Health Reform and the ER

Many years ago, I developed a sore throat and a cough at the tail end of recovering from a cold. The sore throat became worse and worse each day, so I called my primary care doctor. But her office refused to see me. They were swamped with patients, it was flu season, and "you just have the flu," the receptionist told me.

Ultimately, sick and fed up, I dragged myself to my local emergency room. There, the professional and refreshingly compassionate nurses evaluated me and gave me a prescription for antibiotics to treat a raging sinus infection. When I recovered, I found a new primary care provider.

The problem I had was what many uninsured patients face every day: no access to a primary care provider. Without this access, they, like me, end up in the emergency room for urgent but non-emergency problems. This frustrates emergency room doctors and nurses, but they also understand that some patients don't have other choices for care. A pediatric emergency room doctor once explained to me that there was a tacit understanding between some uninsured parents and ER staff that many visits were not true medical emergencies, but their children had an urgent medical problem and the ER was the only place they could go.

Massachusetts legislators hoped to mitigate this and other problems with the health care system by mandating insurance coverage for all state residents, who must be insured through private or government plans. This grand experiment, initiated in 2006, has not turned out exactly as they had planned. But a recent study in the Annals of Emergency Medicine found that, although ER visits increased in Massachusetts after 2006, the number of "low-severity visits" decreased slightly ("Emergency Department Utilization After the Implementation of Massachusetts Health Reform").

Ideally, Massachusetts health care reform should have more dramatically decreased emergency room use. Increasing insurance coverage, however, also increases the need for primary care providers, and these providers are in short supply in both Massachusetts and elsewhere. The state's subsidies to expand health care coverage "do nothing to increase the supply of medical services in a market suffering from shortages of everything from family doctors to nurses to hospital beds," writes Shawn Tully in an article about health care reform for CNN Money ("5 painful health-care lessons from Massachusetts").

The CNN article, and a recent article on the LA Times ("One in three employers may drop health benefits, report says"), also point out that as health care reform is rolled out nationally, many employers might drop insurance coverage for their employees and choose to pay a non-compliance fine instead. This would increase the government's fiscal burden of health care.

There are a lot of challenges ahead for health care reform, and I hope the state and federal governments can work all this out. Although there's work to be done, I'm glad that Massachusetts is making some progress with reform, because I know how frustrating, costly, and inefficient it is to be forced to use the ER when you can't get care elsewhere.

RFID tags in Medicine

Radio frequency identification (RFID) tags can track people, equipment, and paperwork in a variety of settings. They are currently used to track objects ranging from military equipment and nuclear materials to more mundane retail merchandise. These chips are either passive, transmitting a signal only when an electronic device requests information, or active, constantly transmitting a readable signal.

RFID tags are gaining traction in medicine. Surgeons can use "smart" sponges embedded with RFID tags in the operating room, for example. Separate devices can electronically count the number of sponges used and scan the surgical site to make sure none are left in the body, where they can cause pain, infections, and other problems. RFID-embedded identification bracelets placed on infants in maternity wards and linked to alarms prevent unauthorized people from taking the infants from the area.

Outside the hospital wards, RFID-tagged pharmaceutical containers make it easier for the FDA to track the drugs' movement (especially the movement of controlled substances such as the pain reliever OxyContin) and to verify that the drugs are not counterfeit. Some paper medical records have been RFID-tagged to help health care workers find misplaced files.

The Affordable Care Act encourages the use of technology such as electronic medical records and RFID tags to improve medical care and (not coincidentally) to stretch health care dollars by decreasing administrative costs and other expenses. Technology like RFID chips, which can prevent expensive and damaging human errors, should remain just one tool used by health care providers, and does not relieve them of their responsibility to provide the best care they can. Tools can help them with data collection and analysis, but empathy, observation, and insight remain distinctly human, and necessary for good health care as well.

MD Face-Off: Generalists vs. Specialists

Much has been written about the shortage of primary-care doctors needed to treat the influx of patients anticipated when the Affordable Care Act is fully implemented in 2014. To help solve this problem, Kaiser Health News reported today that some states are expanding the role of nurse practitioners to serve as a patient's primary care provider. The KHN Daily Report also cited a Chicago Sun-Times article about the increasing number of medical school students who choose to enter primary care fields ("More young doctors choosing careers in primary care"). These students are spurred on by health care reform's financial incentives for this choice, such as increased Medicare reimbursement.

