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The Math of Medicare for All

(Legislature, U.S. Congress) Permanent link


This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Support for Medicare for All has swept the nation – or at least Democratic primary voters.

In a September Kaiser poll of likely Democratic voters, 40% said they were in favor of replacing the Affordable Care Act (ACA) with Medicare for All. Of that segment 14% said they would only support a candidate who would bring Medicare for All to America (as opposed to other solutions, such as the Public Option).

With two of the current top Democratic candidates – Sens. Bernie Sanders (I-Vermont) and Elizabeth Warren (D-Massachusetts) – espousing Medicare for All, supporters and detractors alike are asking more in-depth questions about the proposal, particularly how much it will cost.

What do Senators Sanders and Warren mean by “Medicare for All”?

Medicare for All is a concept that has been around since the early 1900s, was an unrealized component of President Franklin Roosevelt’s New Deal, and was in the background of the Medicare law President Lyndon Johnson signed in 1965.

Senator Sanders picked up the banner in 1987 and has run on it ever since – most memorably in the 2016 presidential election.

In April, Senator Sanders updated his Medicare For All plan (the fifth time he has done so) in Senate Bill 1129. Among his 14 co-signers were four senators who were running for president at the time: Elizabeth Warren, Cory Booker, Kamala Harris, and Kirsten Gillibrand.

SB 1129 would create a single-payer health system in America, eradicating private health insurance and current government health care programs over four years.

The insurance described in the Sanders plan would be more comprehensive than any policy currently available on the market, more generous than Medicare as we know it now, and more generous than any government program in the world (including Canada, the United Kingdom, and Norway).

Almost every resident of the United States would be entitled to comprehensive health care through a new government program modeled on Medicare (not included: veterans, who would continue to receive health care through the U.S. Veterans Administration; and Native Americans, who would be served through Indian Health Service).

Under Senator Sanders’ plan, Medicare for All would include:

  • Care in any hospital;
  • Care outside of a hospital (free-standing facilities, labs, etc.);
  • All preventative health care and chronic disease management;
  • Comprehensive reproductive, maternity, and newborn care, including abortion;
  • Emergency health care services and treatments;
  • Primary and specialty health care;
  • Palliative and long-term care (including home-health);
  • Care for vision, hearing, and oral health problems;
  • Mental health and addiction services;
  • Prescription medication (the first $200 a year out of the patient’s pocket);
  • Medical equipment and supplies;
  • Diagnostic tests; and
  • Other services (this list is not all-inclusive) 

All this care would be available at no out-of-pocket cost to the patient, and there no longer would be insurance premiums, copays, or deductibles in America.

It is understandable why the concept of Medicare for All has proven so attractive to many Americans.

It is also apparent why the cost of the plan has remained one of the most consistent arguments against it. What level of investment by the federal government will be necessary to make Medicare for All possible?

What does Senator Sanders say about the cost of his plan?

He has historically been vague about the cost of Medicare for All. The last time he ran for president, the “false charms” of his plan were widely criticized (and that was before he added long-term care to the 2019 version of his proposal). 

Variables make projections of the cost of Medicare for All difficult: How many new patients will enter the system? How many health care services will be requested when insurance companies no longer act as gatekeepers? How low can payments to hospitals and physicians go before the health care community closes and creates access issues for patients? What will it cost to build an administrative agency large enough to manage the health care of the entire country? 

Even so, many economists have attached a specific price to Medicare for All. Senator Warren released her price tag recently. Senator Sanders remains more opaque, and inconsistent. 

For example, in an interview in July with the Washington Post, Senator Sanders quoted the price to the government at $30 trillion to $40 trillion over 10 years. 

However, during the September debate in Houston, Senator Sanders did not refute former Vice President Joe Biden’s assertion that Medicare for All would cost over $30 trillion. Instead he added, "Status quo, over 10 years, will be $50 trillion." 

In another interview in October, it appeared Senator Sanders was frustrated by the cost question: “We’re trying to pay for the damn thing” [through, in part, taxes on the top 1% in income in the country]. He later added, “You’re asking me to come up with an exact detailed plan of how every American – how much you’re going to pay more in taxes, how much I’m going to pay. I don’t think I have to do that right now.”

What does Senator Warren say Medicare for All will cost?

Senator Warren does not have a separate plan for Medicare for All, saying instead, "I'm with Bernie on Medicare for All," as she said in the Democratic candidate debate in June. But the two candidates differ on how to pay for the plan, and how much it will cost.

