It is A Matter of Life and Death

This is from an email I received today from Dr. R. Scott Poppen at Doctors for America:

After spending 30 years in healthcare, I thought there was no story of bad luck and catastrophic illness that could touch me emotionally. But last summer, as I sat in a hearing room at the Utah State Capitol, I felt a tear well up in my eye.

I was listening to Emily, a woman in her 40’s, testify at the Governor’s Community Workgroup on Medicaid Expansion. In 2009, her 20+ year job with a software developer was eliminated when the Great Recession hit. A few months later she was diagnosed with advanced breast cancer. About the time her surgery was completed, the COBRA insurance she purchased had ended. She was unemployed, uninsurable, and was unable to afford the recommended adjuvant radiation and chemotherapy.

Now, 4 years after her initial diagnosis, her breast cancer had returned and was widely metastatic. In the meantime, she found employment with another company. But that company didn't offer health benefits and she was uninsurable due to her pre-existing condition. Her job earnings made her ineligible for Medicaid and she was the sole caretaker for her parents. She couldn’t afford to see any doctors.

One hour after her testimony I walked into a subcommittee meeting. As our workgroup gathered, we solemnly discussed Emily’s poignant testimony. One committee member, a Utah State legislator and vehement opponent of Medicaid expansion, commented, “We really don’t need to hear anymore testimony like this.” I was stunned.

One year later that legislator is still opposed to Medicaid expansion. His comment still haunts me.

I was sad to learn from news reports that Emily had died. She did finally get on Medicaid. When she became too ill to work, Medicaid enrolled her and provided the hospice care that hopefully eased her passing.

Twenty-four states still have not expanded Medicaid. Doctors for America is actively working in many of these states to get their governors and legislatures to do the right thing and increase access to health care for the working poor. Your donation to Doctors for America helps us do that work and honors the memory and courage of Emily.     

What if we Treated Poverty Like a Disease?

In a recent article, author Trudy Lieberman describes the work of Dr. Gary Bloch, a family physician at St. Michael's Hospital in Toronto, Ontario. His idea? Treat poverty like a disease, and facilitate the physician led health care team to access the resources that combat it when they are consulted for medical care concerns.

As the article relates, "We've created an advocacy or interventional initiative aimed at changing the conversation about poverty and how doctors think about poverty as a health issue." To aid in their work, the team has developed a clinical tool used by primary care practices in Ontario that is based on strong evidence linking poverty to bad health outcomes. This tool notes that "poverty accounts for 24 percent of person years of life lost in Canada (second only to 30 percent for neoplasms)," and makes the claim that in Canada,  "higher social and economic status seem to be the most important determinants of health." This relationship has also been demonstrated in the United States.

This is what they do:

1: Screen by asking, "Do you ever have difficulty making ends meet at the end of the month?" Using the language of clinical tests,  the tool says that this question yields a sensitivity of 98 percent (the ability to predict the number of people with the disease) and a specificity of 64 percent (the ability to predict those without the disease).

2: Think of poverty when making clinical decisions like any other risk factor. For example, a man living in the lowest 25% income level has twice the risk of diabetes as a high income man. Therefore, when a man without other risk factors for diabetes presents for care with very low or no income, doctors should consider a screening test for the disease.

3: Intervene with probing questions. One powerful question is, have you filed a tax return? Those who have not miss out on supplemental benefits to help address their poverty. What is their living situation? Many will hide the fact that they have no permanent home.

Like all family physicians, I have frequently experienced hearing from my patients that they are unable to afford their medicines or the treatments that they need, and this has even been true for people with insurance! What if the family physicians office was the gateway to identifying and treating THAT problem?

LINK TO CLINICAL TOOL, Ontario College of Family Physicians

Do you hate these parts of Obamacare?

I meet folks who say, "I don't like Obamacare". I find this frustrating, because these same people almost never are able to articulate anything other than a feeling!  When I review the 10 major features of the Affordable Care Act, these same people invariably tell me they are in favor of most if not all. Which one of these ten things do you hate?

