Supreme Court leaves 'Healthy San Francisco' program to its own success

Healthy San Francisco, the city’s healthcare-for-all program, remains firmly in place after the Supreme Court’s dismissal of a suit by the Golden Gate Restaurant Association last week. It may or may not be the model for everywhere else, but a lot of reassured folks here are happy with it. Many are also healthier in the bargain. PBS NewsHour correspondent Spencer Michels talked with several Healthy SF participants for last night’s report, while outlining how the program is working.

Until recently, San Francisco, a diverse city with a population of nearly 800,000, had more than 60,000 adult residents with no health insurance. They were not poor enough for Medicaid, nor old enough for Medicare.

While the nation struggled with reforming health care, this city began a program of its own that so far has enrolled more than three-quarters of its uninsured. It’s called Healthy San Francisco, and it is not, strictly speaking, health insurance. Rather, it’s a way to provide health care, but only within the city limits.

The plan was not particularly radical. It used mostly existing resources, like city clinics and nonprofit hospitals, to supply and coordinate care. Instead of flitting from one clinic or emergency room to another, enrollees choose a medical home, one of 30 public or private health centers in the city, where they go for low- or no-cost health care.

Once you choose your “medical home,” you can’t walk into another and get treatment. But the two Healthy San Francisco participants this writer asked (along with the patients and clinic directors Michel featured on the PBS show) indicate that customer satisfaction with the system — and with their one medical home — is high.

As to the costs, and who covers them, most San Franciscans other than the restaurant owners are fine with the plan. Restaurant-goers have gotten used to the friendly, small-print message at the bottom of the menu that lets them know an amount added to the tab goes to help pay for Healthy SF.

Each patient in Healthy San Francisco costs the city about $300 per month. That’s in line with insurance costs. It totals $126 million a year.

Depending on their income — and most are below the poverty level — enrollees pay nothing or from $20 a month up to about $200, plus co-payments. But that doesn’t pay for it all. The city has mandated that businesses with 20 to 100 employees spend at least $1.23 an hour per worker for health care, and that larger companies pay more.

That money can be used to reimburse employees for health care costs, to buy them health insurance, or it can go to Healthy San Francisco.

The Restaurant Association’s argument before the Supreme Court was not on Constitutional grounds, but rather that the city’s mandate that employers pay into the program violated federal law. The Court declined to deal with it all; the mandate stays. Susan Currin, CEO at San Francisco General, says emergency room use is slightly down. Director Hali Hammer of San Francisco General Hospital Family Health Center (one of the more popular medical homes) says they have hired new providers and expanded hours. The number of participants is growing at about 700 per week, and the Kaiser Family Foundation recently found that 94 percent of those participants are satisfied with the program. Paying that small extra amount for dinner out makes at least a few of us occasional diners-out feel a slight good-citizen glow. Something’s working.

San Francisco Ramps Up Care for City’s Uninsured | PBS NewsHour | Oct. 12, 2009 | PBS.

Best city for geezers? NY lays claim

Landscape photo of Statue of Liberty in the af...
Image via Wikipedia

New York City seems to be all aglow in being named by the World Health Organization to its Global Network of Age-friendly cities. As Clyde Haberman reported about the event in the July 1 New York Times,

“It makes us members of a club of people who are struggling, in their own and perhaps much different ways, with learning about and thinking about and approaching this issue,” said Linda I. Gibbs, the deputy mayor for health and human services. “It’s really a lovely recognition.”

One reason for the acknowledgment was a plan that city officials and the New York Academy of Medicine announced last year to improve life for older New Yorkers. All sorts of ideas were put forth, on matters like transportation, housing, health care, job training, nutrition and cultural activities. To a large degree, it was more a wish list than a concrete program. But at least it showed that the city was thinking about issues that will only become more dominant.

Like other cities, New York has a population that is aging, if you will forgive a somewhat meaningless word that we are stuck with. After all, everyone is aging. It’s called living. The only people not aging are dead.

WHO says, of its Global Nework of Age-friendly Cities, that the problem lies with the fact that too many of us are aging and not dying.

Populations in almost every corner of the world are growing older. The greatest changes are occurring in less-developed countries. By 2050, it is estimated that 80% of the expected 2 billion people aged 60 years or over will live in low or middle income countries. The Network aims to help cities create urban environments that allow older people to remain active and healthy participants in society.

To that end, the Network got off the ground a few years ago, and now lists a few cities across the globe as having been accepted for membership. This week’s bulletin (excerpted above and below) lists the Big Apple as the first U.S. member, although the PDF of member cities also lists Portland, and one has to wonder how Portland’s going to feel about all of New York’s hoopla.

