I admit it .. I am quite a fan of the Affordable Care Act (ACA). Like a host of others I would prefer, of course, a single payer plan. But this law is a great start. If it serves to give our nation evidence that medical care costs can be contained, and even lowered, with an approach that focuses more on health promotion, disease prevention, and efficiency plus effectiveness .. then it promises to go a long way toward dispelling many myths that opponents still tout.
There are several things about the law that give me hope. One is that it is a start toward making prevention a priority, which includes many of the kinds of services that we as nurses bring to the table in large doses! We know how to educate people and families, and how to tune in to what concerns or worries a family about what is going on with their health, and guiding them in ways that address their concerns and find solutions that work best. Of course other providers can do these kinds of things but the fact is that given the structure of our current disease-treatment-oriented system, the kinds of concerns have been shuffled aside and not given much oxygen. Now, there is an opportunity for people to begin to experience the difference that good prevention and health promotion can make in their lives. There are those who decry the expense that arise from some of the new benefits. To those I say — wake up! One of the reasons our country has run-away costs associated with our s0-called “health care system” is that it is a non-system that ignores the benefits of prevention and health promotion, and at the same time gives our economy an avalanche of waste. So to oppose the ACA is to support continued high cost, poor health for our nation (especially the most vulnerable among us), and blatant inequity and disparity in the health of American citizens.
Of course the first priority at this very moment is to make sure that Obama and other ACA supporters can prevail for the next 4 years at least. But just as important, everyone needs to be informed about this bill, what it does, and also, of course, how it needs to be improved. Here are few hints for starters:
1) Get a copy of the book “Health Care Reform” by Jonathan Gruber. It is in comic-book format, easy to read and very informative about the basic elements of the ACA. Gruber is one of the architects of the Massachusetts plan, and in turn the Affordable Care Act. If you do not explore anything else, get this very affordable book, and then pass it along to someone else!
2) Visit the HealthCare.gov web site. One of their recent blog posts is a guide to Health Insurance Costs and Benefits. Be sure to check back in often over the next couple of years, because many of the benefits covered by the ACA will be kicking in over the next couple of years.
3) If you have medical insurance, find out more about how the ACA effects your own coverage, and start taking advantage of some of the benefits that you now probably can receive that you might not have received before. Women in particular need to be informed – and take action. Many of the prevention and disease detection benefits that are now covered by the ACA have not been available to us until now.
Share your thoughts and ideas here. I would love to know about suggestion for how we can all make this bill work for ourselves, our families and friends. And let us know your ideas about what needs to be improved to make this bill even better!
Peggy L Chinn 
The doomsayers have been wrong ever since the days of Thomas Malthus, but the fact is that we live in incredibly rich countries, the wealth of which could only have been dreamt of by our forebears – our parents even. There is ample resource to care for the sick and elderly amongst our number, and engage in health promotion activities which advance the lifespan and health of our population. Stereotypes about the cost of elderly care abound, but I would commend a book by Mullen called ‘the myth of ageing’ which, by means of extensive social and economic analysis dispels many of the myths and the exaggerated and scaremongering discourse popular among politicians and economists of a certain persuasion about the elderly (and ageing) being a problem… It is simply not borne out by the facts. Heaven help the US if Obama is not re-elected. We all know where Romney’s sympathies lie!
thank you so much for adding this note, Steve! Indeed, it is time to recognize that life-long healthy living does pay off in a myriad of ways, including long and healthy elder years with a very low “cost” to society as well as a high quality of life! When I turned 70, my granddaughter asked me if I would live to be 100! My answer — I certainly hope so! then we proceeded to have a little math discussion about how to quickly figure out someone’s age today based on the year they were born! Anyway, back to the point, our medical systems have been so embedded in a deficit model – (deficits of resources, deficits in people), and making a profit from various “fixes” for these deficits, that very few of us have the ability to even recognize the evidence, and the possibilities, for another path. So thanks for contributing this perspective to this discussion.
Steve and Peggy,
As with most things, the “”Truth” lies somewhere within the extremes. So the issue is two-fold: How do you get to this desired end and what are the tradeoffs?
