Low-Income Serving Doctors On Health Care Reform

Speaking at the American Medical Association's annual conference in Chicago this week, President Obama outlined his plan to reform the nation's health care system. The president's pitch was met with mixed reaction, particularly on the point of a public health insurance option. A group of physicians advocating for health care in low-income and minority communities explain how their communities could benefit from a public insurance plan.

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MICHEL MARTIN, host:

I'm Michel Martin and this is TELL ME MORE from NPR News. Just in time for Fathers Day, author and journalist Leonard Pitts Jr. has made a mark with his penetrating writings about fatherhood and the absence of fathers. And now he has written his first novel which is about, perhaps no surprise, fathers and sons. We'll tell you about it in just a few minutes. But first we want to talk about health care. President Obama had strong medicine for the annual conference of The American Medical Association earlier this week.

President BARACK OBAMA: When it comes to the cost of our health care then, the status quo is unsustainable.

(Soundbite of applause)

Pres. OBAMA: Reform is not a luxury it is a necessity.

MARTIN: Just about everybody agrees that the current health care system is badly broken. But how to go about fixing it sparks great and emotional debate, especially when it comes to the creation of a public health insurance option that would compete against private insurance companies. That's a key part of the President's plan to get health care to millions of uninsured Americans. So, we've decided - sorry, we have invited a diverse group of three doctors who treat a diverse group of patients to tell us what they make of the Obama administration proposal. Dr. David Ellington is a family physician in Lexington, Virginia, and medical director of the Rockbridge Area Free Clinic there.

Dr. Hector Flores is chairman of the Family Practice Department at White Memorial Medical Center in Los Angeles and co-director of the hospital's Family Practice Residency Program that trains doctors to serve underserved communities. And Dr. Carolyn Barley Britton is president of the National Medical Association which represents African-American doctors. She is an associate professor of clinical neurology at the Columbia University College of Physicians and Surgeons. I welcome you all and thank you so much for joining us.

Dr. DAVID ELLINGTON (Family physician, Medical Director, Rockbridge Area Free Clinic): Thank you for the opportunity to be here.

Dr. CAROLYN BARLEY BRITTON (President, National Medical Association): Thank you for the opportunity to participate.

MARTIN: Lets hear the president explain one of the key elements of the reform program that he is pushing for. Lets play a short clip.

Pres. OBAMA: I believe one of these options needs to be a public option that will give people a broader range of choices and inject competition into health care market so that - we can force waste out of the system and keep the insurance companies honest.

MARTIN: Dr. Britton, I'm going to start with you. The National Medical Association has long supported some kind of public insurance option, long before the AMA, in fact the AMA famously opposed Medicare when it was being debated some - several decades ago. So talk to me about why your association is supportive of this idea.

Dr. BRITTON: Well, one of the things that we recognize is that people who are poor and disproportionately they are minority populations lack access to care and lack access to appropriate providers. The system that we have currently covers people at the extremes. We have the elderly and we have the extremely poor and then you have the working poor and the lower middle class, where if they have to purchase insurance for themselves all the products that are available are clearly out of their reach. We have since the inception of the NMA in 1895 fought for universal coverage for all American citizens.

We believe that as a principle and we think that everything should be done to accomplish that goal. Its completely unacceptable in this nation for anybody to be without coverage at any point in their life. So, we think we can afford to do it. A public option is one of a broad range of things that can be done to assure that everyone independent of income can have access to quality and affordable care. It is an extremely important concept and I have heard nothing from the private sector that makes me think that this is somehow unfair to them.

MARTIN: Dr. Ellington, lets to you. You serve a very wide variety of patients with all different income levels, as I understand it. At the free clinic you serve low income people, low wage workers and I assume in your private practice you serve people who have medical insurance. So, what's your, so how would you think the president's proposed reforms would affect your work?

Dr. ELLINGTON: Well, Michel, it's - to follow up on Dr. Britton, I think the president's proposals give us another avenue for universal health care. I'm also a director of the American Academy of Family Physicians and we have a very strong support for health care for all and have been. We think that all people in America should have coverage and that that coverage should include a patient-centered medical home and that our workforce should be primary care based.

One thing to remember is that just because people have insurance does not mean they have access to health care. I think one of the things we found in Massachusetts that now I understand has about 97 percent of the people covered with health care is they have difficulty seeing patients. So I think this is just one step. And the American Academy of Family Physicians is supportive of the concept of a public plan. But with the stipulations that it cannot be just Medicare for all. There has to be free choice of both patients and physicians, and there has to be a fairness. What would the result of that be? I think that would be a big step toward universal health care for all…

MARTIN: And…

Dr. ELLINGTON: …which this nation badly, badly needs.