The WHO Age-friendly Cities initiative began in 2006 by identifying the key elements of the urban environment that support active and healthy ageing. Research from 33 cities, confirmed the importance for older people of access to public transport, outdoor spaces and buildings, as well as the need for appropriate housing, community support and health services. But it also highlighted the need to foster the connections that allow older people to be active participants in society, to overcome ageism and to provide greater opportunities for civic participation and employment.

The Global Network builds on these principles but takes them a significant step further by requiring participating cities to commence an ongoing process of assessment and implementation. Network members are committed to taking active steps to creating a better environment for their older residents.

A few years ago (2006) the Sperling’s Best Places people came out with a “Best Cities” list about which do the best job of caring for their aging folks. The “Best Cities for Seniors” study examined the state of senior care in the 50 largest metropolitan areas in the United States.

“This is different from the usual studies of retirement living,” said Bert Sperling, the study’s primary author. “When we first retire, we have the energy for traveling and sightseeing. At some point, we will all need specialized resources and facilities to help us cope with aging. That’s what this study examines.”

This unique new study, produced in partnership with Bankers Life and Casualty Company, identifies cities that offer the best resources for less active seniors. The study analyzed nearly 50 categories such as various senior living facilities, comprehensive medical care, specialized transportation services, and a significant senior population.

Top Ten Cities for Seniors

  1. Portland, OR
  2. Seattle, WA
  3. San Francisco, CA
  4. Pittsburgh, PA
  5. Milwaukee, WI
  6. Philadelphia, PA
  7. New York, NY
  8. Boston, MA
  9. Cincinnati, OH
  10. Chicago, IL

Haberman takes issue with that ‘Senior’ word along with the ‘aging’ word. “What does that make the rest of the populace — juniors?” This space (an unabashed fan of Sperling’s #3 city — sorry, #7; but you’re my #2) concurs. But Great Geezer Towns probably wouldn’t cut it with WHO.

On being treated to death – Part II

Is there a fate worse than death? Yes. In the U.S., often it is the fate of dying slowly: aggressively treated, over-treated and worn down by the system until that fate has made death truly a blessed relief.

Deborah Wright, an ordained Presbyterian minister and writer now working in secular fields while simultaneously serving as personal pastor to many, forwarded an article that proves out the fate-worse-than-death highlighted in this and recent other articles (see June 25 post below.) The fact that stands out, she comments, is that “the length of time we use palliative care services is growing shorter — because we start it too late.”

We start palliative care too late, we treat too aggressively and too long. The opening story in AP writer Marilynn Marchione’s thoughtful, poignant article just published in Daily Finance serves as a classic example:

The doctors finally let Rosaria Vandenberg go home.

For the first time in months, she was able to touch her 2-year-old daughter who had been afraid of the tubes and machines in the hospital. The little girl climbed up onto her mother’s bed, surrounded by family photos, toys and the comfort of home. They shared one last tender moment together before Vandenberg slipped back into unconsciousness.

Vandenberg, 32, died the next day.

That precious time at home could have come sooner if the family had known how to talk about alternatives to aggressive treatment, said Vandenberg’s sister-in-law, Alexandra Drane.

Instead, Vandenberg, a pharmacist in Franklin, Mass., had endured two surgeries, chemotherapy and radiation for an incurable brain tumor before she died in July 2004.

“We would have had a very different discussion about that second surgery and chemotherapy. We might have just taken her home and stuck her in a beautiful chair outside under the sun and let her gorgeous little daughter play around her — not just torture her” in the hospital, Drane said.

Marchione tells other stories of patients who might have had far more peaceful final days — and of patients who chose extensive, aggressive or experimental treatment for a variety of reasons. It should be the individual’s choice. But the reality is that discussion of palliative care or hospice care (there is a difference: hospice involves declining further treatment; with the newer “palliative care” concept some therapies may be continued) simply doesn’t happen until too late. If it happened sooner, many of us — likely including Rosaria Vandenberg — would choose hospice care over aggressive end-of-life treatment.  But physicians are too busy talking treatment, and patients have not considered their other choices. Comfort and peace lose to the system.

An article posted today on the website of the National Hospice and Palliative Care Organization points the finger in the right direction, right at you and me. If we took the time and energy to write our advance directives, and talk them over with family and friends, millions of days of suffering and millions of wasted dollars would be saved.

Recent media coverage on the challenges patients and families face with overtreatment of a life-limiting illness brings the issues of hospice and palliative care and advance care planning to public attention.