But like many things in medicine (heck, in life as well), fixing the problem is more complicated than it first appears. More doctors alone don't always mean better patient care. In February, The Commonwealth Fund reported that a nationwide survey of about 2,500 Medicare patients found that patients with more doctors in their area weren't any happier with their care than patients with fewer doctors in their area. Improving health policy and organizing health care networks better might be more effective than adding more doctors to the mix, the survey's authors said in Health Affairs, which posted the study.

And when we look at the "doctor shortage" problem, should we focus on supporting generalists or specialists? Fierce Healthcare recently reported that a shortage of surgeons (not general practitioners) in some areas of the country leads to higher mortality rates after motor vehicle accidents. A recent study in the Journal of the American College of Surgeons found that in areas with fewer surgeons, accident victims are less likely to receive timely life-saving surgery.

Not that every doctor should specialize, though, because specialization in medicine has its own limitations. The title of a March report from the New England  Journal of Medicine shows the absurdity of current specialization trends: "Specialization, Subspecialization, and Subsubspecialization in Internal Medicine." The report's authors explain that formalized specialization fragments care, and the time spent maintaining certification might undermine a doctor's broader knowledge of his or her field. Patients, on the other hand, are impressed by the skill set implied by specialization. Health plans promote specialization as a marketing tool to attract more patients. There must be a reason to create each specialty, though, the authors write. "A proliferation of specialties without adequate justification may simply confuse the public without creating a social good," they conclude.

Ultimately, the problem of generalists versus specialists comes down to policy: what mix of generalists and specialists will best serve the public good? And what policies need to be in place to provide a steady supply of each type of doctor needed, and to help both types of doctors provide the best possible patient care?

Will Force or Favor Make People Buy Health Insurance?

The mandate that everyone buy health insurance by 2014 is facing a lot of legal challenges. Recently, a federal judge in Virginia decided that the mandate is unconstitutional. There are currently 24 lawsuits challenging various aspects of the Patient Protection and Affordable Care Act, according to a chart created by the Washington Post, with the insurance mandate a top source of friction.

Having both healthy and ill people purchase health insurance distributes the cost of care among both. A responsible society shares expenses for the common good. We don't expect children to pay for their public school education, for example, but expect that they will pay it back when they use their education to get jobs and become tax-paying adults themselves. Similarly, if we want to expand and secure access to health care, we need to all contribute to the expense - even if we are not deriving immediate benefits from our contributions. At some point in our lives, as injuries and illnesses occur, all of us will probably cost insurers more than we are currently contributing in premiums, and we will depend on the contributions of healthier people to cover the cost of our care.

But how do you make sure that enough healthy people purchase health insurance to adequately distribute these costs? Since legislation, now being challenged in the courts, might not work, Fierce Healthcare ran an article on some ways to pay for health care reform even without the individual mandate. Fierce Healthcare drew on a Kaiser Health News story ("Experts Ponder 'Plan B' Options For The Individual Mandate") for ideas, such as:

• Use taxes as an incentive. Raise taxes, then give tax breaks to people who have purchased health insurance.
• Use premium cost as an incentive, as suggested by former CMS director Gail Wilensky. Increase the cost of health insurance for several years for people who do not purchase it when they are first eligible. 
• Use a waiting period as an incentive, as suggested by sociologist and senior health advisor Paul Starr. Prevent those who opt out of insurance from purchasing subsidized insurance on the insurance exchange for several years. Insurers also would not be required to cover those who opt out if they had pre-existing conditions.

As these ideas demonstrate, where persuasion doesn't work, stricter financial penalties often do.

Health Care Reform and the New Congress

The fight over health care reform continues in post-election Congress, as comments from President Obama and from Rep. John Boehner, who will probably become the new Speaker of the House of Representatives, make clear. This week, Kaiser Health News published a transcript of news conference comments that show the divisions between Boehner and Obama over the future of health care reform.

With so many of their constituents concerned about unemployment, Boehner and the Republicans say that the current plan for health care reform is too expensive to implement now. The Republicans have said that their primary goal over the next two years is blocking the implementation of health reform and other agenda items, and unseating Obama in the next presidential election.
 
