Cambridge Forum; WGBH Forum Network; Danielle Ofri on Foreign Immigrants and US Health Care

Welcome to Cambridge forum discussing medicine in translation health care reform at the edge. I'm Pat's or key director of the Cambridge forum rhetoric in the current debates over reforming the US health care system has grown increasingly heated as legislators try to balance access and affordability in an ideal world everyone would have health care. The realities of paying for that care however lead policymakers to find ways to limit universal access. And it is often the most vulnerable groups the unemployed the very poor immigrants that are left out. How can doctors reconcile their ethical and humanitarian responsibilities to care for those patients at society's edges with the limitations of our health care system. What kind of health care reform would make an actual difference in the lives of the most vulnerable and in the lives of their doctors. Daniel offeree is an attending physician at

Bellevue Hospital in New York City where she is practiced for the past 15 years. She is also a writer documenting her experiences as a physician at the world's oldest public hospital. The co-founder and editor in chief of the Bellevue Literary Review. She has published widely in both professional and popular journals including the New England Journal of Medicine Lancet the New York Times and The Los Angeles Times. Her previous books are singular intimacies and incidental findings. Her latest book medicine in translation journeys with my patients serves as a starting point for our discussion. Amy Whitcomb Slemmer is the executive director of health care for all the statewide advocacy organization focused on creating an affordable accessible culturally competent health care system. An attorney by training. She has worked on health policy for more than 20 years

serving as executive officer of the American Red Cross biomedical services and is legislative counsel for the National Association of People with AIDS Missler began her career as a member of Senator Edward Kennedy's healthcare policy staff. We'll start this evening. Welcome to Cambridge forum. Danielle Oh free. Thank you. Good evening and thank you so much. Generally we give grand rounds at a medical center we start with a case where I thought I'd start with a case on this case. It's really a journey a journey I have taken with one of my patients for a very long time so long actually starts back in a previous book of mime. And this essay initially appeared in The New England Journal of Medicine. But as I'm in denial about my need for reading glasses I'm going to read from the book because the font is larger and the chapters called torment. I groan when I catch sight of her name on the patient roster. No not again. I dread her visits and

today is no exception. A small plump woman Mrs. Houdin is cloaked in a robe headscarf and veil all opaque blue polyester. Only your eyes peer out from the sea of dark blue. She's trailed as usual by her 11 year old daughter who wears a like green gown with a light flowered headscarf. Mrs wooden flops into the chair next to me and the scene approaches on the exam table with her white Nike speaking under her floor length gown. This is Houdini unsnap surveil something she only does with her female doctor. And the litany begins. Oh doctor she says pinching the sides of her head with skin peeling force. The pain is no good. After this brief foray into English she slips into Bengali aiming her barrage of complaints at a Xena who translates them to me in fits and spurts while fiddling with her wire rimmed glasses. There's abdominal pain and headache diarrhea and insomnia. Back pain aching arches a ration gas pains itchy ears and a cough no appetite. The smothering

sensation begins if she doesn't stop i will drown in her complaints. I know they should be focused on Mrs. Dean's words but I fear for my sanity. I scan the computer while she moans about her shins in a Cox 6 and I see that she's been to a neurology clinic rehab clinic pain management clinic gynecology clinic all in the five weeks since I last saw her doctor. She's pleading with me now again in English and I hurriedly refocus on her. Why so much pain. The leathery grain of Mrs.. Skin and her seemingly permanent submission in the world of the sick make me think of her as elderly. I'm always shocked when the computer reminds me that she's only thirty five. Why Doctor why her laments are punctuated by the resonant third of a Xena sneakers being repetitively absent mindedly against the metal exam table. The truth is I can't do anything for Mrs. I've talked her endlessly about stress and depression which I'm sure underlie many of her complaints but she never follows through with the psychiatry referrals or the antidepressant medications. Her resistance to my efforts sometimes makes me feel as though she's in a personal battle against me.

I hate to see her in the waiting room. I hate the wind in her voice that is detectable even when she's speaking Bengali. I hate the veil that she wears and the last bit of cultural sensitivity I possess is washed away. How can she let herself be hidden away in a sea of horrid polyester. How could you buy into that culture. I hate that she would team Lee keeps her daughter out of school to facilitate her wild over use of the medical system. Whenever I treat one complaint another burst to the surface and then TASA temporarily relieved her stomach pains. Then she'll have palpitations and hiccups. I can't breathe she says. I don't eat. I don't sleep well. If that's truly the case I want to retort How is it that you are still alive. I shudder as I realize that I am slipping too far. The annoyance and resentment are getting the better of me. But sometimes I wish she would just disappear out of my office out of my hospital out of the city off this planet. How is it that she emigrated thousands of miles from her obscure village in Bangladesh to end up precisely in the catchment area of my clinic and then randomly in my office.