Malthus wasn’t wrong – he just did not anticipate technological developments that increased the level of food produced per acre.
But his recognition of the limits of exponential growth were right on target and all one has to do is look at the work of biologists and epidemiologists to understand that they have not rejected Malthus at all. They just recognize that it didn’t play out the way he imagined over a short period of time. But extinction in animal and plant populations is common.
So, let’s assume that you are correct and we can continue to extend the lives of people and keep them in excellent health.
The normal constraints on population growth having been eliminated, people only die as a result of traumatic injury.
The wealthiest nations will, of course, avail the wealthiest of their populations to such extraordinary interventions – whether that be high tech robotic body replacement parts, better diets or health interventions.
The poorest countries will continue to deal with it as they always have – higher birth rates.
We have 7 billion people on the planet now – most of whom do not have living standards anywhere near as high as the poorest Americans. What course do we take – do they start availing themselves of consumer goods at the level of the wealthiest Americans? Do they start eating the same diet as the wealthiest Americans will eat to preserve their lives beyond 100? Or are they to be relegated to the same, or lower, standards of living as they now have?
Do we tell some people that they cannot manifest their chosen futures by having children while other people are being permitted to live out their extropian dreams of eternal life? If Peggy lives to 100 will her great-great grandchildren be able to live to 150 and have great-great-great-great grandchildren?
At what point do we begin to restrict human freedoms to procreate, extend life, consume more?
Can we deal with a doubling of the human population? Tripling? Quadrupling? Quintupling?
At some point even on so fundamental a measure of having sufficient space to have every human being supported by 2 square feet of space will be reached.
At the moment, each of 7 billion people is supported by about 5 acres of land mass. Quintuple the population and that falls to 1 acre.
Yes, we can build up, but we do live on a finite planet. There is just so much air, water, mineral wealth, energy, food, carbon, oxygen and hydrogen we can produce and use.
The answers in Malthus’ time were:
1. Imperialism – extracting more resources from other countries. By doing that Europe maintained its standard of living and did not have to deal with the limits .
2. The industrial revolution – increased the level of material wealth that could be produced by each human being’s labors.
3. Scientific farming – increased crop yields per acre.
I am sort of guessing here that you don’t think that imperialism is an appropriate solution going forward? But if you want to hold to this standard and everyone rises to the standard of living of Mitt Romney – five houses and multiple cars we reach Malthus’ tipping point long before we double the current population. If the plan is that nobody is going to get to live as well as Mitt I suspect there will be a lot of wars waged by the Mitts of the world to resolve the issue in their favor.
We don’t have to like reality to appreciate it and to start to deal with it. I am old enough that I would like to imagine my health might improve over time – but I tend to doubt that. More likely my body parts will continue to wear down.
But there are other people in my community who have totally different priorities – they want children, grandchildren and great-great grandchildren. They want their children, grandchildren and great-great grandchildren to eat well, go to school, have their health care needs met and have a bright future.
In some countries with great wealth and small populations (e.g. Canada/Australia) these contrary objectives can be met for longer periods of time than in countries with large populations and little natural resource wealth (e.g. Japan).
Which set of objectives should prevail? Who gets to live their lives the way they want and who gets their needs met? Does Romney get to keep everything he has and we slowly move everyone else to his level of wealth? Does Romney lose almost everything he has and we slowly move everyone to a standard of living far lower than his?
What’s the Plan Stan?