Boehner, who called health reform a "monstrosity," said:

I believe that the health care bill that was enacted by the current Congress will kill jobs in America, ruin the best health care system in the world, and bankrupt our country. That means that we have to do everything we can to try to repeal this bill and replace it with common-sense reforms that'll bring down the cost of health insurance.

Unlike the Republicans, the Democrats see substantive health reform as a moral obligation that is worth the investment. Obama explained:

I don't think that if you ask the American people, should we stop trying to close the doughnut hole that will help our senior citizens get prescription drugs, should we go back to a situation where people with preexisting conditions can't get health insurance, should we allow insurance companies to drop your coverage when you get sick even though you've been paying premiums -- I don't think that you'd have a strong vote for people saying those are provisions I want to eliminate.

Republicans who argue that health reform is too expensive tend to ignore the costs of letting the current health insurance system stand. Commonwealth Fund blogger Louise Probst argues that health care has both direct and indirect costs for Americans. Health insurance now averages over $14,000 for a family of four, Probst wrote. "Other leading nations spend half or less of what we do on health care," she wrote, "making it increasingly difficult for American families to retain their standard of living and for American businesses to compete in a global economy." Furthermore, "all Americans pay the nation's health care bill indirectly by way of lower wages, higher taxes, and health benefit costs embedded in the price of non-health-care goods."

Which argument will win: fiscal restraint and job creation, or moral imperative and long-term investment? The outcome will become clear by the next Presidential election.

Don't Get Sick if You're Middle Class

The American middle class, created in large part by the G.I. bill after World War II, is suffering especially acutely in the current economy. A study in the journal Family Relations, for example, found that middle class shoppers are increasingly going to thrift shops and yard sales to buy basics they need such as clothes and small appliances.

Freecycle, an organization through which people give away or request household items, is growing in popularity; online coupon sites are everywhere. The only group that seems to have plenty of disposable income in this economy are childless young women.

But where can middle class families find the bargains in health care? The Census Bureau recently released a study that found that the number of people without health insurance rose from 46.3 million in 2008 to 50.7 million in 2009. Half of this increase is among people with incomes over $50,000 per year, who have limited access to government help with health care costs, as a Commonwealth Fund study pointed out recently.

Here in California, where unemployment tops 12%, health care is excruciatingly expensive. This is especially true in the San Francisco Bay Area, as Andrew Van Dam pointed out in a recent Covering Health blog post. For patients without access to government assistance, hospitals in some parts of the Bay Area bill about $35,000 per inpatient (versus about $19,000 per inpatient in Los Angeles County). Here's a Kaiser Health News map that lays out the statistics.

Health care reform helps, but the insurance exchanges that should provide affordable insurance options to those without good coverage aren't legislated until 2014 (although California is trying to fast-track that process in the state). Meanwhile, people who are uninsured or under insured are left to consult Dr. Google if they get sick. At least the doctor is affordable and always in, if not always right.

More Fees, Less Health

With open enrollment coming up, Kaiser Health News' Michelle Andrews wrote an interesting article about how health insurance costs may increase for consumers with the new health care reforms in place. The potential costs, which will especially impact people with family coverage, include:

• Higher premiums and deductibles. Employers and insurers are passing on greater amounts of the cost of health insurance to their employees. "In the past five years, employees' premium contributions have grown 47 percent, while overall premiums increased 27 percent," wrote Andrews. Furthermore, over 25% of employees pay $1,000 or more in an annual deductible that must be paid before the insurer picks up any costs.
• Both co-pays and co-insurance. In addition to small, flat rate co-pays to visit doctors, some health insurance plans will also require people to pay a percentage of the total bill (co-insurance) for hospital stays, ER visits, and/or prescription drugs. Co-insurance is usually about 10% to 30% of the bill, according to a New York Times article on insurance changes.
• Surcharges for dependents. Some insurers will charge extra for each dependent on a plan. Other insurers might charge a surcharge for employed spouses who have access to other insurance through their employers, hoping to drive them off the family plan.

These extra fees seem especially painful in light of a recent Commonwealth Fund study that found that Americans are faring worse in health outcomes than their counterparts in other countries. The 30-year study looked at health care costs and 15-year survival rates for 45-year-old men and women and for 65-year-old men and women, in the United States and in twelve other wealthy nations.