Senator Warren released her plan for funding Medicare for All in November. Her lack of an explanation on how she could deliver it without a tax increase on the middle class, as has been her promise, was a prominent moment in the last Democratic debate.

And here is her number: $26.6 trillion. (I know the headlines said “$20.5 trillion, but that was ignoring the $6.1 trillion she expects the states to chip in to support the program.)

As reported by the New York Times:

Ms. Warren would pay for the new federal spending, $20.5 trillion over 10 years, through a mix of sources, including:

  • Requiring employers to pay the government a similar amount to what they are currently spending on their employees’ health care, totaling $8.8 trillion over a decade.
  • Changing how investment gains are taxed for the top 1% of households, raising $2 trillion, and ramping up her signature wealth tax proposal to be steeper on billionaires, raising another $1 trillion.
  • Creating a tax on financial transactions like stock trades, bringing in $800 billion.
  • Beyond the $20.5 trillion total, she is also counting on states and local governments to contribute an additional $6.1 trillion to help pay for the system. 

Senator Warren explained more details on her plan in November, but for our purposes, here is the crucial line: “We don’t need to raise taxes on the middle class by one penny to finance Medicare for All.”

Senator Warren’s announcement immediately prompted criticism from Republicans as well as fellow Democrats. Saturday Night Live parodied her talking about her plan on the Cold Open the following night.

In the meantime, Senator Sanders retorted that his plan is “far more progressive” than Senator Warren’s. Recognizing his proposal includes raising taxes on the middle class, Senator Sanders predicts those taxes would balance with lower health care costs, while Senator Warren’s plan “might have a ‘very negative impact’ on job creation because of funds it could take from employers.”

( has more details on the differences between the Sanders and Warren plans.)

What do economists say?

The Congressional Budget Office (CBO) provides Congress with financial estimates on proposed legislation, including Senator Sanders’ SB 1129. In May, the office released a detailed report on the primary features of establishing Medicare for All in America, explaining that the magnitude “is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale.”

The CBO refrained from providing a specific, detailed cost estimate (as it would usually do), noting “that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.”

However, economists outside of the government have been willing to derive specific numbers for the cost of Senator Sanders’ plan.

For my money (pun intended), the best guide to the Medicare for All cost estimates from economists (as opposed to politicians) is an interactive article in the New York Times.

I like this resource because it has dynamic, interactive visuals for each estimate, and compares figures from very conservative sources (such as the Mercatus Center) to very liberal ones (such as the Urban Institute).

I encourage you to access the resource yourself, but here are the bottom-line projections for the total costs of Medicare for All from that publication:

  • Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Sanders campaign in 2016: $2.76 trillion
  • Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security: $3.46 trillion
  • Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals: $3.24 trillion (plus $506 billion*)
  • Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006: $3.20 trillion (plus $706 billion*)
  • Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes. $3.87 trillion (plus $514 billion*)

(*Some estimates of the Medicare for All price tag are not inclusive of all health care costs.)

What will voters say?

This is, of course, the most important question of all.

We will get the voters’ answer in November.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.

Why I am Hopeful for Health Care (And You Should Be, Too)

(Public Health) Permanent link


This story was originally published on Sarah Fontenot’s blog, Fontenotes.

As the visiting associate professor for health law in the Health Care Administration program at Trinity University, I am responsible for teaching our students about multiple legal issues – from criminal liability associated with billing and kickbacks to patient rights regarding consent, end-of-life choices, and privacy; medical malpractice to Medicare/Medicaid; state regulation v. federal initiatives such as the Affordable Care Act and beyond. It is a chock-full semester.

As we approach the end of our time together, I assign a brief memo so the students can each describe their vision of the future of the field they are entering.

Every year, their enthusiasm is inspiring in equal measure to the difficulty of the field they have chosen.

The role of a hospital administrator

To understand why the positivity of my students impresses me, I must explain the role of a hospital administrator for those of you who might not know.

Being a health care executive is a career of stress and change.

A hospital represents the worst fears and the highest hopes of your community. You need to be ready every day to face the intolerable tragedy of the death of a car-crash victim on one floor while celebrating small steps (literally) on the stroke unit, or another day lived in your oncology clinic.

An administrator must manage the non-technology/homey ambiance in labor and delivery favored by young parents, while also supporting the cockpit-like machinery of the ICU next door.

You are the face associated with the entire enterprise – especially in a smaller community where you embody all of these intensely human moments every time you are seen in a restaurant or are addressing your local civic organization.

