Washington State Senator Maureen Walsh (R-Walla Walla), became a national headline this week for alleging that “[nurses] probably play cards for a considerable amount of the day” during debate on legislation mandating break periods.  Many nurses have mailed decks of cards to Senator Walsh and posted pictures of blood-spattered emergency department walls in order to call attention to “last night’s card game,” driving home the point that they aren’t “playing” anything at work. 

  

Senator Walsh has since apologized.  But the mistaken beliefs which underlie her statements should not be overlooked.  Many politicians are out of touch with everyday Americans.  This is not about one legislator, one legislative body, or even one political party. 

This is about the safety and protection of healthcare professionals and their patients. And it is time for the public to pay attention to the disrespect of nurses and other healthcare professionals. 

The purpose of Senate Bill 1155 was to guarantee uninterrupted meal and rest periods for nurses and medical technicians working in hospitals.  This piece of legislation was important and necessary, especially after the tidal wave of hospital consolidation that swept the nation over the past few years.  Senator Walsh believed this mandate was financially burdensome for rural hospitals so argued for exempting critical access hospitals with fewer than 25 beds.  While debating to include this amendment to the bill, she earned the contempt of every nurse and physician in the country. 

The viability of rural hospitals, fighting to remain financially solvent despite implementation of additional mandates, must be balanced with the need for nurses working 12-hour shifts to have protected time for meals or breaks.  Both are important and a viable resolution exists somewhere in between.   Sacrificing meals and breaks for nursing staff already dangerously spread thin is not the solution to keep rural hospitals afloat.   And indeed, Senate Bill 1155 passed with bipartisan support and will now head to the Governor’s desk for signing. 

The Senator’s condescending statements about the work ethic of nurses reveals that their role in healthcare is misunderstood and underappreciated.  Nurses have an impossible job.  They assume the primary responsibility for continuouscare of the sick, the injured, the disabled, and the dying.  The nursing profession is quite literally, the “super glue” which holds the healthcare system together. Every aspect of medical care depends upon collaboration with nurses. Nurses are among the hardest working healthcare professionals and deserve our reverence and gratitude.  Furthermore, nurses improve the health of individuals, families, and their communities.

Senator Walsh has exposed the fact that both federal and state legislators have become overconfident in their ability to reform healthcare.  In reality, it is an industry sector most politicians know little about.  In fact, Senator Kirsten Gillibrand (D-NY) and Senator Cory Gardner (R-CO) recently introducedlegislation to limit the ability of doctors to prescribe opioid medications for more than seven days --even when deemed medically necessary. The hubris of this approach seems to be growing across the legislative branch while reasonable concerns voiced by front-line health professionals are largely ignored. 

Winston Churchill said, “You can always count on the Americans to do the right thing after they have tried everything else.” This sentiment echoes the tactics of lawmakers more so today than at any other time in our history.  Legislators--who have never attended nursing or medical school and have no training or competency—repeatedly attempt to influence healthcare policy without possessing an adequate knowledge base to know what is best.  At the same time, lawmakers appear to prioritize the needs of special interest groups over implementation of real, common-sense solutions. 

We will all be patients eventually.  Our lives will depend on the care provided by skilled and conscientious bedside nurses.  We should hold our elected officials accountable when they disparage the role of healthcare professionals in delivering high quality healthcare to the patients they serve.  But Senator Walsh is just a symptom of a larger problem.  There is no replacement for the real-life experience and expertise that front-line health care professionals can provide. To repair the broken healthcare system, lawmakers should stop trash talking healthcare professionals and focus on representing the needs of their constituents.  Nurses save lives.  Nurses are irreplaceable.  And politicians would do well to remember that. 

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Medicare is a national health insurance program which provides health insurance for Americans aged 65 and older, and those who are disabled or have specific chronic conditions. Medicare covers 17 percent of the U.S. population, including the nation’s oldest, sickest, and most disabled citizens. Medicare has achieved two important goals: ensuring access to health care for elderly and disabled citizens, and protection from the financial risks associated with health care.  By ensuring access, Medicare has contributed to a five-year increase in life expectancy after age 65.