MARTIN: Dr. Flores, I have not forgotten about you but I just wanted to ask Dr. Ellington one follow up. I understand that you are Medicare certified but one of the concerns that you have about a public insurance option is that it would have kind of a varying reimbursement, some of the issues that concern doctors about the current Medicare system is that they can't count on the reimbursements sort of over time to the point where you aren't taking any more Medicare patients, is that true?

Dr. ELLINGTON: That's correct. We see Medicare patients who are in our panel and those that become of Medicare age. But what we deal it with every year is a giant game of budgetary chicken, every September, October, November. This year, due to something called the SGR, the sustainable growth rate, the plan is to cut Medicare reimbursements to physicians 21 percent. There is no way that you can try to plan for the future where every year built into the system is, are these cuts. So we really need to fix the SGR, it's total health system reform. And I think sometimes people get, they get focused on one aspect of it. But our whole system needs to be taken care of it and part of that system is the universal coverage and the workforce issue with primary care. And I'm sure Dr. Flores has something to say about that.

MARTIN: We definitely want to talk to Dr. Flores. Dr. Flores you serve a community that has some of the highest rates of uninsurance or lack of access to health insurance overall. So let's hear your first pass at your first impressions of what President Obama is striving for, particularly this whole idea of a public insurance option.

Dr HECTOR FLORES (Chairman, Family Practice Department, White Memorial Medical Center): Sure, thank you. Well, I like the idea. First of all, half of our patients, we - our group cares for about 30,000 patients and over half are either covered by the Medicaid program which is program for the poor or are uninsured. And we've been always struggling with the challenge of providing not only to access to care to our services but, you know, the biggest hurdle is when that patient needs specialty care or hospitalization, we can speak for our fees but we can't speak for the specialists' or the hospital's fees.

The public option really offers an opportunity to expand coverage to individuals through healthy competition. For example, in California we have the Medicaid managed care. And the local initiatives to me are the perfect example of what the public option would look like, which is these are plans that are focused on enrolling Medical patients which is the Medicaid version in California.

And they have coexisted very successfully with mainstream health plans. The local initiatives are quasi-governmental and their charges to be a public health plan for indigent patients and low income patients with Medicaid. So I think there is some models out there. In New York City the Metro Plus program, the New York City Health and Hospitals corporation, Metro Plus, serves a similar purpose.

MARTIN: But Dr. Flores, California is facing devastating budgetary challenges right now. Are you concerned that if the government is more involved in providing health care that it will be more subject to the vagaries of governmental budget procedures? That the kind of budgetary chicken that Dr. Ellington talked about year to year will then sort of permeate all health care options. Is that a concern?

Dr. FLORES: That is a concern. Anytime you have a monopoly, or in this case monopsony of payers there is that danger that they may pay you fairly at the beginning but then they to begin to ratchet downward. So, that's why I think healthy competition is important. For example, with the local initiatives and Medicaid in California, they were required to provide actuarially sound payments to physicians and hospitals. And that is in itself a rule that I would hope that the president would include in the public option plan. Because when you have that requirement you will not be allowed to ratchet down below the care that is needed by the patients they're supposed to serve.

MARTIN: If you're just joining us, you're listening to TELL ME MORE from NPR News. We're talking about President Obama's health care reform ideas and we're speaking with Doctors Hector Flores, Carolyn Barley Britton and David Ellington. What about the points that the president made, and Dr. Ellington you were there at the speech, as I understand, that got a lot of appreciation from the doctors there is that he talked about quality of care versus quantity. And he pointed out that the U.S., in some ways we're not as healthy - as much as we spend on health care, our health-care indicators are not as favorable as other countries that spend less. And he talked about rewarding doctors for quality of care versus quantity.

Now that sounds great, but Dr. Britton, do you think that that's possible? What would move the country in that direction?

Dr. BRITTON: Well, I think two things. One, I agree with the comment previously, that we are talking about system reform, not just about universal coverage, and it contains a lot of components.

One of the issues has to do with the reimbursement formula, and one of the things that the president affirmed that he understood that there was a problem with the SGR formula that is currently in use and promised to eradicate that, to look at a formula that would be better for determining what fair reimbursement would be for physicians, which is important to having practices be sustainable for anyone.

I think that there is no choice but to look at these issues in the context of the overall budget. We are facing a deep recession. The cost of our health care is very high for the overall quality. It is not that we do not have superb health care in this country for those who can afford it. We do. We are the leader in technology and in research and in innovation in the world. And we are the envy of the world at the top of our game, but when it comes to simple things like primary care and preventable things and wellness initiatives, we fail miserably.

So a large part of our population never gets any care that is appropriate until it is too late to do something for them. This costs the system dearly. It is not a sustainable formula going forward, and we certainly can't sustain that, given the recession that we are currently in. So I think the health-system reform is an important part of coming out of the recession, as the president correctly states.