You were healthy. I say to Mrs. Adding sternly no reaction. I turned to the daughter. Tell your mother she is healthy all her tests are normal as Enos faces blank as she translates. After speaking the daughter looks down her sneakers her light veil tumbling over her shoulders as she lowers her gaze. Are you almost finished. She asks. She looks up at me. I have to take her home on the bus. Then I have to take another bus to school I don't want to miss the whole day. Can't you mother come to the clinic by herself. I ask. We do have interpreters available. My mother is afraid to go out by herself as Zena says in a voice that wants to be belligerent but is too wary. My brother is in college and my father works. So I have to take her to the doctor. She stares back down in her sneakers which stop banging and I know wriggling from side to side like lively caterpillars. I turn from the computer and look really look at a Xena. Her eyes are smooth sandalwood magnified into iridescent discs by her thick lenses. What is it like at home I

ask. She doesn't do anything as in a mumble she just sits there. As you know space has a preview Besson choppiness that is somehow in Congress with the seriousness of her headscarf and glasses tears begin to slide down her cheeks and her voice rises in a warble. She doesn't say anything to us. She doesn't cook dinner anymore. She doesn't go anywhere. My mind begins to paint a picture of the home and I see a little girl cut off from her mother reeling in the wretched vacuum the depression creates. A child conscripted to be the fulcrum of cultures illnesses and torments all while completing the fifth grade. I am mortified now that I was so consumed with my own feelings of being overwhelmed when before me sits a child who was drowning a child grasping the rickety timbers that can barely support her mother and the threatened to sink them both. It is the innocence of this pain its simplicity that will shock you back to reality and humbles me. I realize that never in all my visits with Mrs routine have I paid any attention to his Ina.

She was always a mere appendage to her mother's appointments trailing along obediently translating erecting so many first generation children do though I'd like to write of Mrs Dean as just another complainer as one who can't pick up without demanding an MRI. She is truly suffering. Her daughter is truly suffering. I am not suffering. I am actually the complainer. I am the one who can't face this patient without immediately rolling my eyes and turning off my compassion. The reality is that I am profoundly discomforted by my inability to treat. I take the hands of both Zena and her mother for they are both my patients now. Depression is a painful illness. I say broken souls can hurt as much as broken bones. I explain about antidepressant medications and the importance of psychotherapy and we negotiate a contract for treatment. This time include a stipulation and this is routine must come alone or with her husband as you know must stay in school. As you know wipes her tears gathers her papers and snaps back on the rail. She promises to take the medications and see the psychiatrist. Of course we've been

down this road many times before and I won't be surprised if she's back next month with a new physical ailment. Not taking her medications and having missed a psychiatrist appointment and I won't be surprised if I again dread the visit. But I think at least I hope that I'll no longer view not moodiness a personal torment as you know has cured me of that. This is when I first met Mrs. Dean quite a number of years ago and she's been my patient for quite some time and I see her quite quite regularly now. Dean was back on my list for an appointment for the morning clinic session weeks earlier than her scheduled appointment but I was not surprised. When I called her in from the waiting room she came down the hall company by a slender young woman cloaked entirely in black. A black head scarf covered her forehead resting just above her eyebrows and a thick black veil came up over the bridge of her nose leaving the barest slit for her Kohl lined eyes and even smaller space than the Mrs veil which at least allowed her forehead to be exposed. The young woman's hands were encased in black linen gloves and she moved like an apparition with

barely a rustle for black robes. There is something with exotic and forbidding about her. I ushered the women in. As usual Mrs. unsnapped her veil but the woman shrouded in black did not. I wondered if she was a relative visiting from Bangladesh. Good morning I said. Mrs. Woods face was scrunched with frustration. She took out the bottle of anti depressants I'd prescribe at the last visit and plotted on my desk. These pills no good they make veins in my neck swell fire burning in my head no good. For how long did you take the pills I asked. This is waved away my question like she was swatting a fly. I take few days but no good I need better pills. If nothing else now is moody and offered predictability every visit was consistent. We tussle gently over the same issues negotiate compromises that we tried before and give the whole thing another go. We've been doing this for eight years now. I imagined us aging together each offering the other a strand of stability. How are things at home I asked. Home good Mrs Odeon answered the tautness in her face easing. She leaned toward the woman in black

as Ina visiting so things good for this week. Xena. This was a Xena chubby speckled ezine it was now a slim high school junior. At the mention of her name as Enoch turned toward us she said stop making such a big deal. I could see her eyes roll within the tiny slit of her veil. Just a visit c'mon. As you know was attending a Muslim boarding school in upstate New York and was home for vacation. She's locked in the chair and the cuffs of her jeans peeked out from under the edge of her gown. How was school I asked as you know wondering about her transformation both during. She replied No boys in the class and they don't allow color. She informed me. I was intrigued by the differences between a Xena's veil and her mother's veil hung loosely over her face like a curtain and unsnapped with ease as Enos was a black cloth pulled so tight that I could make out the contours of her nose cheeks and lips was tight somewhere in the back under layers of her headscarf and gown. It looked vastly more uncomfortable to me like it was smothering. She didn't remove her veil with me and I

wondered if that was because she'd become more religious than her mother perhaps as a result of her boarding school experience. As I contemplated this I realized how little I actually knew about the Muslim veil. Perhaps it was time for me to learn. I wasn't sure how sensitive a subject the veil was and wondered if it would be considered an affront to broach the subject. But I felt that I knew Mrs. Dean and by extension as you know well enough by now. So I asked somewhat timidly if I could pose a question about the veil. They both nodded. I asked is enough not taking off the veil in my office like her mother was a sign of increased religiosity. Sina laughed uproariously as soon as the question left my mouth. No she said. The only reason I don't take it off here is because it takes forever to retire and I'm just too lazy. Asked my mom. Her ease with this along with the magnitude of difference between my Sumption and her reality relaxed the conversational berth. I feel comfortable now and asked all sorts of questions about the veil. Even naive ones as Xena took the lead in answering her infectious energy spilling

out despite the tight veil that completely wrecked her face. I wanted to know if it was hot under there. Was it hard to breathe. How do you decide which color or what style. Was it a family norm or a mosque. Norm did it different different countries. As you know her mother chatted amiably seeming delighted to educate me in this nuance of Muslim culture while the subject had been a little touchy for me it certainly wasn't for them taking a bit of a risk and pressing further I asked if there was any pressure or coercion about wearing the veil. Mrs. Houdini answered this one of the medically no veil is my choice. My husband he tell me not to wear it. He said people treat me bad they say I am terrorist. Her voice grew more animated and assured. But the veils between me and Allah she said pointing upward. I wear a veil. No matter what anyone say it is my connection to Allah. The conversation proceeded toward Islam in general and I learned how devout Mrs Dean was and what pleasure religious observance gave her. The most interesting thing for me beside all that I was learning was the transformation that occurred to