Before implementation of Medicare in 1966, 48 percent of Americans 65 and older had no insurance; today, that figure hovers at 2 percent. Older Americans used to cover 56% of their health care expenses directly out-of-pocket, today, they pay only 13 percent.  Medicare is funded through a combination of a payroll tax, beneficiary premiums, co-pays and deductibles, and U.S. Treasury revenue; it is administered by the Centers for Medicare and Medicaid Services (CMS.)

Medicare is divided into four Parts. Part A covers hospital costs, skilled nursing, and hospice services. Part B covers physician and other clinical outpatient services.  For both A and B, there are copays and deductibles, as well as gaps in insurance coverage.  There are no annual out-of-pocket spending limits for Parts A and B, therefore supplemental coverage, known as Part C, protects from financial hardship. 

Medicare has significantly improved the well-being of citizens over 65 years of age.  

The single greatest threat to long-term survival of the Medicare Program is runaway costs, an issue which must be addressed before expanding the program to all of us. Between 1970 and 2013, spending per Medicare beneficiary increased 500 percent from $385 to $12,210, or 0.7 to 3.5 percent of GDP.  Current projections predict that Medicare spending will make up 5.1 percent of GDP by 2030. 

At the same time, researchers at the Dartmouth Institute for Health Policy and Clinical Practice estimated 30 percent of all Medicare spending and could be avoided without worsening clinical outcomes. According to the Congressional Budget Office, eliminating this waste could save as much as $700 billionannually.

Some bipartisan measures that might contain costs include: funding additional primary care physician residency positions, eliminating accountable care organizations, and allowing Medicare to negotiate drug prices with pharmaceutical companies.

First, the Balanced Budget Act of 1997 capped the number of residency slots in teaching hospitals which were eligible for Medicare payments. This mistake has facilitated a shortage of primary care physicians across the country.  A larger supply of primary care physicians is associated with a lower mortality rate. In fact, adding 10 primary care physicians per 100 000 population increases life expectancy by nearly two months, whereas the same increase in specialty physicians only improves life expectancy by 19 days. U.S. Senators Bob Menendez (D-N.J.), John Boozman (R-Ark.) and Chuck Schumer (D-N.Y.) introduced the Physician Shortage Reduction Act of 2019 to increase Medicare-supported doctor training slots by 15,000.  Investing in primary care reduces overall expenditures by lessening morbidity and mortality; at the same time, this legislation would address the physician shortage and improve access to care for patients. 

Second, in 2008, the Congressional Budget Office (CBO) warned Congress that Accountable Care Organizations (ACO) would not save Medicare dollars, yet the Affordable Care Act required CMS to establish them within Medicare. ACO’s—similar to HMO’s –use narrow networks in an attempt to control cost yet bear considerable financial risk, because pay is on a per-enrollee basis with the obligation to provide all medically necessary services for enrollees.

After nearly a decade, studies consistently demonstrate that ACOs fail to achieve cost reduction, just as predicted.  Universal care plans must strike a balance between a free market and government regulation necessary to protect patients.  By eliminating the ACO construct, patients and private businesses will flourish.

And finally, federal law prohibits Medicare from negotiating prices for prescription drugs with pharmaceutical companies in order to reduce costs for nearly 43 million seniors enrolled in Medicare Part D.  U.S. Senator Tammy Baldwin (D-WI) and Senator Amy Klobuchar (D-MN) have reintroduced the Empowering Medicare Seniors to Negotiate Drug Prices Act. Enabling the federal government to negotiate for reduced drug prices is a policy supported by a majority of Democrats (96%), Republicans (92%), and Independents (92%).

Over the last 50 years, Medicare has improved the delivery of healthcare services for nearly one-fifth of the U.S. population.  Cost containment must be coupled with implementation of Medicare For All.  Without it, universal access will be unsustainable.

