My family doctor emigrated to the US from Canada years ago. He has just installed an EMR and qualified easily for meaningful use stimulus funds because he takes Medicaid patients. To qualify for meaningful use under Medicaid, all you have to do is order the EMR; it doesn’t even have to be up and running.

Medicare is more rigid; outcomes must be reported. To report on outcomes, he had to buy another module of the EMR, probably because the EMR he bought was developed before the meaningful use standard or the stimulus money.  In his opinion, it will be difficult to report significant outcomes for Medicare and Medicaid patients, because they often don’t stay in his practice long enough. They move, they change insurance, they drop off Medicaid into the ranks of the uninsured. People in the US no longer stay with a medical practice long enough for longitudinal study — which is why all our EMRs have to talk to each other and we have to track patients as they move from provider to provider.

Today, as part of a wide-ranging discussion on the state of health care in America, he told me a little about his experience and that of his family in Canada. He says America does not look at Canadian health care from the right perspective.  We think it’s great that Canadians have universal health care, but we don’t understand what that means.

When he practiced in Montreal (and today),  primary care docs were capped at a certain number of billable dollars and patients a month. After he hit the cap, which he did very early in every month, he was only paid 25% of what he billed. His colleagues would limit the number of patients they saw a day to about 20, so they hit the cap at the end of the month. He liked to see 30-40 patients a day, so he would hit the cap way before the end of the month, and he wanted to continue to see patients because he enjoyed them. But he finally figured out that it cost him 35% of what he billed to run his practice, so it didn’t pay for him to see more patients. He left Canada.

In Canada, the untold story is that although they are insured, 300,000 people are without a primary care doctor — because no matter how many doctors there are, it won’t be enough if they limit the number of appointments the can grant a month.He told me that’s why people in Canada, including his own mother, have to wait two months for an appointment with a family doctor unless it’s a real emergency. I knew that was true of specialists, but I had never heard about primary care scarcity before. Canadians also pay out of pocket for things like camp physicals; there’s a chart of services and costs on the wall of the doctor’s office that tells patients what the government doesn’t pay for, and what the cost will be to them.

Dr. Kramer loves America because in his own practice he can now happily afford to see 30-40 patients a day.  And unlike many family doctors, he continues to see Medicaid patients, even though they pay less, because they are interesting cases. That energizes him; he has problems he can solve.

But he watches the younger docs go on salary and limit themselves to 20 patients a day at places like Mayo Clinic, and it worries him for the future of American health care. He admits that it’s a great improvement in the physician’s quality of life, but he predicts a huge upcoming shortage of doctors as American docs go on a system more similar to that of Canada, and begin limiting the number of patients they see daily because they are no longer incentivized to see more.

Today’s news that $850 million in funds earmarked for pandemic flu prevention and preparation was stripped from the stimulus package at the request of Republicans who claimed such funds were not stimulative comes as no surprise, but it may be a lesson far costlier than $850 million.

Besides the looming and possibly dire public health threat, this is an illustration of how wrong it is to separate health care and the economic health of our nation. The decision to remove those funds from the stimulus package stemmed from the argument that investments in public health are not stimulative.

How wrong they were.

There’s an old nursery rhyme that carries a timely message for today:

Karl Rove was one of loudest voices against this particular investment, ironically claiming it was “pork”, not stimulative, and an investment in a sector that needed no stimulus. Maine Senator Susan Collins was a key player in getting the provision stripped from the bill, pointing specifically at the provision for pandemic flu preparedness as an example of spending that didn’t create jobs. We may come to understand that it is far more likely to be the horseshoe nail.

Because of the widespread nature of the outbreak in the United States, the DHS has confirmed that it has the potential to become a pandemic. There are 40 confirmed cases spread coast-to-coast in the United States alone. The virus has been confirmed to match the virus linked to 68 cases in Mexico. It is of global concern, and poses a threat to the global economy.

The same politicians that criticized government investment in preventive measures are now appealing to the government to assist in containing the virus. Texas Governor Rick Perry made a large show of refusing stimulus funds and going as far as to suggest that Texas secede from the US if spending continued to reel out of control. Yet, after 3 confirmed cases of the swine flu in Texas, Governor Perry is now requesting an additional stockpile of antiviral medications (a key component of pandemic flu preparation) for the state of Texas.

As well he should. While we all hope this flu is not a pandemic, this outbreak underscores the need for preparedness, but also that politicians get a clear understanding of how closely health care is related to the health of the United States and global economies. If this flu becomes a pandemic, a major factor in its spread will be the lack of access that many have to adequate health care, preventive measures, antiviral medications, and proper education about the simple steps needed to prevent flu outbreaks.

I hope this is not a pandemic flu. I hope even more that the lesson learned by every single politician in Washington is this: Healthcare reform is our horseshoe nail. If we do not invest in and fix healthcare in this country, our economic “horse” will be lost.

More swine flu information:

• World Health Organization
• CDC web site
• CDC Twitter updates

I was going to write a nice dry post about all the changes that the economic stimulus package (ARRA) made to COBRA, but then I noticed that it has been done by many who have spent a considerable amount of time researching it.