“It’s important to remember that quality of life and a patient’s personal wishes, beliefs and values must be a factor when making care decisions brought about by a serious or terminal illness,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization.

“Discussions helping patients and families understand the many benefits of hospice and palliative care must be more common and held long before a family faces a medical crisis,” Schumacher added.

Advance care planning—which includes completing a living will and appointing a healthcare proxy—is somewhat like planning a road trip to an unfamiliar destination.  Very few people would expect to get to a destination safely and comfortably without having a well-thought-out map in hand.   Yet, it’s estimated that 70 percent of Americans have not completed a living will.

  • A living will charts the course for your healthcare, letting your family and health care providers know what procedures and treatments you would want provided to you—and under what conditions.
  • A healthcare proxy or healthcare power of attorney form, allows you to choose someone you trust to take charge of your healthcare decisions in case you are unable to make those decisions yourself.
  • Advance directives can be changed as an individual’s situation or wishes change.

Still, you and I put it off. Or you may be putting it off, at least, and if so you are taking an absurdly unnecessary risk. You could, instead, download free forms, fill them out and avoid that risk.

Deborah Wright has shepherded countless friends and family members through their final days, and knows what a blessing hospice and palliative care can be. Problem is, though, “we start it too late.”

Americans are treated, and overtreated, to death – DailyFinance.

Life: does longevity trump quality?

“We have to get out of the way,” she said; “make room for other, new people on the planet.” Accomplished author/editor Cyra McFadden, at a recent dinner party, was talking about a group of women scientist friends’ excitement over discoveries they have made which show promise of extending life a fraction longer. Cyra was in fierce, though silent, disagreement.

It may be time for those of us who disagree with the rampant prolong-life-at-all-costs theories  to stop being silent.

Americans are, in fact (as reported in Epoch Times below, and elsewhere) living longer all the time. Sometimes that’s just fine, especially if we’re in reasonable health. But what if we’re not? What if we’d just as soon be getting on with whatever follows this temporary time on earth? Millions and millions of people are living for hours, days or extended months and years in circumstances they would not choose simply because we have created a culture that says we must be kept alive no matter what.

Average life expectancy continues to increase, and today’s older Americans enjoy better health and financial security than any previous generation. Key trends are reported in “Older Americans 2008: Key Indicators of Well-Being,” a unique, comprehensive look at aging in the United States from the Federal Interagency Forum on Aging-Related Statistics.

“This report comes at a critical time,” according to Edward Sondik, Ph.D., director of the National Center for Health Statistics. “As the baby boomers age and America’s older population grows larger and more diverse, community leaders, policymakers, and researchers have an even greater need for reliable data to understand where older Americans stand today and what they may face tomorrow.”

Where do we stand right now? Well, the same source that says we’re living longer and enjoying better health and financial security (hmmmm on the financial security business) reveals that Americans are “engaging in regular leisure time physical activity” on these levels: ages 45-64: 30%; ages 75-84: 20%; geezers 85 and over: 10%. Hello? Better health and financial security, just no leisure time physical activity? Could it bear some relationship to obesity factors in the same data: 30+% for men, 40+% for women?

Does living well need to be assessed in the compulsion to live long? Why not? Everyone should have the right to live at whatever weight and whatever level of inaction he or she chooses. But the system is weighted toward keeping us alive under all conditions, and bucking the system is not easy. A poignant, wrenching tale of her father’s slow decline and death — and her mother’s refusal to go down that same path — was recently told by California writer/teacher Katy Butler in the New York Times Sunday Magazine.

Almost without their consent, Butler’s gifted, educated parents had their late years altered to match the system’s preferences:

They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.

Given the limitless sources of victimization floating around, we should not have to add just-try-to-keep-them-alive-forever health care to the list.

My husband and I, having long ago signed advance directives with additional specific issues sheets (“If this happens, do that; if that happens, don’t do this,” etc) recently got them out and talked things over again, a very good thing to do for EVERYbody over 18. We will add dementia provisions to the existing documents while we can remember to do that (the closest you can come to avoid being warehoused in a memory-loss facility for umpteen years.) We are clear, and our friends and family understand, about having no interest in hanging onto life in a greatly diminished state if such an opportunity presents itself; for increasing thousands, it presents itself every day.

All this being said, there’s still a reasonable chance that I’ll be out of town one day when I’m in my 80s (which aren’t that far off), get wiped out by a speeding cyclist and picked up in a seriously mangled state by the paramedics, taken to a hospital that’s not Kaiser (which has all my directives on file,) miraculously brought into some heavily-sedated state of being because the hospital doesn’t consult Kaiser or the living will registry (which also has my directives) and kept alive by assorted mechanisms. By the time my husband or children get there to insist everything be unplugged — which of course will involve long hours and possibly court action — hundreds of thousands of dollars will have been needlessly spent.