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The State Attorney General's office this week settled the antitrust lawsuit with CHI Franciscan, claiming the acquisition of WestSound Orthopedics and affiliation with The Doctors Clinic violated antitrust laws by reducing competition and resulting in higher prices.  As part of the settlement, CHI must divest their majority stake from the ambulatory surgery center in Silverdale and pay $2.5 million to the state.  That amount will be distributed to four entities in an effort “to increase access to health care on the Kitsap Peninsula” according to a recent press release.



It is a well-known fact that one of the largest obstacles to affordable health care is the high cost of American hospitals. In 2018, Americans spent nearly $1.2 trillion on hospital care and the average daily cost of a hospital stay in the U.S. was 2.6 times that of the average of other industrialized nations. 



The single greatest driver of higher hospital prices is the rise of monopolies. The ACA triggered an epic buying spree as hospitals acquired independent medical practices.  Since 2010, hospitals have merged into larger and larger conglomerates, which used their increased market power to extract higher reimbursements from the commercially-insured. 



For instance, in August 2013, Harrison Hospital affiliated with the Franciscan Health System and shortly thereafter, Franciscan Health re-branded as CHI Franciscan.  In February 2019, CHI merged with Dignity Health to become Common Spirit, which is a colossal $29 billion health system comprising 142 hospitals and more than 700 care sites across 21 states. 

According to data from the Center for Medicare & Medicaid Services (CMS), hospital care in Kitsap County is 40% more expensive than in the surrounding communities.   In documents filed as part of the lawsuit, a former physician president at TDC summed up the affiliation with CHI best: “You can now get your outpatient care in a complex, relatively unsafe, and vastly more expensive location.” 



What exactly does this settlement mean for Kitsap County residents? 



While not perfect, the settlement goes a long way toward restoring balance to our one-hospital community.  The ambulatory surgery center (ASC) is simply a hidden gem, where same-day surgical, diagnostic, and preventive procedures can be performed for a fraction of the price of a hospital outpatient department (HOPD.)  



ASCs perform more than 7 million procedures for Medicare beneficiaries annually and cost Medicare just 53% of the amount paid to HOPDs for the same procedure.  For example, Medicare pays hospitals $1,745 for performing cataract surgery while paying ASCs $976 for the same procedure. In general, Medicare beneficiaries pay half as much out-of-pocket at an ASC compared to at a HOPD. 



A second important settlement term requires CHI and TDC to inform patients of alternative imaging options to Harrison Medical Center. Kitsap has a freestanding imaging center, which offers high-quality care at a competitive price.  InHealth Imaging is another hidden gem, which in my personal and professional experience costs one-fifth the price of imaging at the hospital.  



Most importantly, this settlement signifies a symbolic change in the healthcare landscape as the consolidation trend appears to have played itself out. For the first time, the percentage of medical practices owned by hospitals has actually fallen, from a high of 32.6% in 2016 to 28% of the market in 2018.  Hopeful hospital administrators have now learned hospital-owned medical practices are not as profitable as once believed to be, despite the fact that facility fees boost reimbursement considerably.  One example is CHI’s CFO Mike Fitzgerald, who once wrote “I am all for taking advantage of hospital-based pricing… it would be great to drop a couple of million more to our bottom line.”  Unfortunately, the financial windfall has never materialized.  



I commend Attorney General Bob Ferguson for doing his part to improve access for patients to affordable healthcare and have come to believe the way to change the system is through the courts or legislation.  



To that end, Rep. David Cicilline (D-R.I.), who chairs the antitrust subcommittee of the House Judiciary Committee, has stated that hospital consolidation is one of his top priorities. Rep. Jim Banks (R-IN) has introduced the Hospital Competition Act of 2019. In the future, legislation like this would reduce cost of healthcare and protect small communities from hospital monopolization.  