"The United States now spends well over twice the median expenditure of industrialized nations on health care, and far more than any other country as a percentage of its gross domestic product (GDP)," wrote the study's authors, Peter A. Muennig and Sherry A. Glied, in the journal Health Affairs. Although U.S. survival rates have improved during the study time (1975 to 2005), the improvements were greater in the other countries in the study.

The study looked at the impact of population diversity, smoking, obesity, traffic fatalities, and homicides on the health of Americans, but found that these factors did not contribute significantly to the health differences between the U.S. and other countries. Instead, the authors concluded that the high cost of health care might be making the U.S. fall behind the other countries. For example:

• High health care costs have made insurance unaffordable for many Americans. The number of uninsured Americans rose during the study period, and going without health insurance affects both short-term and long-term health.
• High health care costs might divert money from important public health campaigns. "At current spending levels, investments in public health, education, public safety, safety-net, and community development programs may be more efficient at increasing survival than further investments in medical care," the authors wrote.
• Expensive fee-for-service care and the rise of specialized care might lead to unnecessary procedures and poor communication between a patient's different health care providers. Complications from unnecessary procedures and medical errors from poor communication might contribute to Americans' poor health outcomes.

Ideally, health reform will ensure that more Americans have health insurance, create incentives to support public health programs, and reward the medical community for focusing on cost-effective, coordinated preventative care. If consumers become healthier because of these initiatives, insurers will save money on treatment costs. But since we're not there yet, insurers still view Americans as unhealthy and costly, and will continue to charge them heftily for that.    

Annual Check-Ups Covered, Among Other Things

This week, a few key pieces of health care reform legislation went into effect, including coverage for preventative care visits. This very concrete change will have a big effect on families, who often coordinate several yearly check-ups for family members. A check-up required for a child to attend school should not cost a family with insurance coverage $200 out of pocket.

Lifetime caps on what health insurance will pay have also been removed, providing more financial security for people with insurance who become seriously ill. Children with pre-existing conditions must be covered by group health care plans as well.

WebMD has a good video interview with HHS Secretary Kathleen Sebelius explaining the changes that went into effect on September 23, and promoting the healthcare.gov consumer health care plan website.

These reforms have had some interesting consequences, though. A recent Fierce HealthPayer article pointed out that insurers such as Anthem Blue Cross, Humana, Aetna, Cigna, and UnitedHealthCare, for example, are trying to drop individual insurance plans for children in some parts of the country to avoid the expense of covering children with pre-existing conditions.

With more people getting and using health insurance under the new reforms, I was not surprised to read that the University of California at San Francisco approved funding for a new hospital complex this month. I wonder how many other hospital-building plans are going forward now that there will be more patients with insurance coverage to pay their bills. Will this new influx of patients (and payments) improve hospital care nationwide?

I've also heard rumblings about shortages of primary care doctors and nurses who will be needed to serve these new patients, a problem HHS is trying to remedy with financial incentives for health care providers who can fill this gap. The ongoing nursing shortage in particular seems to be a deeply entrenched problem nationwide.

I wonder what other changes - anticipated or not - health care reform might bring?

Health Care Reform Basics Explained

The family issues activist group MomsRising met with HHS Secretary Kathleen Sebelius in a web chat recently to ask questions that they had gathered from their million-plus membership of mothers. Since I've questioned MomsRising's tactics in the past, I was curious to see how this chat would go. It's certainly an important topic: a HealthDay/Harris Poll of 2,100-plus Americans, released today, showed that many are deeply confused about what changes to expect from the Affordable Care Act that passed in March.

Actress Fran Dreschler, who survived uterine cancer and now works to improve cancer awareness among women through her website Cancer Schmancer, joined Sebelius and MomsRising's National Campaign Director Donna Norton in the web chat.

It was an odd collection of personalities: the articulate, calm Sebelius; the passionate and occasionally off-topic Dreschler; and the smiling, friendly Norton, who wore a MomsRising T-shirt (as MomsRising representatives do when meeting publicly with government officials, a habit that I dislike) in contrast to the smartly-dressed Sebelius and Dreschler.