I consider myself a highly valuable member of society, and my life a gift from God. But would those dollars not be better spent on a few kids needing specialized care?

Epoch Times – Americans Are Living Longer, According to Federal Report.

Your doctor's in shape… but may just be getting in shape to retire

U.S. doctors as a group are “leaner, fitter and live longer than average Americans… male physicians keep their cholesterol and blood pressure lower… women doctors are more likely to use hormone-replacement therapy than their patients,” according to several recent surveys.

That’s the good news.

The bad news is that they are taking all this health and fitness into early retirement. And thanks to the hordes of baby boomers hanging up their stethoscopes for good, finding enough doctors in any shape at all is going to be a challenge, particularly in light of the numbers of newly insured.

Nearly 40 percent of doctors are 55 or older, according to the Center for Workforce Studies of the Association of American Medical Colleges. Included in that group are doctors whose specialties will be the pillars of providing care in 2014, when the overhaul kicks in; family medicine and general practitioners (37 percent); general surgeons (42 percent); pediatrics (33 percent), and internal medicine and pediatrics (35 percent).

About a third of the much larger nursing workforce is 50 or older, and about 55 percent expressed an intention to retire in the next 10 years, according to a Nursing Management Aging Workforce Survey by the Bernard Hodes Group. New registered nurses are flowing from colleges, but not enough to replace the number planning to leave the profession.

“Moving into the future, we see a very large shortage of nurses, about 300,000,” said Peter Buerhaus, a nurse and health-care economist and a professor at Vanderbilt University. “That number does not account for the demand created by reform. That’s a knockout number. It knocks the system down. It stops it.”

According to the census, baby boomers include the 66 million Americans born between 1946 and 1964.

In an article for the Journal of the American Medical Association, Buerhaus and colleagues Douglas Staiger and David Auerbach predicted that there will be at least 100,000 fewer doctors in the workplace than the 1.1 million the federal government projects will be needed in 2020 under the health-care overhaul.

“There’s a much more rapid retirement of physicians,” Buerhaus said. “What does this retirement mean? This will mean at least 100,000 fewer doctors in the workplace in 2020.”He said the article does not estimate the change in demand or the level of recruitment by medical colleges, which is being beefed up significantly under the health-care law.

Although current studies involve more than a little conjecture — Will professions in the medical field continue to be as attractive as other areas? Will doctors and nurses work longer if truly needed? — there is no doubt about the coming shortage.

Lori Heim, president of the American Association of Family Practitioners, said someone might soon have to replace her. “My age group is looking at when we are going to retire,” said Heim, who is 54. “More physicians are changing their practice, doing things that have less calls. They want administrative roles.”

Heim said her statement is based on an impression. “I haven’t seen any numbers on this.” But, she said, her association is among the many that for years have pointed out the shortage of primary care doctors and nurses to the White House and Congress.

Staying healthy might be the best defense.

Retirements by baby-boomer doctors, nurses could strain overhaul.

Abortion foes are winning, folks

WASHINGTON - JANUARY 22:  A pro-choice advocat...
Image by Getty Images via @daylife

Will women in the U.S. soon be unable to have a safe, legal abortion? That scary possibility becomes more likely every day. Does anyone really understand the pre-Roe v Wade horrors which abortion foes want to see returned? Not really. That’s because huge numbers of women who could have told the horror stories died at the hands of back-alley abortionists, and those of us who did survive are dying off fast, unheard.

This space welcomes writer John Leland’s front page article in today’s New York Times to the voices crying in the wilderness — just in case someone other than Nancy Keenan might care to listen.

At least 11 states have passed laws this year regulating or restricting abortion, giving opponents of abortion what partisans on both sides of the issue say is an unusually high number of victories. In four additional states, bills have passed at least one house of the legislature.

In a flurry of activity last week, Gov. Haley Barbour of Mississippi signed a bill barring insurers from covering abortion in the new insurance exchanges called for under the federal health care overhaul, and the Oklahoma Legislature overrode a veto by Gov. Brad Henry of a bill requiring doctors who perform abortions to answer 38 questions about each procedure, including the women’s reasons for ending their pregnancies.

It was the third abortion measure this session on which the Legislature overrode a veto by Mr. Henry.

At least 13 other states have introduced or passed similar legislation this year. The new laws range from an Arizona ban on coverage of abortion in the state employees’ health plan to a ban in Nebraska on all abortions after 20 weeks, on the grounds that the fetus at that stage can feel pain.