As a health care executive, you are a huge employer – in rural America, second only to the public-school system. You must care for your caregivers: from your professional staff to those who maintain your physical plant at the highest standard of cleanliness and safety.

As a hospital executive you are running a city. Issues regarding power (keeping the respirators alive if the electric grid fails), transportation (how to safely and compassionately roll patients through miles of hallways), traffic and access (can you take more ambulances in your ER or do you need to divert trauma to other hospitals?), public health (controlling infectious diseases), communication (continually updating and protecting digital records that allow all members of the team to understand each patient’s needs), and law enforcement (are you ready for the combative patient in drug withdrawal or an active shooter in your ER?).

Increasingly the public expects you to do all this while maintaining a facility with delicious food options and a lobby plucked from a high-end hotel.

You invest in technology that is quickly made obsolete in an environment where the physicians you depend on to care for your patients can be lured away by a shiny new toy at another radiology or surgical suite. And you can’t fight back with offers of any financial benefit to those same physicians – that would be illegal.

Speaking of which, the number of laws on both the state and federal level that dictate how you perform most of your processes would shock other business executives. Compliance with all is critical. Many of those you employ will never touch a patient: They exist to keep your facility within legal bounds to avoid all the penalties, both civil and criminal.

Those penalties could close your doors permanently because you are running your enterprise with a trajectory of decreasing revenue and tighter profit margins (I use the term “profit” lightly when referring to publicly owned and community hospitals).

To be a leader of a hospital requires inordinate skill in managing finances and budget.

What you charge is never what you are paid. Government programs and private insurance companies are continually changing your payment (always lower) without the negotiation standard in other industries.

And in this world, health care executives face each day’s list of priorities knowing that invariably there will be a crisis waiting to sabotage all other essential duties – loss of internet service because a road repair team nearby cut your cable, a sheriff serving your hospital with a medical malpractice complaint, a surprise visit from an auditor or Medicare-required compliance review (the unscheduled accreditation team from The Joint Commission will be on-site at least three days).

Then, of course, there is always the possibility of mass casualties streaming in from the explosion of a nearby plant, responding to an environmental hazard from a chemical spill at a local train crash, or transporting your patients from an incoming weather disaster such as a hurricane or tornado.

And all this time, 46% of surveyed physicians don’t trust you, you must address accusations that you don’t sufficiently appreciate your nursing staff (nurses are increasingly joining unions in the U.S.), and the majority of the public has no idea what you actually do.

This is the career my students have decided to enter.

What my students say

Understanding all of what I have said about being a health care executive, these are samples of what my students say when asked about the future of American health care:

1) They are excited about technology that can make health care more humane – not less so:

“Health care in the U.S. is notorious for being clunky and confusing … The only way that these problems can truly be solved is through utilizing data in a thoughtful manner and pairing it with technology that works for patients, rather than for administrators.”

“The expansion of technology in medicine has created more access to health care and, therefore, to information … as our consumers become more informed, our care delivery will have to adapt to become more patient-centered.” 

2) They view their role as administrators as facilitators for the greater good:

“To stay relevant, health systems will need to adapt to fit the patient’s experience and convenience, rather than the provider’s schedule.” 

“Health care in the U.S. may be fragmented and siloed, but now is the time to fix it. I believe aligning incentives and controlling costs are the key components to solving this problem.”

3) They demonstrate compassion for the patients who are the reason why:

“We need to move back to a time where physicians, patients, and their families were responsible for making important medical decisions, not the individuals taking and giving money for that care to be administered.”

“I believe that quality of life and conversations about what patients value are going to be more common … I see people being more comfortable with having these conversations and more forward in asking for them. I think it will be a shift in both physician training and patient culture that will help move us forward in this area.”

4) They see themselves as guardians of the future:

“For me personally, beginning my career at this time in the scheme of health care in America, I am excited and anxious to be a part of the changes we will experience over the next 10-20 years … How will we, as new [master’s in health administration] students, be able to affect such a large complex system? I believe it will come through the support we offer to new ideas, and the new ideas we will bring to our companies during residency.”

“I believe that health care will have vast changes midway through our careers in 2040 and towards the end of our careers in 2060. The way we mine and utilize data, improvements to technology, and changes to patient and provider behaviors will drive the outlook of our health care delivery system over the next 50 years.”

The positivity, professionalism, and commitment demonstrated by my class at large (and each student therein) leave me every December with a smile on my face and a confident outlook for American medicine.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.

Electronic Health Records: The Dream vs. the Reality

(Public Health) Permanent link


This story was originally published on Sarah Freymann Fontenot’s blog, Fontenotes.