1. The individual mandate is probably the most commonly disliked provision, and yet, it is essential.  This is how insurance works. Everyone pays in and "pools their risk". Only the extremely wealthy could possibly afford to go it alone.
2. The exchanges are an important innovation that allows the customer to compare plans in a standard fashion, to pick what works best for them. This can be done through insurance brokers, paper applications or hopefully, via the new web sites when they are working.
3. The expansion of Medicaid is a crucial change for the working poor - those families for whom coverage would otherwise be impossible.
4. Elimination of the donut hole. Seniors on Medicare no longer have to deal with the strange gap in prescription coverage that affected so many.
5. No pre-existing condition limits. This gets rid of the favorite insurance company way of refusing to pay for needed care.
6. Young people up to age 26 can stay on parents' plan. An easy administrative change that has helped millions of young people just getting started.
7. No copay for preventive care and screening tests takes away the barrier to get things that save illness and money down the road.
9. Tax credits to small businesses to encourage them to provide health insurance to employees. This helps employers do the right thing for those who work for them, and attract and keep good employees.
10. Subsidies for lower income Americans. The sad fact is, medical care has gotten so expensive that millions of people who work full time cannot afford the insurance or the care. This costs all of us in higher fees, and this change helps to end that spiral.

The Washington State Health Care Innovation Plan

Imagine a state where everyone had a personal connection and easy access to the medical care they need, and where the care was coherent, coordinated and focused. That is the stated goal of the Washington State Health Care Innovation Plan, according to Karen Merrikin, the new administrator of the plan, who came to Bellingham to meet with interested leaders in our health care community on October 17.  She told the group, “Our current health care system too often provides high-cost, low-value health care and our goal is to collaborate with payers and providers toward health system transformation that delivers reliable, higher-value, lower-cost care in Washington State.”

How to make that happen? The Washington State Health Care Innovation is a five year plan to use the purchasing power of the state to align incentives across all areas of health care delivery for care purchased or administered by the State of Washington. These are the tools she identified:

• Basic infrastructure to manage care
• Aligned quality incentives
• Aligned payment incentives tied to outcomes
• Support for primary care practice transformation, to achieve the patient centered medical home
• Strengthened health IT
• A modernized work force to meet current needs, with emphasis on primary care and behavioral health
• New tools for people to understand and access care
• Local accountability for organizing and delivering care, based in the community. An example would be our local Whatcom Alliance for Health Care Advancement (WAHA).

In order to achieve the above goals, Merrikin described a new organizational structure, with the state divided into 7 to 9 regional zones. The NW Washington region would contain Whatcom, Skagit, Island, San Juan and Snohomish counties. Medicaid administration would move to these areas. Other features would include a community health organization (ACHO), and an embedded regional extension center to support needed practice transformation activities. Key state supports would also be aligned to the region, and a transformation trust fund is envisioned to support training and innovation.

Remaining key questions include “how will the savings be re-invested”?

The draft plan will be presented at the beginning of November, feedback will be solicited through mid-November and the final plan will be finished December 31.

Contrary to What You May Hear, Congress Must Get Their Medical Insurance Coverage Through Obamacare!

Perhaps you have gotten one of these emails yourself. The author is very upset because:

"The federal Congress has just approved with the help of Obama to waiver all Congressmen and their staff from having to use the Obamacare exchanges." 

"For too long we have been too complacent about the workings of Congress.  The latest is to exempt themselves from the Healthcare Reform that passed ... in all of its forms. Somehow, that doesn't seem logical. We do not have an elite that is above the law. I truly don't care if they are Democrat, Republican, Independent or whatever . The self-serving must stop".

The emails often go on to urge you to forward the email, so that we can pass the 28th Amendment to the US Constitution, so that all laws passed by Congress must apply to them as well.

The trouble with all of this outrage is, none of what the email says is true!