The web chat touched on some changes coming in 2014 (the health insurance exchange), but focused on what will change in 2010. Changes to expect this year include:

• preventative care coverage without out-of-pocket costs to the consumer 
• new insurance pools for people denied coverage due to pre-existing conditions
• expanded health care coverage for adults up to age 26
• elimination of annual caps on insurance coverage for individuals

Sebelius, Norton, and Dreschler also discussed more innovative disease-prevention strategies included in the bill, such as calorie labeling on menu items in fast food restaurants. I was glad to see MomsRising lead a substantive discussion of health care reform.

A timeline of when various benefits will begin is available on the new healthcare.gov site, which also has an interactive section that lists health insurance options for different groups of people.

It's unclear to me whether health insurance will become less complicated under the new law. Billing paperwork from health care insurers and providers is currently so complex and error-prone that Quicken has developed Health Expense Tracker software that interacts electronically with certain health insurance companies to help consumers keep track of everything. The 1996 HIPAA bill was designed (in part) to reduce and streamline insurance paperwork; instead, it has increased it.

On the other hand, the Affordable Care Act offers Americans assurances that their medical expenses will be covered more fairly. To pay for this, the bill is structured to provide financial incentives for insurers (and other organizations) to focus on preventing disease, rather than dropping patients when their diseases become too expensive. With more than half of all U.S. bankruptcies caused by unpaid medical expenses, it's about time for the change.

COBRA Bites Back

Unless Congress takes action soon, the federal COBRA health insurance subsidy will run out this month, Kaiser Health News writer Andrew Villegas pointed out recently. For people who were laid off from their jobs or lost health care coverage because their work hours were reduced (a "qualifying event" that makes them eligible for COBRA), the federal subsidy covers 65% of the cost of extending their employer-based coverage for 15 months. This subsidy is only available for employees whose qualifying event occurred before May 31, 2010, however, so people laid off in June are out of luck.

Those who have benefited from the COBRA subsidy since March 2009 also hit the 15-month limit this month, Villegas stated, and now must pay full price for their COBRA benefits for the remaining three months of COBRA coverage (in most cases, COBRA coverage only lasts 18 months).  

Plans offered by employers (and extended by COBRA to unemployed workers) usually provide better coverage than anything available on the individual health insurance market. COBRA can be very expensive, however, as cash-strapped former employees must pick up the full cost of a health plan that their employer used to subsidize, along with a 2% administrative fee. One study found that paying full price for COBRA coverage could consume 84% of a laid off worker's unemployment check, according to MarketWatch reporter Kristen Gerencher. The federal subsidy helps make COBRA an affordable option for laid-off employees and their families.

Like unemployment benefits, COBRA was designed as a stop-gap measure, providing temporary coverage while an employee looks for a new job that will provide more permanent, employer-sponsored health insurance (or pays well enough for the employee to purchase individual health insurance). That formula does not work too well in this stalled economy, however. Because good jobs are hard to find, many people rely on COBRA and unemployment benefits for far longer than they were intended.

A while ago, I wondered whether the federal government might use COBRA as a vehicle for health care reform. What if the federal subsidy for COBRA continued indefinitely, allowing eligible ex-employees to continue to receive health care from high-quality private plans, regardless of whether they found a new job or not?

A COBRA subsidy extension might not happen, however, either in the long- or short-term, because it is both expensive and politically volatile for Congress to pursue. Meanwhile, many long-term or newly unemployed people and their families will need to pay much more for health care coverage under COBRA or individual plans, end up in federal or state programs such as Medicaid or the Children's Health Insurance Program, or go without insurance altogether.

219 Democrats

With gangs of protesters roaming Washington, D.C. this weekend, and Republican congressmen egging them on by holding up "Kill the Bill" signs from the Senate balcony (see slideshow), with spitting and name-calling, with emotions and political influence tangled up together on both sides of the abortion debate, the Senate's health-care bill narrowly passed in the House of Representatives on Sunday with 219 votes (all Democrats).

On Tuesday, President Obama is expected to sign the bill, as the men and women of Congress continue to hash out the details of reconciling the Senate and House versions. It seems that health care reform is all over but the shouting, and there's been plenty of that already.

I've been in favor of health care reform for a long time, primarily because I believe that it would keep Americans healthier and protect them financial ruin if they do become seriously ill. Thirty-two million uninsured Americans will be covered by this new bill, easing the considerable logistical and financial strain that the uninsured place on our emergency rooms and hospitals when they don't have access to regular medical care that can keep them out of the ER and hospital in the first place.