Last week, I sat with my 95-year-old mom in the exam room with her primary care doctor. I watched Dr. T sit with a small digital tablet on her lap, knee to knee with my mom. 

Throughout the visit, Dr. T’s fingers skittled over the screen as she accessed lab reports, other doctors’ records, mom’s medication list, and any other necessary data. By the end of the visit, without ever leaving her chair, Dr. T had provided mom with a full review of the status of her health, with details about every other physician’s involvement in her care. In the process, she had ordered one medication, changed a dosage on another, ordered homecare and records from a physician mom saw before she moved to Texas. The pharmacy, lab, physician offices, and assisted living center where mom lives had all received orders, faxes, and release forms under Dr. T’s capable fingers on the little tablet.

This, I thought, was the epitome of all we hoped for in a “paperless” medical world in 2004, when I first started teaching about the possibilities and pitfalls of electronic health records (EHRs).

Two days later, an article from Kaiser Health News and Fortune hit my desk: “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong.” It is an extensive, brutal, revealing account of all the ways EHRs are leading to increased costs, inefficiencies, and opportunities for fraud. Lack of interoperability causes critical orders and records to be dropped or missed; the article tells the tale of many people who have been injured or killed by these lapses. For more than 15 years, doctors have complained about the tedium of data entry that takes them away from patient care and is a considerable component of physician burnout.

In summary, the article is a damning report on the status of the drive toward integrating health information technology (HIT) into American medicine.

The contrast between my experience at mom’s side and the world depicted in the article is startling.

Which version is true? Is it possible both are?

Electronic Health Records: The Vision

There is no doubt the paper medical-record system that spanned ancient Greece to the 1990s (and still now) needs to be replaced. Unintelligible handwriting – long the most common joke about physicians – leads to patient injuries. Information in one setting (such as the doctor’s office) is unavailable in another (such as in the emergency department). Paper is inherently at risk of destruction – such as from a spilled cup of coffee, or on a regional level as seen during Hurricane Katrina when tens of thousands of patient records were swept away.

Paper records are cumbersome to write out longhand, and therefore can be incomplete. Documentation is critical for billing government programs or private insurance companies – so those same incomplete records mean many physicians (particularly primary care) leave money on the table because they do not have time to write everything they did on every patient every day.

People often have difficulty accessing a copy of their medical chart, and if their paper file is misfiled (a possibility with even the best record clerks), their information could be lost forever.

The “silo” nature of a paper medical office also makes monitoring physicians for quality of care, licensure violations, and fraudulent billing practices by both state and federal authorities more difficult.

Population-based research (can we cure the common cold?) is impossible in a paper world.

EHRs were going to change all of that.

The Slow Move Toward a Paperless Health Care System

The vision of a “Paperless Health Care System” began in 1972, but it wasn’t until the development of the internet in the 1990s that communication technology became relevant to health care.

Switching from a paper-based medical system has a long history of support from the White House. In 1991 President George H.W. Bush championed a model electronic record, and that same year the Institute of Medicine (IOM) suggested all physicians switch to a computer-based record by 2000. The U.S. Health and Human Services Department proposed the first national standards to protect patients' medical records under the Clinton Administration in 1999, in keeping with the HIPAA Privacy Act passed in 1996. President George W. Bush “pushed” computerized medical records in 2004; Barak Obama “proposed a massive effort to modernize health care by making all health records standardized and electronic” when he was still president-elect.

However, even with the push from Washington, adoption, especially by individual physicians, has been slow.

From the outset, money has been a significant barrier (an electronic record system cost $32,606 per physician 15 years ago). Third parties that may have been willing to help physicians purchase systems could not do so because of anti-kickback law.

Not only was the cost of a new system expensive, the necessary ongoing technical support added to the ballooning overhead for most physician offices. Training costs for all office employees, plus compliance with wave after wave of security concerns and privacy protection regulations, added exponentially to the initial investment.

As this transition was occurring, 30% of physicians were “boomers” who frequently lacked adeptness at a keyboard and felt stymied in their documentation and access to patient information.

From inception, adoption of an electronic record system has been voluntary (and remains so today). Multiple federal initiatives added incentives (and increasingly penalties) for doctors that said “no.” But many, with a conviction mirroring that of the late Charlton Heston, continued to hold their pens in their “cold (ok, alive) hands.”