Mrs. Dean while discussing Islam and the veil. She became buoyant while her whininess disappeared. The aches and pains seem to evaporate. Her voice and body language reclaim the heft and vitality one would expect from an otherwise healthy 43 year old woman. This was not a meek oppressed woman. I thought this was not a woman beaten down by a patriarchal religion. This was a woman inspired fortified dare I say empowered by her religion. As I finished my visit with Mrs. Dean I rose we just gained a new clinical insight perhaps even a new therapeutic tool. I realized that I might finally look forward to Mrs Judeans clinic visits so I didn't want her to keep out of school for her appointments I hope she would come to some of them so we could continue my education as well as for mother's treatment. The last part that I'll read just a short last part happen actually quite recently. Now smooching was on the schedule for an appointment but is ina now a freshman and Community College in Queens showed up instead. Mrs Union wasn't feeling well and sent her daughter to pick up her

prescriptions. The elevators were packed. So as you know it's printed up the three flights of stairs in order to be on time. She was breathless when she arrived. Skin flushed cheeks puffing from exertion upper lip peaked with moisture. Her hair was coming undone from its ponytail. It was only when she used the back of her hand to wipe off the sweat that it occurred to me what was different. There was no veil no headscarf. The thick strands of her dark hair were glistening even under the harsh fluorescent lights. She wore jeans and a sweater no gown covered her clothes. I'm sorry my mom can't make it she said taking quick breaths between words. She promises not to miss the next appointment. She pulled a clutch of refill slips out of her bag. These are the prescriptions that she needs. As you know I said my mouth hanging open what would happen to you. Then I stopped unsure if I was treading on territory that might be too personal. I had a scene embarked on a college rebellion. Was there a falling out with her family. Did she find a boyfriend who was less religious. Was she making a statement about assimilation. But then I recalled how forthrightly and

warmly as he not spoken to me about the veil the last time. So I decided to ask. As you know what happened to your veil as you know laid the papers on my desk and smoothed them carefully. I had an incident three days ago an incident. I said What do you mean. I was waiting for the bus on my way to school and there was this guy at the bus stop. As he looked past me as she spoke directing her words toward the wall he was looking at me funny. Then he starts to talk to me. 911 was your fault he said. You killed 3000 Americans. So I said to him I'm Bangladeshi Bangladesh didn't have anything to do with 9/11. And he start to walk over me in this threatening way saying over and over it was your fault. 9/11 was your fault. At backed up against the wall of the bus shelter and then he pulled out a knife and waved it in my face. You people ruined our country healed. I couldn't move he had me pinned against the wall. Then he reached over with a knife and tore my veil and headscarf off with it.

I was so scared he was going to stab me. The only thing I remember was that the pins that held it in the back scratched my neck as the veil came off. I must have screamed I don't even remember. Some teenagers passing by jumped on him and pulled him off me. As you know his voice sounded wooden as she spoke but to me it was a sledgehammer in the chest. Someone call the cops she continued they came pretty quickly but I felt so naked so exposed in front of all these strangers so embarrassed that I was the cause of all this. The police brought me home but I wouldn't leave the house for two whole days. Today today's the first day have gone out. My father told me to stop wearing the veil that it was too dangerous. I looked up at his ina her somber demeanor a punishing contrast to the voluble engaging teenager who'd spoken to me last time. I reached over and touched her sleeve. As you know I'm so sorry this happened shouldn't it's okay she said cutting me off it's not anyone's fault there are stupid people everywhere he was just a stupid guy. But still I said this is horrible. I'm getting over it she said the color returning to her voice. I've decided that I'll probably wear my

headscarf but maybe not the veil. My father is against it but this is America and I can do what I want. Besides I can't sit around thing sorry for myself and use my energy to finish pharmacy school and to take care of my mother. She rolls her eyes dramatically. And you know how much TLC My mother needs. Thank you. Thank you now let's hear from Amy Whitcomb Slemmer of health care for all. Amy how could the people that Danielle cares for be helped by the current proposals for health care reform. Oh my goodness thank you so much it's a pleasure to be with you this evening. And I guess I have a very quick answer and that is we need to make sure everyone has access to somebody as wonderful as Dr. Overy. That's a remarkable story and one of the things that health care for all is challenged with

is raising up awareness about the difference that a culturally competent provider has when interacting with their patients. So I think you've just heard from Danielle a transition that happened because she spent a significant amount of time listening to suffer persevered through difficult visit after visit before getting to the root of some of the problems that. Ms Dean was having so that was a remarkable and very powerful I appreciate that very much. I know that most of you in this room are very aware of the fact that we find ourselves at an unprecedented moment in the history of health reform in this country. As you heard at the beginning in my introduction I began my professional career as a member of Senator Kennedy's health policy staff. And it was there that I learned at the hand of a master about the importance of cultural competence and making sure that when we talk about

health care for all we mean everyone. And it is my privilege to continue his life's work as the executive director of health care for all. And at this moment when we are at the precipice of reforming our national health care system I think having this opportunity to talk about some of the folks who are marginalized and often hardest to treat and reach in our country is a remarkable opportunity so I welcome this opportunity to talk a little bit about where we are and what national reform actually holds in store for some of the people that Dr. retreats and sees. First of all contrary to popular belief the entire world has not changed with the election of one senator in the great state of Massachusetts we have elected a new senator for the great state of Massachusetts. I do not believe we have derailed the movement for national health reform as I believe that I do.