One of the provisions written into law with the Patient Protection and Affordable Care Act (commonly known as "Obamacare") passed by Congress is the requirement that lawmakers must give up the insurance coverage previously provided to them through the Federal Employees Health Benefits Program and instead purchase health insurance through the online exchanges that the law created. The exact wording contained in the law is noted below: 

(D) MEMBERS OF CONGRESS IN THE EXCHANGE. 

(i) REQUIREMENT — Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are: 

(I) created under this Act (or an amendment made by this Act); or 

(II) offered through an Exchange established under this Act (or an amendment made by this Act).

An August 2013 ruling by the federal Office of Personnel Management (OPM) was widely and inaccurately reported as exempting members of Congress from this requirement, but,  that reporting was incorrect. Lawmakers are still required to purchase health insurance through government-created exchanges; what the OPM's ruling actually declared was that members of Congress and their staffs did not have to give up the federal contributions towards the costs of their insurance premiums which they had previously been receiving (and which are afforded to millions of other federal workers). 

There is a nice discussion about all of this at: http://www.snopes.com/politics/medical/28thamendment.asp#SWW7Rgj0DiIUEVPg.99 

Obamacare Insurance Exchanges are coming!

Very proud of my state! Washington Health Plan Finder - Starting this fall - click - compare - covered! http://t.co/63sodzlMA2
— David Lynch, M.D. (@DrDaveLynch) July 29, 2013

The pace of change in medicine

As I consider the money we waste and the millions of people in our country without access to the medical care they need, I sometimes feel impatient and frustrated that it has  taken us so long to see the change we need to actually happen. When these moods strike, I have found that a little perspective on the rate of change in medicine over the years often helps me to feel better. 

Sometimes ideas that are obviously correct, and meet stated needs still take forever to be adopted, and medical history documents that progress is usually measured by decades. Consider that it has been less than 400 years since the English physician William Harvey published his study suggesting that it was the heart, acting as a pump, that was responsible for the movement of blood throughout the body. The acceptance of this "radical theory" by the medical establishment of the day was very slow in coming, and almost 200 years had to pass before Harvey's revolutionary understanding was fully substantiated and accepted by the doctors of that time.

When the Scottish naval surgeon James Lind published his findings that citrus fruit cured scurvy in 1754, it took more than 40 years for the Navy to include lemon juice in the sailor's diet.

In our modern era, the number of medical "firsts" that have changed the practice of medicine, and improved patient health and wellness has dwarfed all of those in previous recorded history, and the promise of what can be done has never been greater. What has not changed, however, is innovation in how our society can pay for and provide care so that these benefits are available and sustainable for our citizens of all ages who need them. That is the breakthrough that our generation is called upon to make.

How To Solve Most of our Budget Problems and Improve Our Medical Care

Over the last 10 years, average wages in the United States have increased 38%, while the cost of health care has risen 131%. If other costs during my lifetime increased at the same rate, a dozen eggs would now cost $38, and a gallon of milk would be $48. Why this difference? What can we do about it? What should we do about it? That is what we should be talking about every day.

To listen to the superficial analysis of our politicians and talking heads on TV, we face a stark choice: we must either go bankrupt as a nation, or cut back on the benefits of programs like Social Security and Medicare that people have paid into for years. Are these really our only two choices?

The answer is, we do have a better way! As a family physician with over 35 years of experience, I can testify to that fact that I see copious waste in our medical care system occur every day. Every doctor can tell you the same thing, and many others have documented this waste as well. In fact, the Institute of Medicine has published information that reveals a total of $765 Billion dollars of waste in 2009. If we can solve this problem, our budget concerns go away.

So, where is this waste, exactly? Well, $190 Billion comes from wasteful administration - all of the forms and complex rules we deal with every day, that are different from plan to plan. $130 Billion comes from poor efficiency - the lack of coordination that results in tests being repeated, and one part of our system not talking well with the other. Unnecessary care cost $210 Billion dollars in 2009. These are the tests you didn't need, and the care that didn't really address what would solve the problem. Missed opportunities to prevent illness cost an additional $55 Billion dollars - flu shots,  immunizations and good primary care that was never given. Fraud was also a factor, accounting for $75 Billion in waste. Criminals need to be prosecuted and locked up.