Well you only asked Stan about the plan (I like the rhyme!!), which I am curious about as well. But I will chime in .. I don’t have a plan but I would offer some possibilities to consider in terms of assumptions (pesky as they are!!). First, I do not believe that many folks aspire to live or be like Romney — some do of course, but I believe, and I assume, that most folks find his situation more on the repulsive side, and also find the extreme waste of money invested in not only his world, but in this election, not only repulsive but immoral. If we had that money to invest in health care for all world wide, then we could see what kind of plan might be possible. The other possibility to consider is that as folks are able to live in situations that meet basic needs and have a modicum of education, they do not aspire to have large numbers of children. Some do, of course, but is you ask women who are taking the largest share of responsibility for families, they mostly want to have families they can provide for and manage. They (we) do not want or need the burden of large families that drain our health and well-being. Of course we take great joy in children and grandchildren who are healthy and happy, but when that “healthy and happy” part fades away, you probably do not even want to know what is really happening in those worlds. So, if I were to have a plan, it would be to do the best we can to provide for as many folks as possible, focusing on making sure that they have what they need. We engage in praxis .. we do the best we can at the moment, reflect on what we are able to do and consider what more we might need and want to do, and try again. To me, that is the point of celebrating the ACA … it is a start in the direction of doing what we can at the moment, then taking it a step further as we go along, learning from our mistakes, and moving forward. This discussion adds immensely to the “reflection” part that must continue … and every single point you guys have raised is vastly important … so thanks for getting these ideas on the record!!
🙂
OK, unaccustomed as I am to self-promotion, I have finished the second edition of “Standard Errors: Our Failing Health Care (Finance) Systems And How To Fix Them” and even started putting together the website:
http://www.standarderrors.org/
The thing I like about Obama is that he plays multi-dimensional chess – he doesn’t approach things the way Romney does. Romney looks for temporary fixes, incremental steps and short term profits.
The only advantage to having Obama as president is to start using the longer horizon – to stop focusing on what will work for days, weeks or months and start thinking through what will happen and what needs to happen over years, decades and centuries.
If most people believed as you do, and to be honest, as I do we wouldn’t have half the American voters even remotely thinking about voting for the likes of Romney and Ryan.
But it isn’t just voting that is the problem – that 47% of the electorate that are hard core Romney/Ryan supporters are more than happy to kill off the 47% who vote for Obama to support Romney’s lifestyle.
Yes, they are dumber than turnips if only because they are voting against their own best interests but that is where they are.
They will not only vote to affirm Romney’s lifestyle but they will vote to wage war on those of us who vote for Obama and indeed on most of the rest of the world.
They will gladly vote for nuclear assaults on Iran, re-invading Iraq, staying in Afghanistan for a millennium and they will add to the roster of invaded countries every country that has the animal, vegetable and mineral resources needed to sustain Romney’s lifestyle and secure some tidbits for themselves.
They will go, or send their sons and daughters to war on the same misbegotten premises as almost every war has ever been fought.
Obama made some severe missteps in 2009. Were they anywhere near as bad as the missteps McCain would have made? Of course not. But they gave Romney and the people who support him a great deal of justification for waging the current campaign.
Rather than a massive bailout of banks – there should have been a massive governmental takeover of mortgage companies and failed banks. Banks didn’t use the money they were given to refinance houses – they sat on it and are still sitting on it.
There were a few policy successes but there were also other similar problems and failures.
But it is because these were areas in which the planning was short term – not the best Obama could have done – but he let too many of the people who caused the problem hold sway on how to fix it.
But if we really want to support him, and his ability to play multi-dimensional chess and plan for the long term health of America and the world than we all need to start thinking the same way and planning over longer horizons.
We, in nursing need to know what the long term consequences of our actions will be and we need to have a plan for how we are going to achieve our goals and that takes a lot of math, statistics, operations research as well as caring, consideration, tenderness and aesthetics.
It isn’t a matter of simply having visions of the future – the visions need to have roots, trunks, limbs, branches, leaves and flowers. We aren’t in the 1960s – when we thought that visions alone would win the day. We have seen that that approach didn’t get us what we could have had.
Less than 5 years after JFK was killed this country elected Richard Nixon as president. !7 years after JFK was killed this country elected Reagan and in the worst mistake of the 20th century, 37 years after JFK died this country elected George W. Bush as President.
Yes, in our highly insular worlds women want what you describe – but a large portion of American women want to deprive other women of their reproductive rights and a much larger proportion of American men are on the same page.
I can only hope we do a better job than we have done of developing a plan for the future that the 50% of Americans who have an entirely antithetical view of the future can understand and endorse with their votes, hearts, minds and bodies.