I feel very strongly that the politics may have changed we've gone from a super majority in the Senate to a really good majority in the Senate. But the principles have not changed we continue to have 40 million uninsured people in this country who are waiting to have access to lifesaving health care. And as many of you may know some of the most remarkable parts of national forum that we're talking about are built on the experience that we had here in Massachusetts. In Massachusetts we have the privilege of being able to talk about the fact that we have the lowest uninsured rate in the country and health care for all what that means is we hear from thousands of people across the commonwealth who call to tell us what a difference it's made to have access to the health care system in their lives. Folks who had never had access or gone to a doctor or a provider before have shown up and found that in fact they need treatment and are able to receive the treatment that saves their lives or others who were discriminated against

based on preexisting conditions who now are able to have a relationship with a provider and are able to manage a host of problems and maintain good health and live healthier and more productive lives because of health reform in Massachusetts. So I'm going to talk a little bit about the provisions in national reform and then some about some of the direct benefits that we have in Massachusetts and then finish with a charge for action and then happy to have questions. And both the first of all let's all remember Congress has voted for health reform. Both chambers have voted in favor of national health reform and now we need to figure out the next steps to get it to the president's desk. In both the House and Senate versions they both bills contain something called the Community Living assistance and services support program. This is a program authored by Senator Kennedy to provide benefits for people with disabilities to help them live independent lives. And as I

say because it's in both bills we feel very confident that this will be part of national reform that passes all consumers will benefit from national health reform because of something called consumer engagement. Another element that is from based on the work that we've done here in Massachusetts we know that if you suddenly have a requirement to become insured or you insure tens of thousands and hopefully millions of people there is a huge shift that needs to take place so that people like the patients in doctor or phrasebook need to have access to information about how to take advantage of the insurance. How do you pick a provider. How do you access the services that you now are eligible for and health care for all. Has pioneered a helpline we have an 800 number that people from all across the commonwealth call in tens of thousands of calls are fielded each year and the counselors at health care for all connect people to the care they qualify for.

So we help students figure out what they're eligible for we help newly uninsured people new people to the Commonwealth people who have been disenroll for their from their insurance for whatever reason connect to the services and the benefits that to which they're entitled. And it's not just a one way street it's the reason it's referred to as consumer engagement at the national level is because this is a two way street. These helplines not only provide a direct service to people who need them and are trying to navigate a fairly complicated system but it also is an opportunity to aggregate the information that we're hearing to improve the system we're working with so with healthcare for all. We feed back the information we get from our callers to the state so that Massachusetts can improve the health reform bill and implementation process in respect direct response to the callers who talk to health care for all. One of the things that we feel most strongly about and I appreciate the mission statement for health care for all for all being read because we truly are

advocating for comprehensive affordable culturally competent health care for everyone. Including and especially we call out the most vulnerable among us and one of the things we know is needed for vulnerable populations is culturally competent care. And we also know that you need to pay special attention and provide incentives for people to go into the health care system so that we better reflect the communities that they're trying to serve. Imagine what it would be like for Dr. Friese patient if there was a Bangladeshi doctor on staff who could jump in and provide a direct experience and a relationship based on common cultural factors. I believe you made amazing inroads in a relationship and a connection with the family. But wouldn't it be wonderful and it sounds like the daughter is going to become a member of the health care system which is marvelous. And another testament to your good work I'm sure. But we are pushing hard to have workforce

diversity initiatives included in national reform. And there are some very impressive provisions in the Senate bill and in Massachusetts there are some incredibly innovative programs going on recently UMass talked about a marvelous program to reach into high schools identify high school students who would otherwise be at risk in poorer neighborhoods and connecting them to the med schools so that they will be mentored through high school through college and will have med school scholarships which is very exciting. I've just learned about a program that has decided in fact high school maybe too late to attract health care providers. They are mentoring and becoming pen pals with second graders. So these second graders at this giant Boston based hospital system are received notes and encouragement from professionals on staff at the hospital and come in twice a year and the hope is that they'll feel some sense of connection and comfort in a health care system that is often

foreign and used as an emergency basis without the kind of appreciation and use for primary or preventive care. The. National legislation that is in front of us makes some true investments in loan forgiveness programs in reaching into communities to attract providers who will better or be able to represent their communities. The other thing that we have healthcare for all are working very hard on is having an amendment included in national reform that will lift the 5 year bar for legal immigrants to this country so right now there's this arbitrary requirement that you must be here legally for five years before you can access any of our public benefits in the country. And in Massachusetts I'm very proud to say that when we passed health care reform in 2006 we extended that offer health care reform to all residents of the Commonwealth regardless of your birth