What would a different system look like? To me, the answer is simple. It would be a system built around the actual needs of patients, that gives every person a primary care medical home to provide most of their care, and coordinate with other care givers when they are needed. Payments would be partially based on the quality of care outcomes and satisfaction of those we serve. 

If we make this choice, we will not only solve our budget problem, we will also lay the foundation for a healthy and productive population for years to come. Let's have that discussion!

What did Mitt Romney learn about health care on his trip?

 Republican presidential candidate Mitt Romney has just returned from traveling abroad, where he said he wanted to learn and listen. In Israel, he commented that Israel was a “pretty healthy nation” that spends far less on health care than the United States does. 

“Our health care costs are completely out of control,” he said. “Do you realize what health care spending is as a percentage of the [gross domestic product] in Israel? Eight percent. You spend 8 percent of GDP on health care. . . . We spend 18 percent of our GDP on health care. Ten percentage points more.”

 Did he learn something new about health care, or just drift off of his message again? He visited three countries:

United Kingdom:
Health care costs as a percentage of GDP: 9.6%
Life expectancy at birth, both sexes: 80.6 years
Infant mortality, per 1,000 live births: 4.2

Israel:
Health care costs as a percentage of GDP: 7.9%
Life expectancy at birth, both sexes: 81.7 years
Infant mortality, per 1,000 live births: 3.7

Poland:
Health care costs as a percentage of GDP: 7.0%
Life expectancy at birth, both sexes: 76.3 years
Infant mortality, per 1,000 live births: 5.0

He returns to the United States:
Health care costs as a percentage of GDP: 17.6 percent
Life expectancy at birth, both sexes: 78.7 years
Infant mortality, per 1,000 live births: 6.1

What do you think Mitt will conclude after comparing these numbers?  How about you?

What do you have wrong about Obamacare?

Obamacare has been confirmed as the law of the land, and the common belief that it was unconstitutional has been shown to be incorrect. 

The Affordable Care Act will affect all of us, so what other common beliefs that people have about  this law are also wrong? The following is a list of common misperceptions that I have observed.

Common belief: Obamacare is a government takeover of health care. 

ACTUALLY: The Affordable Care Act has no government plan. It preserves private plans and strengthens the private insurance market, making it easy to shop for a plan you like, while protecting people and their health. 

Common belief:  the law is just about insurance and not about cost. 

ACTUALLY: the law promotes new models, innovations, and research to start improving care while decreasing costs. Here in Whatcom County, the Whatcom Alliance for Healthcare Advancement (WAHA) has received one of these grants!

Common belief:  the law is just about insurance and not about health. 

ACTUALLY: the law creates a national Prevention Fund, and invests in training for doctors, nurses, and other needed health professionals 

Common belief:  the law is hurts small businesses. 

ACTUALLY: the law will help most small businesses a lot! Companies with less than than 50 employees get tax credits for up to 35% of employee health insurance 

premiums. Beginning in 2014,  tax credits rise up to 50% of insurance premiums. 

Common belief:  the law just  increases premiums and costs for families. 

ACTUALLY: health premiums were skyrocketing before the law, and this is a major reason for the law! Insurance companies will now have to explain why they are raising rates, and the reasons will be published on a publicly available website. If insurance companies don’t spend most of your premium dollars on health care, they are now required to send you a rebate at the end of the year. 

Common belief:  the law hurts Medicare and seniors. 

ACTUALLY: the law saves 600 million dollars by reducing extra payments to insurance companies, and strengthens Medicare to help seniors  afford prescription drugs, get annual checkups with no co-pays and to make Medicare work better for seniors and doctors. 

Common belief:  We can’t afford Obamacare

ACTUALLY: the law's expense replaces costs we already pay that have been going through the roof for years, and we can’t afford not to have it. The law extends coverage, promotes access to the right care, in the right place, and at the right time. This is one way the Affordable Care Act was designed to save money by keeping people healthier. 