The first real boost to physician adoption of EHRs came with the HITECH Act (part of the Recovery and Reinvestment Act of 2009), which offered the first financial incentives to physicians and hospitals investing in EHRs. By 2017, 86% of office-based physicians were electronic, and 96% of nonfederal acute care hospitals were on board as well. (It is worth noting that some physicians, admittedly a small minority, are reverting to their old paper records.)

However, as depicted so well in “Death By 1,000 Clicks,” the achievement of near 100% participation in electronic health care records did not alleviate the problems with the technology. In many cases the issues have become more entrenched. The top five the article discussed in detail are:

  1. Continuing patient harm;
  2. Ease of fraudulent billing;
  3. Gaps in interoperability and access;
  4. Doctor burnout; and
  5. Secrecy due to policies that “keep software failures out of public view.”

David Blumenthal, President Obama’s national coordinator for health information technology and an “architect of the EHR Initiative,” reflects the disappointment – the gap from the vision to EHRs in 2019 – in this quote: "EHRs have not fulfilled their potential. I think few would argue they have.”

Why Does Dr. T’s EHR Work for Her?

Looking back on mom’s visit to Dr. T, how can I reconcile that technology-driven excellence in delivering care with all the above?

I believe there are five reasons why Dr. T’s EHR experience avoids so many of the problems with EHRs encountered nationally:


  1. Length of use: Dr. T has been on an EHR for more than 15 years. She is “an early adopter.” The standard rule of thumb on EHR adoption is it will take a physician (and the staff in a medical office) two years to fully acclimate to this new model of recordkeeping and communication. Partly Dr. T’s skill can be attributed to her years of experience.
  2. Proper IT support/upkeep: Dr. T works in an office with multiple physicians, who collectively invest in readily available IT support. Many physicians can’t sustain the cost of on-site HIT support, notably the 15% that remain in solo practice.
  3. Mobility (tablet) and eye contact: Another major complaint about EHRs from physicians is they detract from the closeness of the traditional physician/patient relationship; lack of eye contact is the No. 1 patient complaint about EHRs. The small tablet Dr. T referenced from her lap allowed her to sit knee to knee with my mom and establish the connection necessary to leave them both satisfied. However, tablet models of EHRs only became available in the past decade (the University of Chicago was the first hospital to work with tablets on a large scale in November 2010).
  4. Recent technology: As is true with all technology, EHRs modify and advance significantly – and rapidly. In 2012, many EHRs were on their second, even third, iteration. Dr. T represents a physician who has continued to update her technology as advances came on the market. However, the cost of new HIT software will keep many physicians holding onto older technology as long as possible.
  5. Interoperability (at least within her system): As explained in detail in the "Death By 1,000 Clicks," arguably the biggest disappointment about EHRs in 2019 is the continuing lack of interoperability. Globally, that is also true in our hometown where Dr. T practices. Many hospital systems (large) and individual hospitals/medical communities (small) have conquered interoperability within their system. In a rural community where all providers are interwoven, local connections mimic what was imagined on a grand scale. Sitting in her office, Dr. T was connected to all the doctors and labs she was referencing in mom’s care (save the one doctor in Rhode Island from before mom’s move). The vision of EHRs can’t be realized without true interoperability across all barriers local, state, and federal. But in the interim, Dr. T can work happily on a local level.


How Do We Address the Problems with Our EHRs?

We are approaching 30 years from the birth of a vision for a national electronic medical recordkeeping system, and we are almost 20 years beyond IOM’s 2000 due date for complete adoption.

Nonetheless, and as extensively detailed in ”Death By 1,000 Clicks,” the problems with EHRs are enormous. But even those authors do not suggest the answer is to return to paper. The problems encountered in the old system are untenable in our technology-driven world.

The only way forward is to continue to improve the electronic record system we have, but to do so with a vigor we have not expended to date. We need a significant increase in federal funding and to draw the best minds in technology to build a fully integrated system. We need significant input from physicians and nurses to create EHRs that are intuitive, efficient, and reliable.

Most of all, we need to make technology companies responsible for true interoperability across the nation – with consequences if they fail.

Unfortunately, we also need more time.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.

Texas Neighborhoods Worlds Apart in Life Expectancy

(Public Health) Permanent link


Sometimes, statistics make you wonder – especially when they don’t add up. 

The Houston-based Episcopal Health Foundation last week issued a report comparing the life expectancy at birth of someone born in each of Texas’ 4,709 census tracts. The data came from the U.S. Small-Area Life Expectancy Estimates Project, which is run by the National Center for Health Statistics. 