origin. But if you're here legally you had access to health care services. And we think it's vitally important that the National Work reflect the fact that if you're here and you're contributing you deserve the right to have access to health care coverage lifesaving health care coverage. And we're motivated health care for all of the statistics that we've read about how the death rates that happen for people who don't have health care coverage. There are 40000 people a year die needlessly because they didn't have access to our health care system. In Massachusetts we're incredibly lucky that that number is significantly lower because we have so many folks who are covered but these it's a waste. It is a missed opportunity for these people to contribute to our society and imagine the devastation that they leave in their wake. We believe firmly that this has to be stopped that we must pass national health reform so

that we can bring all people into the health care system as I say for US health care for all truly means everyone. There are some stories that we've collected at the helpline from people who can point to the fact that they now have access to lifesaving medication that they have relationships with providers that having access to health care coverage has literally saved their lives. And Massachusetts we made a strategic decision to work on health care coverage first and I will say that health care for all was a little reticent and we had some concerns about the bill that was pending in 2006. We wanted more generous benefits. We thought there were opportunities to go after quality improvement. We very much want to talk about cost how ever we got to the point of passage of the bill. And I invite you to think about the current environment and decided that as a consumer advocacy organization. As the

organization dedicated to getting health care coverage for everyone in Massachusetts we would work within the compromise and support the bill that finally passed in 2006. And I will say that I know there were a lot of internal discussions and I know that as we talk about in Massachusetts shared responsibility that business was having some of the same qualms and the state government was trying to figure out if they could truly provide the subsidies that were going to be required. However the interests aligned and we were able to pass reform. And I know as I say what a tremendous difference this has made to individuals in Massachusetts. Now we are three years beyond that. We get to talk about having the lowest uninsured rate in the country. We have covered 400000 people in Massachusetts since we passed reform in 2006 and now we have the opportunity to work on phase two of health reform. So in Massachusetts we're now working on

quality and cost. We're talking about thinking about ways to improve the quality of the health care that's delivered to us and reducing the cost to individuals to the system that that health care that our current coverage demands. I believe there were an awful lot of people who went to the polls and supported Senator elect Scott Brown because health care coverage is taking up more and more of our budgets. I know that for health care for all my health insurance costs for my organization went up and it's very difficult when in fact our our fundraising didn't necessarily keep pace with our health care cost increases. And I believe that's reflected in individual family budgets all over the Commonwealth. However we have an opportunity to talk about the next phase of health reform. And as I say for us that is in the realm of payment reform health care for all is working using recommendations that were put out by the.

A Reform Commission over the summer to look toward a time when we move past and beyond fee for service health care. We know that studies show and I believe intuitively we can probably appreciate the fact that a fee for service system often rewards the quantity of services we were CVS without necessarily rewarding the quality of the services we receive. So our providers the more tests that are done the more times we're seen. The more money our provider receives. However if she keeps us well if she puts us on the right path as Dr. Offit clearly has been able to do in a visit and makes sure we're connected to the services we need there's no ancillary benefit for the provider. We think it's really important to think about a different payment system so that we can discuss our comprehensive health profile so that we can work toward wellness instead of working on our

sick profile. And we think this is a very exciting opportunity. Again if you look at the national stage we are once again at the cutting edge and about five years ahead of where I think an awful lot of people in Washington find themselves. However in national reform there are some very exciting pilot projects that are included in legislation that would allow some of these pilots to begin across the country. So we're very encouraged about that. And for people who are not sure about national health reform and how it fits in or would benefit Massachusetts I would remind us that there are a whole lot of benefits that would come to the Commonwealth even though we have taken the steps to cover our folks even though we have some of the finest health care in the world at our disposal here in Massachusetts. There are still things that we feel strongly will be of benefit to the consumers in the state including increased subsidies for people who make up to 400 percent of the federal poverty level. One of the compromises that had to be made in

Massachusetts in 2006 was that we could only provide subsidies for people making up to 300 percent of the federal poverty level. So right now for a family of four that's about $66000 a year if you make above 60 $6000 a year you don't qualify for state based subsidies for your health care coverage in the federal bill. That would increase to fourth or 400 percent so that a family of four making up to $88000 a year under current numbers would be eligible for subsidies. And we think that's vitally important. We know that there is the struggling sector of folks who want to buy coverage who want to have access to health care. However really struggle with family budgets and the cost of health care. We know that this will make a tremendous difference. We also know that there are some tax exemptions for small businesses. You've heard an awful lot and I think it is vitally important that we pay attention to the fact that employers in Massachusetts one of the scare tactics we heard in

2006 was that employers would drop coverage if you have better state based programs if you have more wide availability. There would be crowd out and employers would no longer provide coverage. And in fact to the credit of the employers in Massachusetts that hasn't been the case at all there are now more employers that provide their employees coverage than there were before health reform. And we have an exchange as you listen to the national debate and you hear people talking about whether there should be exchanges or not exchanges here in Massachusetts our exchange is called the connector. And our connector actually has some power to negotiate with a health care provider with insurers to lower the costs of plans that are provided. And we've seen a decrease a significant decrease for the people who have bought these plans for individuals and the small market which has made a big difference. And again in national forum there will be increased subsidies and tax tax incentives for small businesses to make health care coverage more affordable. There are also grants for medical research and innovation and we

know this is incredibly important and Massachusetts is poised. I don't know of any other jurisdiction that is more ready to take advantage of these grants and subsidies than Massachusetts. There will be money for innovation not unlike the stimulus money that's being spent and invested with. I will say that with alacrity around the state there will also be grants available for research and innovation. And finally the Medicare donut hole will be closed almost immediately so that seniors will see a decrease in their drug coverage costs immediately and we think that's vitally important. So from a macro perspective I have some concerns and those concerns have to do with timing. I think the longer we go on not having passed reform the more people get worried and back away from the edge of making a significant difference for this country. And I worry about that. I think the interpretation of the Scott Brown election