Common belief:  The law is too complicated to understand.

ACTUALLY:  The basic facts are simple. 32 million more American citizens will be insured. There will be help for those who cannot afford coverage. Most insurance company abuses will end. We will start building a system that improves quality and controls cost for all of us.

If you want to be informed, ignore most of what you hear and visit HealthCare.gov which is an easy to use site that explains the law and how it is being rolled out. 

What do money, Winston Churchill, Obamacare and an informed public have in common?

It was Winston Churchill who noted that "The best argument against Democracy is a 5 minute conversation with the average voter". As we await the Supreme Court decision, recent events are once again proving the truth of his assertion. 


It has now been two years since this landmark legislation,  and a recent Kaiser Foundation poll shows that fewer people today know what is actually in the bill than did when it was passed! This lack of knowledge parallels the decreasing public support for the bill. What is responsible for people dumbing down? A just released New York Times article documents that opinion about the Affordable Care Act is related to the money spent on advertising by its wealthy special interest group opponents.  Consider this:  opponents of the legislation have outspent those in favor by a more than 2:1 ratio since the law was passed, and more than 3:1 in the last year. The same study notes that since July 2011 there have been 164 different attack ads produced, and only 16 in favor.


It seems clear that wild spending by monied interests can sway public opinion on this and many other matters. Can it do the same with the Supreme Court? Stay tuned.

The Affordable Care Act in Washington State - Why we need it more than ever

Over 1 million Washingtonians have no health insurance, and unfortunately, Obamacare is their only realistic hope for getting coverage. Millions more will see real benefit from important consumer protections built into the law. That is the conclusion of an important new report just released by Mike Kreidler, the Washington state Insurance Commissioner.

As the graph above shows, the lower your income, the less likely you are to have health insurance. People without insurance in Washington State are usually working, but simply earn too little to afford the medical coverage they need, even when working full time. Their employment is the gateway to their poverty, instead of a way to earn their way out. That is why medical coverage must eventually be decoupled from employment status.

Read the report itself for a county by county breakdown of what we will lose if the Affordable Care Act goes away.

What’s at stake: The Affordable Care Act in Washington state: A county‐by‐county analysis

When adequate health care was an inconceivable notion - How Our History Contributes to our Troubles Today

Why is it that we have such a contentious argument about providing an equitable system of medical care to the citizens of our country? We have already talked about the fact that our employer system of paying for insurance causes unique difficulties, but I believe that there is another, core reason for our troubles. When the founders crafted our Declaration of Independence and United States Constitution, there was no such thing as effective medical care. The average age of death at the time of our founding was in the early 40s, and there was little difference between the rich and poor. Indeed, those who could afford medical care in those days were often treated barbarically, and a good case can be made that the net effect of such care was deleterious and not helpful. The Father of Our Country, George Washington himself, died at home in his bed in Mt. Vernon from the complications of a strep throat. In other words, the same people who proclaimed  "that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness " would never have thought of the fact that access to life saving medical care might be a right that would follow from this assertion. 


Today, we understand that in order to enjoy our constitutional rights and fully participate in a democratic society, we need and deserve access to basic health care services. It seems ironic to me that our effort to ensure that our citizens are healthy and able to strive for their rights of  "Life, Liberty and the Pursuit of Happiness" will be judged on the basis of a document that has its origin in a time where adequate health care was an inconceivable notion. The Supreme Court will be thinking about interstate commerce, the rights of the states and the federal governments ability to regulate. They will have no guidance from our Constitution on why the inadequate access of millions of citizens to modern health care serves as a denial of their most basic, "unalienable rights". 

Is it time to end employer sponsored medical insurance?