“Drive 15 minutes through the biggest counties in Texas and you can go from a neighborhood where people usually live more than 85 years to another where the average person dies before he or she is 65,” Elena Marks, president and CEO of the Episcopal Health Foundation, said in announcing the report. “These numbers should spark important conversations across the state on how we can all take action to address the non-medical, root causes of these dramatic differences in health.” 

Given the growing recognition of the importance of social determinants of health, I thought I’d dive into the report to find some good examples to share with you. I didn’t realize how deep that dive would become. 

After finding, creating, downloading, unzipping, and sorting dozens of Census Bureau files, I’m still scratching my head. Maybe, in general, the levels of poverty, educational attainment, and minority population are good indicators for life expectancy in Texas neighborhoods. But at the extremes? Not so much. 

I started here in Austin, with Travis County, since a map of the neighborhoods here makes some intuitive sense to me. To my surprise, among the county’s 217 census tracts, the one where residents can expect to live the longest is right next to the one with the lowest life expectancy. They’re both south and west of Austin, in and around the community of Oak Hill. 

Astoundingly, there’s a 20.3-year difference in expected length of life between these two areas. The life expectency for children born in census tract 19.15 is just 68.6 years. Just to the west, in census tract 19.08, it’s 88.9 years. Wow! 

I know South Austin pretty well. I’ve lived the past 30 years or so within 5 to 10 miles of both of these neighborhoods. I would have guessed that 19.15 is a little bit worse off than 19.08, but not by much, and these two areas are far from the best or worst – socioeconomically – in Travis County. Right? 

Answering that question required me to spend some time with the U.S. Census Bureau’s American FactFinder project and the searchable data it provides from the 2017 American Community Survey. Once you figure out how to ask for what you want, FactFinder is really quite amazing. 

Here’s what I found about those two Travis County census tracts:

  • In 19.08, where folks can expect to live 88.9 years, the median household income is $110,833, 86% of the population is white, 89.4% have health insurance, and 60.1% have a high school diploma or some college education.
  • In 19.15, where babies can expect to live to be just 68.6 years old, the median household income is $64,599, 81% of the population is white, 78.3% have health insurance, and 63.6% have a high school diploma or some college. 

So, OK, the 19.08 population is generally in better shape than the people in 19.15 – except for education levels. But 26 of Travis County’s census tracts have higher median household income than in 19.08, and 99 tracts have lower income than in 19.15. Those trends hold for the other key variables: one tract is in the top decile or quartile, and the other is in the bottom group. But both are far from the extreme ends. 

So how do these two areas compare to the other 4,707 census tracts in Texas? When it came to life expectancy, they were in the top and bottom 1%, but they were again quite ordinary when I looked at the social determinants of health that supposedly drive length of life. 

More travels through the Census Bureau rabbit holes led me to these rather confounding findings:

  • The neighborhood where babies can expect to live the longest – 89.7 years – is right on the border with Mexico, in Hidalgo County, in the middle of the city of Weslaco.
  • We know that the Rio Grande Valley in general, and Hidalgo County in particular, are some of the poorest places in the country. By those standards, Weslaco is maybe a bit better off. The median annual household income in the neighborhood with the longest life expectancy is $37,257; for the county as a whole, it’s about $400 less. But for all of Texas, median household income in 2017 was more than double that: $70,136.
  • If you sort all of the state’s census tracts by life expectancy from highest to lowest, Hidalgo County again stands out – at the high end. Five of the 25 Texas tracts where babies born live the longest are in impoverished Hidalgo County. Only Harris County, home to Houston, has as many, and that’s likely a statistical anomaly driven by Harris County’s immense size and diversity.
  • At the other end, the lowest life expectancy in Texas falls to babies born in census tract 102, which is smack-dab in the middle of Wichita Falls. That’s a rather poor neighborhood (median household income is $19,406), but certainly not the poorest in the state. In fact, household income is lower in 51 other census tracts.
  • By the way, the poorest census tract in the entire state? It’s nearly across the street from where I’m sitting now and encompasses The University of Texas at Austin campus. The Census Bureau says median household income there is just $8,975 a year. And the life expectancy for a baby born in the shadow of the UT Tower? Not listed. 

If you’ve made it this far with me, I owe you some concluding remarks. 

First, the Census Bureau has amazingly detailed amounts of data and statistics about Americans, broken down into some of the tiniest slices, and it’s really pretty easy to navigate. 

Second, statistical analysis of population groups may be well suited to looking at data about groups of groups – e.g., how do income or educational level compare with life expectency for each 10% slice of the state’s census tracts? Looking at the individual neighborhoods at the extreme ends of this list leads you to … well, to not much at all other than a handful of large Census Bureau spreadsheets. 