The bill will also make health insurers take more responsibility for the people who pay their premiums. Health care insurers will now be required to invest in preventing disease (and ultimately saving money on health care costs) by covering annual check-ups and and childhood immunizations. Reform will create larger pools of payees, including healthy young adults, to offset the costs of treating the patients who have expensive (often chronic) illnesses, and eliminate the lifetime cap on how much health care an insurer will provide to a patient. (Note to uninsured twenty-somethings who will now need to purchase health insurance: some day you, too, will have an expensive and/or chronic medical problem, for which you deserve - and no doubt will demand - quality care.)

Recent headlines such as "Eight healthcare lobbyists for every member of Congress" (Fierce Healthcare) and "Big Jump in Blue Cross Premiums Sparks Outrage" (San Francisco Chronicle) have made it clear that health care consumers have had little influence, and their needs have not been met, under the current insurance system. It was time for some legislation.

The Washington Post has an interesting chart showing how the House members voted, how much funding they get from the health care industry, and the percentage of uninsured people in their districts. Wondering how reform will affect you? The Post's interactive graph explains the costs and benefits of the bill, based on your income, marital status, and the size of your family.

Reframing the Health Care Debate

As health care reform lurches forward uncertainly, with the special election of Massachusetts Senator Scott Brown giving Republicans enough votes to block the passage of the reform bill in its current form, The New England Journal of Medicine has published a very thoughtful Perspective called "American Values and Health Care Reform."

The term "values" has been a battering ram for both political parties for so long, each side claiming that their values are better than the other's, that the word itself makes me a little nauseous. But Thomas H. Murray, Ph.D., the author of the Perspective, offers a different interpretation of the word. He argues that the values that Americans like to think they hold, such as liberty, fairness, and responsibility, are not applied evenly throughout the health care system. This inconsistency is an ethical, moral and financial loss for all Americans.

Do we really value liberty, Murray asks, when so many people are shackled to jobs they dislike because they need access to employer-sponsored health insurance? For example,

Under our current system, a young entrepreneur with a brilliant idea for a new business, a creative vision that can create jobs and wealth, can't necessarily follow that vision: if this person has a job at a large firm that provides good health insurance and has a child or a spouse with a chronic illness, the aspiring entrepreneur's freedom to pursue his or her dream is severely limited by the "job lock" imposed by our current patchwork of health insurance. The catch-22 of insurance underwriting for preexisting conditions is likely to make insurance unaffordable or unattainable for such a family on its own.

Similarly, Congress passed the 1986 Emergency Medical Treatment and Labor Act so that anyone in need can get emergency medical care, whether or not they have insurance, demonstrating that Americans feel responsible for others in dire circumstances. "Yet our achievements do not always live up to our values," Murray writes. "Consider the 20,000 people each year who, according to the Institute of Medicine, die for want of health insurance."

Americans need to see health care as a common good that benefits us all, not an individual choice. Murray writes that we need to pitch in to finance health care for everyone, and work together to make health care more efficient and effective.

Maybe calmer heads will prevail if we reframe health care reform as a reflection of our best instincts as Americans, rather than a political fight or a battle between individual and community rights.

YouTubilicious: Science and Entertainment

This week, I attended a press preview of the new digital show, Journey to the Stars, at the California Academy of Sciences' Morrison Planetarium (billed as "the largest all-digital planetarium in the world") - the show officially opens on September 26. The stunning images, of the Orion Nebula (see picture), the Milky Way, and the spiderweb paths of satellites that criss-cross the earth, were created based on the latest astronomical data.

As the show zoomed through images of the solar system, showing how it might have looked 13 billion years ago and ending with a projection of the sun's demise 5 billion years from now, portentous music swelled in the background. The narrator on this galactic tour? Whoopi Goldberg.

I like Whoopi Goldberg; she's smart, funny, and sassy, as was her planetarium narration. But it's hard for me to imagine the stand-up comedien, The View co-host, and star of Sister Act seriously pondering the origin of the universe or the magnetic fields of Saturn.

