretching my health center’s fiscal limits.

Unfortunately, $6 billion in proposed cuts to health and human services, including the ones mentioned above, passed in March. Now further hobbled, families are at the breaking point.

The state Republican proposal released last week continues the pile on with further reductions to mental health and early child development programs.

The Governor’s May revised budget released today revealed that the state is unexpectedly bringing in $6.6 billion dollars in revenue. But our problems are not yet solved if you count the $10 billion deficit that remains. Critical health services will continue to be threatened until the budget is resolved with revenue sources.

So what if legislators are unable to agree on tax extensions?

A New York Times Sunday Magazine feature article about Governor Brown quotes him as saying: “You have to keep cutting to the point where people say they want to increase their contribution.”

As intractable as the situation appears, this solution is wrong headed and completely ineffective. A cuts only agenda will grind down the growing numbers of people who are bearing the brunt of this recession past their ability to rebound. They will have nothing left to contribute.

Recognizing the cumulative impact of further cuts on California’s families, we must urge our legislators to pass a final budget that includes sensible tax extensions and revenue sources.

[Originally posted on SFGate: http://www.sfgate.com/cgi-bin/blogs/rchoi/detail?entry_id=88328]

Should pediatricians be punished for asking about guns in the home?

Far be it for me, a Bay Area pediatrician, to tell Floridians about how to keep their kids safe. But having spent half of my life in the south (and I don’t mean LA), perhaps I am only partially carpetbagging.

Florida’s Governor Scott is on the verge of signing into law a bill that would penalize doctors for asking about guns in the home. The original bill shockingly included a $5 million fine and a five year prison sentence if a doctor asked about a patient’s gun ownership, entered gun ownership information into a medical record, or refused to care for patients who declined to answer related questions. An unsatisfying compromise amendment between the NRA and the Florida chapter of the AMA limited the penalty to the possible revocation of a medical license and would allow questions about gun ownership and entry of that information into the medical record only if “medically necessary”.

Similar legislation is making its way through the Alabama legislature.

Particularly bewildering to me were claims made by state legislators that gun safety was outside the scope of a pediatrician’s practice. According to Marion Hammer, a past president of the NRA, “Families take their kids to pediatricians for medical care, not to talk about guns.”

I would beg to differ.

While there are several directions I am very tempted to go with this outrageous bill, I am coming to rest here: my scope of practice is health.

Scope of practice traditionally refers to a license authorized range of a provider’s services. Not surprisingly, the range of a scope is charged with turf battles between specialties and different health professions -like the time your neurosurgeon and orthopedic surgeon wrestled over who got to perform your back surgery.

The scope of practice I am talking about we all can own. I have a responsibility to ask about, diagnose, educate, and treat obstacles to health. For those who see children in their practice, discussing topics such as swimming pool safety and smoke detectors are routine at regular check ups.

But let me take it a step further. I would argue that nutritious food, safe medications, air quality, domestic violence, affordable housing, access to health care, sex trafficking, cultural factors, schools, safe neighborhoods, voting, human rights, international trade agreements, and the state budget, to the extent they impact health of my patients and communities, are also in my scope of practice.

Not only do I feel an obligation to explore these issues, my patients expect it of me. When my infant patient is drinking contaminated Chinese formula or if children can’t play in their front yard for fear of gun fire, it is my problem too.

Commonly called the social determinants of health, addressing only the downstream impacts of unhealthy and violent circumstances in the form of specific diseases (or even death) is addressing a fraction of the problem and woefully insufficient.

So yes, to ask if a device that is associated with over 30,000 deaths a year and over 50% of suicides is unloaded, locked up, and kept out of reach of children is also well within my scope of practice.

At issue is not only whether or not a gun should be in the home, but also the right of physicians, free of legal entanglements, to provide the anticipatory guidance for an environment where their patient can thrive.

[Originally posted at: http://npalliance.org/blog/2011/04/04/ages-and-stages-of-aca-at-1-yr/]

 The Patient Protection and Affordable Care Act (ACA) turned one year old last month and as a pediatrician; I find it helpful to review its progress in developmental stages.  Just as a child learns to roll, crawl, and then walk, the ACA has made incredible strides this past year and its benefits will also continue to grow over the years ahead.

On March 23, 2010 the United States witnessed the birth of a new law that will eventually allow 35 million people to get affordable quality health insurance and for patients to get important protections from most of the worst practices of health insurance companies.  Witnessing the flaws in the health care system that leaves 16% of Americans uninsured, many had been dreaming for decades about this day. However, the pregnancy was difficult.  Some people expressed dissatisfaction with the likely changes it would bring to our lifestyle and questioned if we were financially prepared.

May 2010 was the first milestone when some Medicare recipients started to receive checks to help them pay for drug prescriptions.  The ACA baby could now roll and was on its way to sitting up.  As of September 23, children under 26 years of age could join their parents’ insurance plan and children with preexisting conditions could no longer be denied health insurance.  Starting this year, Medicare recipients can get free annual physicals and those in the “donut-hole” will get 50% discounts on brand-name Rx drugs.

The past milestones are setting the ground work for the ACA to walk independently on January 1, 2014, when most of the ACA’s provisions will enacted.  On that date people under 400% of the FPL will get subsidies from the government to help them buy affordable policies through state health insurance exchanges or become eligible for Medicaid.  Furthermore, the ACA allows the development of innovative models to improve the quality of care.  However, as with rearing any child, the ACA is a shared responsibility. Some vocal critics overlook the fact that the individual mandate makes possible popular provisions like banning the denial of insurance to those with preexisting conditions.

At my community health center in Oakland, the ACA is bringing life saving benefits.  Last year a staff member prayed daily that her uninsured young adult son would make it to the end of September without an accident or getting sick.  Several of our devoted doctors are able to stay working at the health center thanks to loan repayment programs offered in the ACA.  When fully implemented, the ACA will provide insurance to 5000 of our current uninsured patients through Medicaid expansion and bring many more newly insured people to our doors.  Increased funding for community health centers through the ACA will allow us to expand our operations such that we could double the number of people who benefit from our high quality services.

So, as we celebrate the ACA’s first birthday, we should celebrate the ways that this new addition has improved the lives of the Americans; and look with eager anticipation to the next stages of development. Raising a child is one of life’s most difficult challenges, but parents would agree that the benefits far out way the sacrifices.