Fetal pain is a subject of debate in the medical community, and the United States Supreme Court has recognized the government’s right to ban abortions only after a fetus becomes viable, which is more than a month later.

“Fetal pain” is just one ploy; its determination can easily go from 20 weeks backward to ban the morning-after pill. Other ploys? Forcing a pregnant woman to look at ultrasound pictures, prohibiting a physician from discussing fetal abnormalities with his/her patient, and “in Utah, after a pregnant 17-year-old paid a man $150 to beat her in an effort to induce a miscarriage, legislators passed a law that would allow a woman in such circumstances to be charged with homicide.”

Unwanted pregnancies happen. When they do, the man involved can simply walk away, as countless millions have done and will continue to do. Why, then, should so many men purporting to have such omnipotent wisdom be empowered to eliminate a woman’s right to choose what happens to her body?

It’s going to get worse. Unless people — and that includes males of the species who still have brains and some concern for the future of womankind — start paying attention, and standing up to the fundamentalists of all stripes, the U.S. Conference of Catholic Bishops and the religious factions who claim authority over all women, it’s going to get worse than many people in today’s society can even begin to imagine.

Opponents of Abortion Advance Cause at State Level – NYTimes.com.

Abortion foes winning with fear tactics

This is the way abortion rights end (apologies to T.S. Eliot): not with a bang, but with something worse than a whimper. The steady, relentless chipping away of those rights, state by state. And where a straightforward denial of women’s rights might face opposition, abortion foes are stooping to emotion-twisting, privacy-invading, fear-inducing tactics the likes of which have not been seen in a half century.

The “pro-lifers” (which is to say, the people who worry about some potential, unwanted life but don’t give a tinker’s dam for the lives of grown — often just barely grown — women) want abortion absolutely banned in this country. They are pushing closer to that goal every day. They like to talk about “protecting the unborn,” but the big losers in this dangerous game will be those who most need protection: poor, disadvantaged, un-empowered women.

New York Times editorial writer Dorothy Samuels offered a sharp overview of the dangerous times ahead for women’s rights, after reporting on a recent lunch celebrating the 40th anniversary of New York’s becoming the first state to fully legalize abortion. That law, Samuels notes, “began to reduce the death and injury toll from back-alley abortions and set the stage for the Supreme Court’s Roe v. Wade decision in 1973, which made abortion legal nationwide and recognized a constitutional right to privacy.

But abortion-rights groups are newly anxious about new assaults on women’s reproductive rights, including a fight over abortion that snarled the last days of the health care reform debate. Anti-abortion groups are newly emboldened.

The health care reform law contains advances for women’s reproductive health care, including enlarged access to insurance coverage for maternity care, contraception and other services. But President Obama and pro-choice Congressional lawmakers made abortion coverage vulnerable as part of the effort to secure the measure’s passage.

Kelli Conlin, head of Naral Pro-Choice New York, told guests at the lunch that “anti-choice forces are mobilizing in every single state to limit a woman’s access to abortion in more insidious ways than we can imagine.”

As Ms. Conlin was speaking, members of the Oklahoma House were getting ready to override vetoes of two punishing abortion measures. The state’s Democratic governor, Brad Henry, rightly viewed these intrusions into women’s lives and decision-making as unconstitutional.

One of the measures, which seems destined to spawn copycat bills in other states, requires women to undergo an ultrasound before getting an abortion and further mandates that a doctor or technician set up the monitor so the woman can see it and hear a detailed description of the fetus.

The other law grants protection from lawsuits to doctors who deliberately withhold fetal testing results that might affect a woman’s decision about whether to carry her pregnancy to term.

Several states have either passed or are considering bills that would ban abortion coverage in insurance plans sold through the state exchanges established by the federal health care law.

A new Utah law criminalizes certain behavior by women that results in miscarriage. Embarking on a road that could lead to the Supreme Court, Nebraska last month banned most abortions at the 20th week of pregnancy based on a questionable theory of fetal pain.

About two dozen states are looking at bills to increase counseling requirements or waiting periods prior to abortions. About 20 states are considering new ultrasound requirements. This is on top of an already onerous regimen of state restrictions that has drastically cut down on abortion providers and curtailed a woman’s ability to exercise a constitutionally protected right.

Draconian laws will not stop unintended pregnancies. Once abortion foes succeed in eliminating a woman’s right to privacy and ability to make her own, often difficult, choices the lucrative business of back-alley abortions will once again thrive. And women will die.

Editorial Observer – A Spreading Peril for Women’s Privacy and Freedom – NYTimes.com.