On the other hand, a low-tech, soporific, Carl Sagan-esque explanation of how stars are formed might not be the right approach to teaching science to the public. I remember visiting Chicago's Adler Planetarium in Chicago with friends in high school many years ago - bright future alumni of MIT, Brown University, and the United States Naval Academy, among other schools - and watching them doze off one by one in the darkened room as the image of Orion the Hunter was superimposed over the constellation of Orion's Belt on the ceiling.

Science doesn't have to be boring, especially with the new technologies available today. If Pixar studios can give a desk lamp a sparkling personality with computer animation, why can't science be presented in a more engaging way? Maybe a little more entertainment is just what the doctor ordered. With that in mind, here are my favorite, toe-tapping music videos about my two most recent obsessions: swine flu (novel H1N1) and health care reform.

Dr. John D. Clarke, FAAFP, won a recent public service announcement contest sponsored by the department of Health and Human Services with his "H1N1 Rap". Who knew that HHS could be so hip?




In response to data that ranked the United States 37th in the world for the quality of its health care, Paul Hipp wrote the rock-and-roll song "We're Number 37", proving that you really can write a song about anything.

Making Politics Palatable to Moms

A while ago, I signed up to receive emails from the political group MomsRising. The organization advocates for progressive, family-friendly policies such as paid family leave, expanded health care coverage for children, and better-quality child care options. I support these causes, but I was hesitant to join MomsRising because they are linked to MoveOn.org.

I remember well when MoveOn ran a notorious full-page ad in the New York Times in 2007 that criticized the war in Iraq by making fun of General Petraeus' name. I am constantly telling my children not to tease other people (or each other), but MoveOn had no problem with name-calling. Should an organization that uses ridicule to advance its objectives provide political leadership to mothers?

And what does it mean, exactly, to organize mothers into a political entity advocating for improvements in child health and other family-friendly causes? Are American mothers that cohesive ideologically - or that easily lead? If they are, I'm not sure I want them to be.

When MomsRising - or other political or social organizations - send emails summarizing an issue and include a simple "click here to send a letter to your senator" button, I get a bit suspicious. If I take the time to do some research, the topic is inevitably more complex than it first appears. Furthermore, MomsRising tries to make political involvement fun, such as decorating a onesie to send to local politicians, or dressing in a superhero cape to advocate for health care reform - an approach akin to making smiley-faces out of your child's vegetables in order to persuade her to eat them. They forget that mothers are adults, not children.

I'd like to see less drama and more thoughtfulness from an organization that advocates for mothers and families, particularly if they're going to talk about such a fraught issue as health care reform. Moms (and Dads) need to flex their critical thinking skills. It's following without thinking, believing rumors and hearsay about health and health care instead of facts and reports, that gets everyone in trouble in the first place.

Health Care Reform's Impact on Business

I think that the health care system will be fixed gradually with the next administration. Perhaps the new president will kick-start health care reform with an action designed to build goodwill toward the process, such as an announcement of federally-subsidized catastrophic coverage or medical debt forgiveness for a small segment of Americans, and build out slowly from that.

If employers no longer need to purchase private health insurance for employees, they might need to pay into a local, state, or national health care plan fund. If the plan (either government-based or private) is structured and administered well, with a reasonable level of services for patients and reasonable reimbursement rates for providers, it can provide better care at a lower cost than the patchwork of plans currently available. The debate about the cost of such a plan is raging in San Francisco now, though, with the city mandating employers to pay into a fund that would cover uninsured adults. The Golden Gate Restaurant Association fought the plan, claiming the mandated costs are higher than restaurant owners can afford.

If employer-provided health care is decreased or goes away completely, I think that there will be some unintended consequences for large companies in particular. Many people hold on to jobs they don't like at larger employers solely for the access they provide to quality health insurance. If other affordable, high-quality options become available, I think that these employees will leave their employers. Some will move to work in different fields, but others will move to competing companies, or start their own businesses to compete with their former employer.

According to the White House, small businesses are the engine of job creation in this economy, providing two out of every three new jobs, although the nonpartisan National Bureau of Economic Research questions these rosy statistics. Small businesses freed from the burden of taking on large health care costs once they reach a certain size, however, are likely to grow rapidly. As some larger businesses lose employees and smaller businesses gain them, will the revenue gap between the two types of businesses decrease? Will that change ultimately decrease the gap between rich and poor, and shore up the middle class again?