Instead, I’m going to update my COBRA story.

I. Draconian Decisions

Like any employee working for a large company, at the time of my layoff I was given the option to extend my health coverage, at the low, low price of $1400/month for health coverage and an extra $100/month for vision and dental. I also had a dilemma: Part of the terms of severance was a short extension of health coverage, but as far as I could tell, I had to opt-in to COBRA to receive it.

So I did. I also set aside the $1500 for the February coverage from savings, leaving me with very little in the way of cash to get by, but for us, health insurance is an imperative. Beyond February, I wasn’t sure what to do. There was no way I could afford another $1500 payment, and if I didn’t have another job I wasn’t going to have coverage, so it was back to comparing plans that were no comparison at all to what I had.

My current plan is a PPO with a low deductible, pharmacy benefits, and decent catastrophic coverage. The individual plans I was comparing had $10,000 deductibles, no pharmacy benefits, and I would more or less be out of pocket for any doctor visits. The upside? I could get one for about $700/month.

I tried to estimate what doctor/pharmacy costs would be entirely out of pocket, and realized my net cost would be about $500/month on top of the $700/month, because without the pharmacy benefit, I pay full retail for medications that are necessary for our family.

It wasn’t much of a choice, because adding a monthly cost equal to a decent-sized house payment to the budget in a time where I wasn’t working (and freelance work is scarce, too) really meant I would have to risk having no insurance at all, and paying the out-of-pocket costs for the medications.

It also meant that I did not have the means to go down the route of self-employment and a reinvented career, and most importantly, the risk of having no insurance meant we could lose our house or declare bankruptcy if one of us became seriously ill.

These are not light decisions to make. No matter which way we went, the pathway was dark and uncertain. They are decisions millions and millions of laid-off workers are making every day. I am not unique at all.

II. President Obama understands that health care reform is the center of recovery

My light came in the form of the House version of the economic stimulus bill. The original version included an 18-month subsidy for laid-off or terminated workers (provided it wasn’t for cause) of 65% of the COBRA premium. Do the math for me, and it comes out to something far more manageable (around $490/month, plus $100 for the dental/vision if I opt into that).

As I watched the bill go from the House to the Senate, my hopes were dashed. The Senate version of the bill had no provision for COBRA subsidies, and the rumors I was hearing said they had no intention of including them. Fortunately, enough noise was made about it (from those within the administration and those like me, who were urging calls to Senators) that it was included in the compromise.

Unfortunately, the compromise watered down the subsidy to 50% and 12 months. Still, better than nothing.

Now we have the final version. It provides for the 65% subsidy for a 9-month period. This means that those of us who have joined the ranks of the unemployed can now breathe a little easier while we figure out what to do next, whether it be to launch a new venture, find a new job, or do whatever we have to for our families to eat and have shelter.

III. Real stories of how it works

Health care reform is at the center of our economic well-being. Extending COBRA gives unemployed workers a chance to breathe and get affordable insurance to bridge the unemployment gap. It also leaves those same workers with a far higher percentage of disposable income to put back into the economy in the form of spending, or perhaps simply being able to swing their house payments and stave off foreclosure while getting back on their feet. Either outcome works to better the economic big picture.

My neighbor’s story is similar to mine, except that she is a casualty insurance underwriter who has been out of work for nearly six months. At the time of her layoff, she’d just managed to renegotiate her mortgage to a manageable level and was getting back on her financial feet after nearly losing her home.

Being laid off meant she had to make a choice between health insurance and mortgage payments. She chose the mortgage. Opportunities in her line of work are scarce and far between. She goes on interviews all the time for related jobs, but a job with her skills is hard to find right now. When AIG has to be bailed out and bought by the federal government, it’s not a great time to be looking for casualty underwriter jobs.

The stimulus bill, though, offers hope. All of those projects to build bridges, fix roads? They’re going to be bid on by contractors, and those contractors are going to have to have casualty insurance as part of their package, which in turn means that casualty underwriters, particularly ones with experience in the building/contractor market, will be in demand.

That means she may have employment sooner than she thinks. When she’s employed, she can catch up on her mortgage, and begin to buy things that may be more than the absolute minimum to get by. It means her college-aged daughter can go back to school instead of working full-time at a minimum wage job to help with family expenses.

For me, I now have the space to consider the possibility of launching my own business or at the very least, working freelance while the web community landscape stabilizes a bit. If I go the route of self-employment, I will be putting funds back into the economy and becoming part of the backbone of what makes this country great: the small business meeting niche needs in creative and cost-effective ways.

Remember these two stories when you hear the naysayers tell you that the country is going to hell in a handbasket because the government is spending money. Make no mistake: The government has been spending money for years, long before President Obama was elected. It just wasn’t spending it on us.

Now it is. And we have a responsibility to be responsible, too, and take care of business, try to find jobs, try to invent ones. I honestly think there will need to be a second piece of legislation that extends the 9 month period, because the key to true, long-lasting economic recovery is going to be true, deep health care reform that doesn’t put a bandaid on an ailing system.

Tell us how you’re affected by the stimulus package. Do you have more hope for your future? Do you see opportunities? Leave a comment.