Finally, if you’re going to put a statistical report through a does-this-make-sense test, start with some examples that mesh with your personal experience and intuitive knowledge. (If life expectancy in Travis County had shown up as lowest in parts of East Austin and highest in Northwest Hills – which is what I would have expected – I probably would have stopped right there. And maybe you wish I had.)

An Insurance Company Auditor Tried to Destroy My Career

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It’s no secret that in today’s health care market, insurance companies are calling the shots. As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape – final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care.

Niran_Al-AgbaDecisions made by insurers, such as MassHealth, have arguably killed patients. But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particularly virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under 9 are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from the insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross-checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The auditor in charge of my case failed to turn up any irregularities in our documentation. But, still, she issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called the auditor. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them; clearly a bid to save her employer even more money. I was shocked. Her directive amounted to practicing medicine without a medical license — which is, of course, illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, she took it upon herself to report me to the Medical Quality Assurance Board, the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate, which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with the auditor made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

Niran S. Al-Agba is a pediatrician in Sliverdale, Wash., who blogs at MommyDoc

Retiring the R-Word: The Right Thing to Do

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Quiz time. Which of the following words or phrases are now officially in the American Medical Association’s “not-preferred” category? (Apologies ahead of time if this Type-K question elicits stormy med school flashbacks among physicians of a certain age.) 

  1. Retarded
  2. Junkie
  3. Aid in Dying
  4. Schizophrenics 
  1. A only
  2. both A and C
  3. both B and D
  4. A, B, and C
  5. All of the Above 

The correct answer, obvious to those of you who know the difference between “person-first language” and “person-centered language” is No. 4. The AMA House of Delegates last month adopted policy that would put the first three phrases on the verboten list for physicians. When it comes to “schizophrenics” – as opposed to “people with schizophrenia” – the answer is, it depends. Typical Type K question, eh? 

Kudos to the delegates for recognizing that words, especially in the mouths and pens of powerful people like physicians, really do matter. 

Good words, the right words, spoken and written, inspire, inform, enlighten, uplift. The wrong words confuse, hurt, intimidate, discourage. 

Take “mentally retarded.” Clinically, it may be an accurate but overly broad term to describe a person with an intellectual disability. That’s yesterday. The R-word is toast. Parents should no longer have to hear a doctor say, “Your child is mentally retarded.” 

Some argue that opposition to that phrase is just part of parental delusion over the intellectual shortcomings of their son or daughter. That may be some of it. But when a word becomes a generic putdown and a nasty schoolyard taunt, it’s time to retire it from a physician’s lexicon. 

I’m proud of the Texas Medical Association’s Medical Student Section, who got the TMA House of Delegates to recommend that physicians use the term “intellectual disability” instead of “mental retardation” in clinical settings. Then they worked with the Texas Delegation to the AMA to win approval on a national scale. 

Briefly, on some of the other word-choice decisions the AMA house made:

  • Stigmatizing terminology such as “abuse” and “junkie” in the language of addiction, the delegates agreed, interferes with good patient care and puts extra potholes in the road to recovery. U.S. Surgeon General Jerome Adams, MD, speaking at the AMA meeting, said Americans should be “wrapping our arms around” people with substance use problems, not demeaning them.
  • Supporters of “aid in dying” lost out as part of a decision, finally, that upholds AMA’s ethical guidelines against physician-assisted suicide. “Despite its negative connotations, the term ‘physician assisted suicide’ describes the practice with the greatest precision,” the AMA Council on Ethical and Judicial Affairs wrote. “Most importantly, it clearly distinguishes the practice from euthanasia. The terms ‘aid in dying” or ‘death with dignity’ could be used to describe either euthanasia or palliative/hospice care at the end of life, and this degree of ambiguity is unacceptable for providing ethical guidance.”
  • The delegates also put the kibosh on such titles as “nurse anesthesiologist” and “podiatric physician.” That’s an important tool in our fight against scope-of-practice creep. And, of course, a physician is not a provider. 

Finally, there’s the question of labeling people by their disease or disability. I’m hoping “the gall bladder in room 418” is something you no longer hear in a hospital ward. The concept of person-first language has been around since the early ’80s. By saying, “Mrs. Smith is a person with diabetes” rather than “… is a diabetic,” you acknowledge that there’s more to her than that particular diagnosis. She’s also a carpenter and a mom and a soccer coach, and maybe even schizophrenic. Person-first language, which the AMA uses and is part of TMA’s official style guide, also does away with phrases like “cancer victim” and “wheelchair bound.” 