Obama can play a much better game than he has – but we need to provide the intellectual as well as the moral support for that or we will get another 4 years of compromised policies. And a lot of the “voices” of nurses that have Obama’s ear have horribly flawed advice to render – we have to stop that or we will have an even bigger mess to deal with in 4 years and a Romney clone will undo everything Obama might achieve in the next 4 years because it will fail.
Excellent! thanks so much for this … and put it up on your own web site!
While I agree on the importance of re-electing the president – I am inclined to think that prevention is a problematic solution.
As reference consider:
http://www.ssa.gov/OACT/NOTES/as120/LifeTables_Body.html
In essence, many of the problems we have today, particularly our high health care costs, are direct consequences of earlier successes in prevention.
Throughout the 20th century, with only a few exceptions, the life expectancy of US citizens has been increasing for all ages.
But rather than reducing costs this has increased costs and there is little reason to believe that this will change in the next few decades.
Prevention, desirable as it is, does not eliminate illness and injury, it simply delays the time at which illness occurs. In the interim other health care costs are incurred which means that for most people the discounted costs of future health care rise with increased prevention expenditures.
The advantages of prevention are of course extended lives – but this comes at a cost: increased levels of chronic disease, increased health care costs, increasing dependency ratios, decreased solvency of public and private pension plans and the social security and Medicare trust funds.
While nurses can take credit for some of the positive effects of our activities – cost savings is not something we ought to be waving flags for very proudly because it is not a promise we are going to be able to deliver on.
There are all sorts of things we can do to reduce costs – not the least of which is implementing the most efficient possible insurer – a national health insurer – which unfortunately the PPACA failed to do – but prevention will always result in increasing longevity and this in turn will always lead to increased average costs when all other factors are held equal.
Thanks for adding this perspective! However I am inclined to focus more on the benefits in terms of quality of life, particularly for children and women, who are likely to live a long time but can be saved from life long situations that result in avoidable costs (monetary and otherwise). Consider obesity and certain stress related outcomes associated with family violence – preventable situations that make huge differences in health and well being. I guess time will tell and I hope at least we have the chance to see how realistic these various predictions play out!!
🙂
The point I was making is that it is not a matter of a prediction – it is what has already happened.
50 years ago, before massive public health improvements including water systems, sewer systems, ambulance services, 911 systems, and advances in primary and secondary prevention the average retiree died within a few years. So the experiment has already been run and we are collecting the long term data now.
Now retirees are dying a couple of decades after retirement and the costs are far greater than anticipated by social security actuaries.
Yes, I agree that the lives of these people are improved, but the social costs involved are only beginning to be experienced.
Our generation is far larger than the generations before us and there is no plan for how to meet these costs or how to meet our generation’s needs.
Now Paul Ryan is an innumerate and his voucher plan for Medicare would bankrupt Medicare in the first 2- 5 years after implementation. But just because Paul Ryan and Mitt Romney have terrible plans doesn’t mean we nurses ought not be discussing the implications of our successes.
If we want to be taken seriously we should be analyzing both the positive and negative consequences of what we plan to do. If we don’t do it we will be dismissed as soon as it becomes clear that the cost savings we promise will never materialize.
It is sort of like Kenneth Arrow’s rationale for capitation – where the cost savings are actually cuts in care – not improvements due to capitation induced efficiency.
Excellent points for sure! These are indeed very very complex issues and we will never even scratch the surface in this brief discussion. It does occur to me that the provision in the ACA for contraceptive coverage just might (might, I emphasize!!) serve to help stabilize the burgeoning population growth that is also contributing those aspects of cost that you are very wisely addressing here!! I also know that you understand this situation at a level that few of us nurses do … so thanks for chiming in on this very important issue! I hope that our exchange here will set the stage for more thought, research, and other kinds of scholarship as we move into a (hopefully) new era in US health care!
I am all for birth control and recognize that there are many people who probably wish there had been far better contraceptives available in late 1945…
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LOL!! In 1941 too!
Peggy Chinn My Blog: https://peggychinn.wordpress.com/ IMAGINE what could happen if the USA 99% showed up to vote in 2012!!