MARTIN: Dr. Ellington, what do you think would move the country most toward better health at lower cost?

Dr. ELLINGTON: Well Michel, I'm going to pick up on something that the president said when he was there and which got a raucous standing ovation, and that is the increased emphasis on primary care in our country.

There's a physician named Barbara Starfield who has done extensive research for the Johns Hopkins School of Public Health, and this has been supported by other people throughout the United States. And what it does is compares our health system with other industrialized health systems that provide care at about half the cost of the United States. And the single biggest differentiating component of that is these are primary care, foundational health systems, where anywhere between 40 to 50 percent of the physicians are primary care physicians.

In the United States right now, we're between 30 and 35 percent. And as Dr. Flores can tell you from personal experience, we're having a lot more trouble getting young medical students to go into primary care. So if there is going to be a change, I think it's going to have to be fundamental change to provide more primary care, so exactly as Dr. Britton says as a neurologist, that we will be preventing the strokes that she deals with by treating high blood pressure appropriately on the front end.

Because I think that is the key, is a primary care foundation. And with what the American Academy of Family Physicians is really emphasizing is a patient-centered medical home, which is a team of physicians, nurses to take care of the patient.

MARTIN: Dr. Flores?

Dr. FLORES: Absolutely. There's good models already here in California. Dr. Starfield has done wonderful work in giving us the rigorous research, but one of the most successful systems in the United States is Kaiser Permanente. And their strategy is anchored on ample access to primary care.

Over half of their physicians in their workforce are primary care physicians. I know from experience that they actively recruit our graduates because they know that they have to have that balance. And really the key point of the president's proposal is that delivery system redesign, emphasis on primary care and prevention. You know, for too many years we've had a system of care that's geared around treating illness, and unfortunately because that's where the resources are, that's where most physicians tended to go.

MARTIN: And finally, we only have about two-and-a-half minutes left. So I did want to hopefully hear from each of you on how optimistic are you that some of the things that you've been talking about and working on and concerned about in your field for so long are finally going to be addressed? So, Dr. Flores?

Dr. FLORES: I'm optimistic. I think what we will settle on will be incremental reform. I think it's difficult to do a wholesale reform of such a large system in the United States. So I'm very optimistic about incremental changes.

MARTIN: Dr. Ellington, what about you?

Dr. ELLINGTON: Michel, I got out of medical school in 1975, and I have never been more optimistic that we are going to address this problem now than I have since that time.

MARTIN: Because? Why?

Dr. ELLINGTON: I think the American public realizes that something has to change. I think the president of the United States realizes that it has to change. I believe the physicians realize it has to change. So if the stars and the planets are in alignment, and more importantly, I think everyone realizes that financially it's not can we do it, it's can we afford not to do it?

So I think it's just everything is in alignment right now, and we just need to go ahead and do it. I agree with Dr. Flores. I don't think it's going to be a sweeping change, but I think we're going to take some very significant forward steps in achieving our goals of universal health care.

MARTIN: Dr. Britton, what about you?

Dr. BRITTON: National Medical Association, we agree with my colleagues here. I think - I am very optimistic. I think we are going to really start to move this ball down the field. And we are all - one thing is that we are all in agreement on the goals, where it is we need to be, and that is an extremely, extremely important moment, that nobody can be left out of the game. And once you decide that, it's a matter of how you bring them into the game, and that's going to be the challenge. But I think that we're going to do it.

I think the American public now understands the extent of the problem, that we can't sustain the expense the way we are doing it, that the lack of a primary care model has really cost us dearly in terms of health disparities and in terms of unequal access and in terms of poor health outcomes. So we will be a better nation. We'll be healthier, and I think we will have a firmer control of cost containment if we approach this problem systematically and really commit ourselves to it. So I'm optimistic for it.

MARTIN: All right, we'll see. Dr. Carolyn Barley Britton is president of the National Medical Association, which represents African-American doctors. She's also an associate professor of clinical neurology at the Columbia University College of Physicians and Surgeons. She was kind enough to join us from our New York bureau.

Dr. Hector Flores is chairman of the family practice department at White Memorial Medical Center and co-director of the hospital's family practice residency program in Los Angeles. And he was kind enough to join us from NPR West in Culver City, California.

Dr. David Ellington is a family physician in Lexington, Virginia, and co-founder and medical director of the Rock Ridge Area Free Clinic in Virginia. He serves on the board of directors of the American Academy of Family Physicians. All very busy people, and he was kind enough to join us on the phone from his office. Doctors, I thank you all so much for speaking with us.

Dr. FLORES: Thank you.

Dr. ELLINGTON: Thank you.

Dr. BRITTON: Thank you so much for the opportunity.

MARTIN: You're listening to TELL ME MORE from NPR News. I'm Michel Martin.

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