has been surprising in that one person might stop a debate that's been going on. You know it for those of us who've been working on this for decades it is astonishing to me that we would back away from being on the precipice of doing marvelous things for millions of people in this country based on the election of Senator elect Scott Brown. I will remind everyone and I'm positive you all know this that Senator elect Brown supported health reform in 2006 in Massachusetts. He lives with constituents who can speak about the importance of this reform in their lives. And we hope that he'll be able to spend some time in Washington talking about the benefits of health reform in Massachusetts and that is awaiting the rest of the country once health reform is passed. I think in Massachusetts one of the things that we learned and I would call on any legislators to pay attention to the fact that in this commonwealth we had almost instantaneous benefits to

passing health reform. There were people within four months of the bill passage who suddenly had access to care in national form. I think it's vitally important to pay attention to what some of the instant benefits will be. I think in the Commonwealth we take for granted sometimes the fact that we have had insurance reforms before we had health reform. So we are not discriminated against based on preexisting conditions. Please hear the national debate and know that those reforms that are baked into the reform legislation are based on the work that we've done here in Massachusetts. So no denial of benefits based on preexisting conditions. Medical loss ratio that's limited and importantly a limit on the amount you're allowed to charge people based on age. I had no idea until I returned to Massachusetts that we were in the vanguard of limiting that amount to I believe the amount

is a fairly modest increase but I know around the country there are some folks who pay three and four fold what young person does based on age which is just wrong and will be taken care of with national reform. So having run through scenarios and some of the benefits in Massachusetts I want to say this. As a charge a call to action. We learned in Massachusetts that you will not get a perfect bill. Had we waited there would be 400000 people in Massachusetts who didn't have access to health care coverage. I believe now is the time. And I know from experience that we won't get this time again. So it is vitally important that those of you who are working on health reform those of you who care about consumers those of you who have been working for social justice for any part of your professional volunteer career

need to get in touch with the members of the House and the House of Representatives has to pass the Senate bill and then make the changes and the adjustments that we care about during reconciliation. If they don't do it soon I don't think we have another opportunity I certainly don't see one. And as the president has said we don't quit. So this will be a process of ongoing improvement. But the time is now. For the people you heard about in Dr or for his book for the people who are voiceless around the commonwealth and around this country for the people who are worrying about medical debt and choosing medicine over mortgage or a mortgage over medicine for the people who cannot sleep at night for fear that they will get sick and not be able to care for their children and not care for themselves. We absolutely have to pass national reform. So I invite you to join me in this effort. I believe it'll take all of us working hard. I know the Massachusetts delegation can play a leadership role in

promoting this change and I know it will make a huge difference for all of us. Thank you very much. Thank you. Thank you. OK let me remind the radio audience that you're listening to Cambridge for a moment as we discuss medicine in translation health care reform at the edge with Dr. Daniel of free and Amy Whitcomb Slemmer of health care for all. I like to start off the questions by asking Danielle. Oh free. You talked about a case you talked about patients you talked of your observations are very very people centered. And you were obviously able to find time. And and the ability to interact with Mrs. Dean and her daughter. Could you reflect on that experience in the context of the system

that you work in at Bellevue Hospital and the demands on your time and the demands on billable hours or whatever they're called at Bellevue Hospital. And talk a little bit about how you bring that really human experience of being a doctor. To you and. Functioning within this health care system. Thank you. One of the challenges in medicine is the tension between things that we measure as quality and I'll put that in quotes. Things we need to accomplish various administrative requests and then what it takes to really practice medicine and I think they're often not the same thing are often in conflict. There's this increasing trend toward quality measures and in our hospital we get various reports on our blood pressure levels cholesterol levels anyone see these. That's one aspect of health care. But when you are looking for a doctor for your child

or for your parent or for yourself and you ask someone to please recommend a good doctor it's rarely where they graduated or their statistics on the web. But it's who the person is who is going to take care of you because I think that ultimately you're entrusting yourself with a physician or a nurse. And that's going to be the most important thing. And it's very hard to quantify and so I think about these rating systems. I get all worried because I don't know if they measure what it is that when I think of who's a good doctor who I take my family to that that I would measure. It's a real challenge we have a 15 minute session and patients may have three or four illnesses. They may have psycho social issues. Language barriers economic barriers that all have to come into play we need to document everything we need to use an interpreter. It's hard to get that all done and address your patients really is often the agenda is not what they come in saying they may say I have chest pain but in fact there's something else going on. And sometimes it's only when we shift away from the standard exam the example that I

use is now that computers are everywhere in our system they're very efficient they're great data collectors. But I find they actually compete with the connecting part between the doctor and the patient. In my clinic in order to finish on time I must write while I talk to patients impossible not to. So then I'm looking at my computer screen not my patient. And it's a very stilted experience so I find that when I go to the exam table when we're now touching when we're not sitting with the computer when there's a physical intimacy it's not a romantic intimacy but intimacy Nonetheless the dynamic changes and often that's the time the patient can say what's really on their mind when the trust is established. So it's a real challenge so it advice I give to my students who often freshet How do you do this in 15 minutes. Simple things like for the first two minutes. I don't write anything down don't look at the computer. It's a small amount of time but it's very long and making a connection. Making sure to ask you know did we get everything. Is there something else on your mind. And then sometimes over time with Mrs. Houdini took many years. She's been my patient