This bill would:

1.      Approve a 400% increase in FTC staff to ensure hospital mergers do not increase costs,

2.      Reduce the incentive to merge by lowering Medicare reimbursement rates in monopolized markets,

3.      Provide grant funding for states trying to improve hospital competition,

4.      Eliminate the facility fee and reimbursing HOPDs at the same rate as independent physicians,

5.      Repeal incentives for accountable care organizations (which have not saved money),

6.      Repeal the ban on physician-owned hospitals, and

7.      Require hospitals to publish the cost of their 100 most common services

When healthcare prices increase, everyone pays, whether consumers realize it or not.  Higher insurance premiums are passed on by employers, the uninsured pay through bankruptcy proceedings, and the increased cost for Medicaid/Medicare patients is borne by the taxpayers.  Competition lowers prices.  And this settlement is a step in the right direction for patients in Kitsap County who value choice.  

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I will never forget her face.  She was only thirteen.  She had a significant cognitive disability, a result of a brain injury at birth. She found her way to my clinic one late Friday afternoon in July almost two decades ago.  Her mother was a nurse and noticed her daughter had not had a period in the last two months. Her pregnancy test came back positive.  I wanted to cry.
  

The questions I had to ask this young girl were agonizing.  When asked if she had sex, she looked at me and shook her head back and forth, to say no, she had not had sex before.  She was telling the truth.  Having sex implies consent. When I asked if someone had touched her private area, she nodded her head up and down and said there were two boys.  She thought they might have been about her age. She did not know who they were.  She had never seen them before or since. I asked if she could remember their faces.  She could not. 


The two boys pushed her down on a grassy area next to the high school football field when she was walking home one day.  She remembered it was raining because she had been looking up at the sky until they stopped hurting her.  She told me about the pain she experienced, down there, and she pointed to her vaginal area.  She told me there was some bleeding afterward at home.  She did not tell anyone about what had happened, even her mother.  I am not sure if she really understood what had been done to her.  I tried to put myself in her place to understand how hard it must be to be telling me her story now.
  

Taking her small hand in mine, I told her she was pregnant.  Her shoulders slumped forward and she looked at the floor.  “Do you know what that means?” She nodded her head up and down, then said “there is a baby in here” gesturing toward her abdomen.  It was more question than answer.   She was not capable of understanding how horrifying it was that she never made a choice to become a mother. 


She was still a child herself.
  

For the record, in regard to my uterus, I am pro-life.  I believe children are a gift to those of us who are lucky enough to have them, if even for a fleeting moment.  As a pediatrician, I have devoted my entire life to taking care of children, from the instant they are born until they go on to have their own children.  And then I have the privilege to care for those children as well.  There is no greater thing on earth than a child and protecting that child, the one in front of me, will always be my priority.
  

But how can any civilized society reconcile being pro-life with forcing one child to bear another child – one that the child never consented to produce in the first place? 


It is inhumane. 

How many other victims can tell this same story?  There are far more than the pro-life movement wishes to acknowledge.

In fact, the Alabama Human Life Protection Act is not intended to protect human life; this legislation is a veiled attempt to place value on one life over another. And by exempting victims of rape and incest, Alabama will serve as judge and jury, disrespecting the work already done by the highest court in the land.  The question of legalized medical abortion has already been asked and answered by the Supreme Court in 1973.

The Alabama legislature is sanctioning physicians to be jailed for up to 99 years for performing an abortion, while at the same time, knowing full well that a first-time rape conviction carries a sentence of 20 years or less.  The pro-life movement wants the nation to believe being pro-choice is akin to being anti-life, while obscuring the fact that women and children will be forced to give birth after victimization. Fighting to protect the right of women and children to make decisions about their own bodies is not the same as being pro-abortion.
  

In my opinion, Alabama is not pro-life.  They are trying to legalize morality, which is dangerous.  For the record, I am pro-life; the kind of pro-life that believes all human beings are equal.  No civilized society should prioritize the life of an unborn child over that of the defenseless child who stands in front of them.  Physicians, especially, must not acquiesce to politicians who want to force vulnerable women and children into back alleyways with coat hangers.  The lives we must protect are those of the innocent women and children and their choice not to give birth to children they did not consent to make.  

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