It has been more than a little hard to follow the politics of the healthcare reform "debate" over the last few years. Sponsors of reform have been treated to accusations of death panels, the President has been portrayed as a Nazi and republicans have uncharacteristically complained that money saving measures were an attempt by President Obama to "gut Medicare". Now, the strangest twist of all may be the new proposal from Sen. Roy Blunt (R) Missouri. Simply stated, the "Blunt Amendment" would allow employers who provide insurance coverage and insurance companies themselves to refuse coverage of any health care service required under the new health care law if they feel it violates their “religious beliefs or moral convictions.”  Wow. 
Unfortunately, this phenomenon is uniquely American. 
Coverage of contraception services, for example, has been a settled issue in the majority of our states, supported by both democrats and republican legislators for almost 40 years. Other countries, even predominantly Roman Catholic nations such as Spain and Italy, also provide contraception coverage, and they do not have the conservatively devout trying to end the coverage! The difference is that our way of doing things revolves around the unique way that medical insurance is sponsored in the United States, and that is our reliance on employers to sponsor private insurance options for their employers. 
As I witness this debate, I can't escape the feeling that the only way to end this kind of messy politics may well be to end our dependance the private insurance system itself. We can't have it both ways. If private employers and plans can pick and choose conditions and services to pay for, then the rights of those covered to follow their own conscience and make their own choice is impossible. Diseases felt to be due to an unhealthy lifestyle, for example, might join contraception as prohibited items to cover. The result would be chaos and anything but a just and equitable situation.
It would be ironic in the extreme if the immoderate rhetoric used by the extreme right to oppose efforts to improve our system actually led us to a true national health insurance system such as Medicare for all. President Obama's efforts to compromise on this issue for the passage of the Affordable Care Act may still lead us to a government plan. 

Washington State Medical Association (WSMA) supports the Washington State Health Benefits Exchange

The Washington State Medical Association (WSMA) has announced support for the Governor’s requested legislation on the Washington State Health Benefits Exchange (SB 6178/HB 2319), authorized by the Affordable Care Act. WSMA testimony before the Senate Health & Long-Term Care Committee and the House Health Care and Wellness Committee made the following points:
 
·         The WSMA supports an Exchange that promotes the purchase of health insurance, ensures administrative simplification, ensures patients have access to local providers, provides coverage for key benefits and promotes the viability of physicians and their medical practices.
·         Qualified Health Plans - Any decisions to expand Qualified Health Plan standards should be analyzed carefully with mindfulness towards barriers that can limit access to affordable health coverage.
·         Market Rules - The exchange must be stable and sustainable. Market rules imposed should keep an eye on affordability for patients and the viability of medical practices.
·         Powers of the Exchange Board and the Office of Insurance Commissioner (OIC) - In regulating the Exchange, the Board must be responsive to the interests and needs of Washington’s physicians and consumers. Policies that drive payment rates down to Medicaid levels will jeopardize access to care.
·         Washington High Risk Insurance Pool - WSMA supports operation of the WSHIP for patients who are most vulnerable. Consideration should be given towards keeping it open past January 1, 2014.
 
In my view, this common sense input is important advice to heed that will make our Washington State Health Benefits Exchange strong, sustainable and useful.

Announcement from Larry Thompson, Director of the Whatcom Alliance for Health Care Access

A momentous accomplishment for our community that will go a log way to assist in our work to build a safe, efficient and effective Accountable Care Organization for Whatcom County.

"I am pleased to announce that the Center for Medicare Services (CMS) has recommended the Whatcom Alliance for Health Care Access (WAHA) for award of funds under the Care Transitions program (Project Impact). There are conditions on this award which have not yet been shared with us. We are scheduled to review these conditions by phone with CMS on January 17.

This is a multi-year award which carries with it up to $5.7 million to reimburse us for the cost of assisting patients to make safe transitions between care settings.

As you can appreciate, this is one key piece of several funding awards we must secure to fully implement the vision called for in our Phase I ACO work. On the other hand, the scale of the award relative to the current WAHA budget will present us all with stewardship and management challenges.

I would like to take this opportunity to thank our many community partners in this venture without whom this effort is merely a shell. As well, please join me in thanking our staff, especially Elya Moore, whose hard work and inspiration led to this success.