The problem is, some groups of people with disabilities – like the deaf – and some individuals, don’t like person-first language when it refers to them. They identify with their condition and want that word to come first. And so, we’ve come to person-centered language, which “focuses on each person’s individual preferences rather than using generalizing terms for a group when referring to a disease state or disability.” That’s the approach the AMA house adopted in June. 

So back to the quiz. “The schizophrenics” might be a phrase you avoid. Or not.

Photo: Taro Taylor

With a Grain of Salt

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Salt, sodium chloride, NaCl, is about 40% sodium and 60% chloride. It is ubiquitous and found in many different food items. It flavors food and is used as a binder and stabilizer. Salt has endured as an important part of our culture, and many different salt variants are available to meet our needs. 

The use of salt is now universal. Salt is thought to have entered the human diet about 5,000 years ago. Ancient Chinese texts described more than 40 types of salt about 4,700 years ago (Peng-Tzao-Kan-Mu, pharmacology). It is a food preservative – as bacteria can’t thrive in the presence of a high amount of salt – that helped humans migrate longer distances. 

NishantThe word “salary” was used to describe how Roman soldiers were paid for their duties with salt (Latin salarium). In 1930, Gandhi led thousands of Indians on a 240-kilometer salt march in defiance of the British Salt Act, which is considered a maiden event in India’s independence. 

Today salt is used as a way to preserve foods to prolong foods’ shelf life. 

The average American man and woman are estimated to consume 10.4 and 7.3 grams of salt per day respectively. The U.S. Department of Agriculture and Department of Health and Human Services recommend no more than 5.8 grams of salt (2.3 grams of sodium) per day, with a lower target of 3.7 grams for most adults (people over 40, blacks, patients with hypertension). One gram of sodium is equivalent to 2.5 grams of salt or sodium chloride. 

It is estimated that we need about 500 milligrams of sodium daily for our vital functions. But too much sodium in the diet can lead to high blood pressure and stroke. 

A study entitled “Salt Appetite” by University of North Carolina at Chapel Hill nephrologist Philip Klemmer, MD, showed that when he and a colleague went on an extremely low salt diet of 10 milliequivalents per day, they noticed a weight drop of 1.4 kilograms along with a drop in blood pressure. 

Multiple articles have shown weight and blood pressure drop with lower salt intake. A paper by Kirsten Bibbins-Domingo, MD, PhD, and others published in the New England Journal of Medicine showed that reducing salt consumption by 3 grams per day reduced coronary heart disease in the U.S. by 60,000 to 120,000 cases per year; the number of strokes decreased 32,000 to 66,000 cases a year. 

A study published in 1975 looked at the “salt-free culture” of South America’s Yanomami tribe, who had relied on food obtained by hunting and fruits. Of all the people studied in the tribe, the mean urine sodium excretion was 1.02 milliequivalents per day, whereas the mean systolic blood pressure was <110 mm Hg across all age groups. They also had high renin aldosterone levels given their high potassium, low sodium diet. 

Salt consumption is a cultural thing, where consumption is driven by taste and our appetite for processed food. 

Most salt we consume today comes as a preservative in foods that we buy. Table salt and salt added while cooking contribute to about 10% of salt consumption. (Figure below) 


According to the Centers for Disease Control and Prevention (CDC), the top 10 salt contributors (in mg) are:

  1. Bread and rolls (80-230),
  2. Cold cuts/cured meats (1 bacon 194/1 beef jerky 443),
  3. Pizza, 1 slice (500-700),
  4. Fresh and processed poultry (300-700 mg),
  5. Soups (300-500),
  6. Sandwiches like cheeseburgers (700-1700),
  7. Cheese, 1-oz. slice (330-440),
  8. Pasta dishes like spaghetti with meat sauce (400),
  9. Meat dishes like meatloaf with tomato sauce (600-1100), and
  10. Snacks like chips, pretzels etc. (140). 

This helps me talk salt to my patients, informing them that the real salt that one needs to cut is the salt that’s in packaged and processed foods. Feel free to sprinkle that salt on your watermelon! 

Nishant Jalandhara, MD, is a clinical nephrologist practicing in the Greater Fort Worth area. His areas of interest are hypertension and chronic kidney diseases prevention and management with a special emphasis on home dialysis. He graduated from the Texas Medical Association Leadership College in May 2019.  

Photo: Lexlex