now for more than a decade. And like I said I feel like we're an old married couple at this point and often I don't get that that luxury of continued care but if there is that chance and she keeps coming back you no matter what I do she's always coming back. And so part of me never wants to leave because I have patients like this I've had for decades so I think that you can have continuity of care. But I just worry that these measures of quality don't measure what I think is the real quality of compassion and healing. Yes I want a doctor who is good but you know what. Most doctors are good enough I really do think they all graduated at the top of their class they did OK. There's probably a few bad apples. But what really makes the doctor the person you want to entrust your life in are things you can't quantify. And that's what you I think most patients react when they say this is a good doctor. I like to follow some of the things you talked about relate to the concept of the patient as the consumer. And you've you've given at least a little bit of

of response to that idea. What kind of a consumer what kind of a consumer of medical services can a patient be. And and in me I would like you also to talk about the idea of how can a patient a sick person or somebody looking for a doctor for their sick child or a sick parent. How can that person be a consumer the way somebody's going out and looking for a new television set or a car or a blender. Is it consumer and is a health care reform effort based on the consumer's choice. Really going to cover all of the intangibles that Danielle of free has mentioned. Well you know I use consumer and patient interchangeably I think it is vitally important as we look to improvements in our health care system to make those

changes patient centered. So imagine if you were a non-English speaker and your provider you only have 15 minutes with him or her and one of the things you have to get over is a language barrier and a cultural barrier and you have all this time that needs to go into being put at ease before you can begin to discuss your intimate health details and for whatever reason you happen to be there for the appointment you know we've heard stories on our helpline and I should say at health care for all we work hard to be culturally competent and answer questions and English Spanish Portuguese and Mandarin. And I always am looking for. The opportunity to expand beyond that because we know there are certainly communities we're not yet able to serve but we hear stories about providers doing the best they can but to try to get language translation services pulling somebody off the janitorial staff or someone who has no medical training whatsoever to do some

of this translation. And again if you can think of how you would feel if a stranger were to come in and try to translate the information that you're trying to convey to your provider. It's simply a nonstarter. So we believe that there must be incentives built into health reform that will attract culturally competent providers and will include training for all health care providers so that they understand some of the linguistic barriers cultural barriers and will allow people to break those down so you can get to the underlying medical issue. And again part of payment reform in Massachusetts is the opportunity to talk about not paying providers in 15 minute increments but in fact being able to incentivize the ability to spend whatever time amount of time it takes to be able to make some of the connections that Dr. free was able to talk about with her patients.

Sounds like you don't think that a patient is actually a consumer like the buyer about a television set. That's crude. OK if I just to be clear I'm struck by the choice of language when I hear the term consumer just seems like the wrong word. When I've been a patient I don't feel like a consumer. I actually want to be a patient I want to be taken care of not being treated like I'm shopping for television and also our possible use of the term provider to and I was thinking am I working at Burger King I mean I am a doctor and I are trying to be inclusive of all caregivers but there are doctors and nurses and and I'm often called the hospitalist. I think we're strange in that I take up hospitals. I'm a doctor and my patients are my patients in this setting. It's not a business transaction and it's you know is so different than shopping because when a patient comes to us they're very vulnerable and it's very different than when you're shopping for something you're not in that vulnerable position your can be in a position of power and even an educated well-off person with many resources who comes in sick

isn't of almost position and they don't I don't think people feel like consumers maybe when you're shopping for your health care plan maybe you're a consumer when you're with your doctor. I think most people feel like patients and there's something honorable about that not not that we should should really give honor to and treat that vulnerable time which is why the measures of quality that go into shopping for TV aren't really the same when shopping for your doctor or your hospital think statistics can really convey what that interaction is. I'm curious and then I'll open it up to the audience so be thinking of your questions. I'm curious if you can imagine aspects of health care reform that would take this view of the patient as a patient as a vulnerable individual who is in need of care and doesn't have all of the options available that the legislators sitting in his office writing the bill or the the

lobbyist sitting in his office writing the bill might have at his disposal. I could think of one whenever I finish a visit I have to code in order for our hospital billers to Bill. So it's fascinating about codings all different levels of visits a lot of it is based on elements of the history and physical and of course very much procedural base the more procedures you do the more you Bill. Well in terms we don't do procedures we talk and it's very hard to bill for talking. Now you can you can code that you've actually spoken for 20 minutes about medications diabetes. But learned that's a red flag and if you code for that too much talking with your patients you'll be audited. So the thought that could be one place that that shouldn't be the red flag that should be the standard that we do say we speak for 20 minutes and that part can be considered as valuable as you know sticking a tube in in an orifice because I think that's really that's the major part of medicine we talk and we talk and we talk and we listen and you know procedures are a very small part for your general primary care doctor. So that would be my solution. Amy.