Larry Thompson"

3 Principles that can bring us together for meaningful healthcare reform

The usual discussion about health care reform often resembles a food fight in middle school. Insults pass for argument, and facts get ignored or selectively presented only when they bolster one's opinion. What would it look like if we talked about what we all truly care about. Could we have a different discussion?

When I have discussed this issue with others in my community, there are 3 important principles that seem to ring true with most of us.

First, we need to invest  in "us" and the future we want to build. If we envision America as a successful land of opportunity, it means that we need a healthy workforce, able to compete and healthy students able to learn new skills. Our investment now in an equitable system that allows that to happen is simply a requirement needed to  make it so! This future will not happen by accident, and our failure to act now will doom our next generation to a future much different than we would like for them.

Secondly, we must end waste! It makes no sense to spend money on treatments that do not heal, or on complicated paper work that drives up costs. Fraud must be eliminated. Research on how to improve care must be supported, and the public should see the benefits!

Finally,  we need to end cost shifting, and share the burden fairly. Medical pricing today makes no sense. The cash paying person is charged the most. Hospitals overcharge for some things to pay for what is not covered. Some people get a tax break on insurance and some do not. A healthy society needs every one to be covered, and the cost must be affordable for all, or our society will remain broken and care will remain out of reach for many.

A Twitter Debate about Health Care reform

I had an interesting experience after  I used Twitter to note and lament the resignation of CMS Director Dr. Donald Berwick.  Craig Casey, an insurance agent in San Diego, sent several "tweets"disparaging Dr. Berwick and taking issue with"Obamacare". It is impossible for me to tweet an adequate reply to Craig, so I am using this column to reply point by point:
20+ million more on Medicaid equals Dr. shortage in / or rationing. you have elderly relatives Dave? 
This statement assumes that these folks were not receiving care before, and that suddenly they will now show up! The reality is, however, that they have been  seen for expensive and uncoordinated care in emergency rooms, and for complications due to no consistent primary care access. Obamacare will shift that to early primary care, and yes, we will need more folks to provide that care as things change.
Quoting his own comments about #Healthcare #rationing, he committed political suicide, no assassination. Good bye Obamacareite. Actually, Dr. Berwick has been a tireless advocate of safety in health care as head of the Institute for Health Care Improvement, and he has always focused on the patient and how we need to work together to achieve better outcomes of care. This work takes study and organization, which has caused him to step on a few toes in the insurance industry and elsewhere. This has lead to pressure by republicans in Congress to make his confirmation impossible. He should be proud of who his enemies are. Organized medicine has supported him completely.
The cost curve was bent upwards, health #insurance rates have jumped 20% since #Obamacare was passed UNaffordable care act. This is just not true. Insurance rates have been going up at an astronomical rate for years. The Employer Health Benefits Survey by the Kaiser Family Foundation, which specializes in health care issues, found that health insurance premiums have jumped by 9 percent in 2011. Drew Altman, president and CEO of Kaiser, said that the premium increase was not because of Obamacare but that the Obamacare law accounted for 1 to 2 percentage points. He noted, “It reflects the costs of covering young adults up to 26 years of age under their parents’ policies" and also "the costs of providing prevention benefits without cost-sharing". We can actually expect cost savings later from these measures!
Not when their reimbursement rates are being cut by the false promises of coverage via #Obamacare. This makes no sense to me. There is a problem at present due to the fact that Medicare rates are due to decrease 27%, because of the flawed update formula from years past, but that has nothing to do with Obamacare.
Since you And Berwick brought it up, MedPAC, IPAB, & CER. #Rationing equals #deathpanels. disprove it then. This is nutty talk. The reality is that we ration care now, and always have, by ability to pay. Even people with insurance are now often having trouble affording care. If we don't start paying for health care based on quality instead of volume, and work together to organize and provide services that we all need for a healthy and productive society, more of us will be priced out of needed care ever year. That is not an outcome that we can afford.