Well I would say there are a couple of benefits to health. National health reform including one that I think is vitally important and that is there are incentives for primary care docs I think it's a practice that we have not valued as much as perhaps other disciplines lately and I think that there is an opportunity with national reform to attract more primary care providers in the state in the States. I also there are some reimbursement improvements so that. Primary care providers will actually be paid slightly more under Medicare than they currently are which again I hope will make a big difference. But again the idea that doctor or free would have to worry about how to categorize what she's doing with the patient when in fact she's trying to spend that time talking about overall health is a real frustration and I think we do have an opportunity to move beyond that so that if she in fact is talking about overall health and is able to

avoid a second follow up appointment for her patient which is great for the patient not to have to leave work or or find another way to get back to her. There should be some benefit. Talked to Dr. Friese good talents based on that success. Now let's take some questions from the audience and I'll remind you to come forward and use the microphone here in the center aisle. And feel free to line up at the microphone. I'm just wondering the the message chooses health care plans. I know there are several classified is Commonwealth Care I know you know what that is. Is this thing from the. Yeah the Medicaid or the Mass Health. Do you find it difficult to get health care providers who will take who will accept say the Commonwealth care of the Mass Health has it been a problem or is it sort of a non problem. In fact we found that some of the disparities are based on

geography so that there is plenty of capacity in the state in some areas and then not in rural areas and that's a challenge that is echoed across the country. But right now I'm sure that there are examples of people being very frustrated with waiting times but we've been very pleased with the number of providers who have opted to provide services to dog populations who buy into Mass Health or con care. Thank you for a stimulating discussion Amy. You commented on documented immigrants and the services that they can access. Can you comment on the undocumented and what is available to them if anything and decreasing funding for our safety net hospitals. Well it's a real challenge the safety net in Massachusetts is losing money and it is a provider reimbursement of absolute last resort. We know that in Massachusetts there are folks who are here

undocumented who wait until the absolute last minute to go and seek assistance and therefore are at a more acute stage of need than they would otherwise be and it's a real challenge for the system. We at health care for all have been advocating very strongly on behalf of the 30000 people who are here legally have been here for less than five years and used to have access to the Commonwealth Care Program. They are as a cohort generally a younger and healthier population than the general masters of the population. But budget cuts were made last year and those 30000 folks who in the parlance of our. State legislature are referred to as aliens with special status. So these special status immigrants were lost access to Commonwealth Care and were given access to a new program that does not provide the same level of benefits and includes co-pays and that's called Commonwealth Care bridge program.

So we're advocating as strongly as we possibly can to return this group of folks back into calm care because it is wrong we believe to exclude them based on their place of birth and how long they've been in this country. You know if you if you have come back to the microphone so we can hear you still commenting on the document when you say they're legally here. Yes. What's available for those who are undocumented. There is emergency based care the rule is you cannot turn people away. However there is not access or the ability for people who are not documented to get primary or preventive care. So what we see is they become sick and wait until they have acute needs. There are no efforts at the moment for health care for all too. Get those folks preventive or primary care. We answer the helpline we know that people are referred to us so that we can connect them where we know they can get care but right now there's no program

available. And I wish there was political will to talk about all people in Massachusetts but right now we are talking about folks who are here legally. And Dr. 03 Can you comment on your patient population in New York if there are any services that are in our hospital is open to all and a large percentage of our patients are undocumented. I don't know the number because I don't ask but I know that many patients they come in a self-pay which means uninsured and a majority of those are undocumented. I do have a number of patients who are recently employed and then lost their jobs and lost their insurance in a new population. I think that a public hospital tends to be a refuge and patients come generation immigrants always come to Bellevue even when the immigrants have groups have moved on socioeconomically off and continue to come to Bellevue once they're employed and citizens because it's a very warm and welcoming place and it is quite multicultural. So all of our city hospitals are the places that are immigrants

where the documents are not can get primary care. We're limited simply by whatever limitations we have for services in general the wait is long the next available for Dr. June 23rd right now so my patients call I have to overbook them or they have to wait until June to get an appoint with me so that's a problem. And it's the reimbursement mainly federal that helps support the health hospice Corporation which is New York's City hospital system but we're in the red for sure. There was recently the front page story that talked about the gentleman who needed a heart transplant was here without undocumented was here and was bounced I believe when the globe picks up. He was on his third hospital all of that incredibly acute care. And imagine the disruption to himself and his family but also the extraordinary expense of the health care system rather than allowing him to have access to care that may or may not have prevented that need but would certainly have shortened the amount of emergency work that's going on for him.

So I think it's incredibly important. I also know that it's a challenge in Massachusetts and I believe we'll begin to hear more and more about it as the budget numbers become harder and our policy options become more constrained by budget. So it's a real challenge but vitally important health care for all means all. I'd like to ask Danielle. We heard a little bit from Amy about how she is looking at the proposals for national healthcare reform. How are you as a doctor looking at them. A little bit overwhelmed certainly those of us in New York look at Massachusetts and with a little bit of a roll of her eyes. Could you guys do that to us. But I think we view the idea if there's any way for more of our patients to get coverage that will be better. And I realize that there are shortcomings in the Senate bill compared to that to the House bill that are significant. I think most practicing physicians are simply

overwhelmed by the number of details and that we just can't take in any more. We have a gut sense that is probably good and probably better than nothing at all. But to be honest most practicing clinicians just can't delve into the details. And we have to keep our nose to the grindstone to stay afloat. I think for most Again our patients to do have access to care with or without insurance and there are co-pays but there are fee scale so most patients can it can be affordable although not for all that's that's true. There is a place to come to. But if you don't live near a public hospital then it's really it's a different situation then the issue of coverage becomes that life or death situation. We are lucky to live in New York City and have public hospitals but some public hospitals have closed or have really consolidated. So I think my gut is that it's good but I'm not sure I'm nervous about some of these quality measures of quality mandates things that I don't think really actually measure quality of care. They're easy to measure but they don't actually capture the essence of good quality care. I hope that it will be a good

thing. Keeping my fingers crossed. The other questions. I'm an adult and child psychiatrist in the late 80s when managed care became an intense thing to deal with I resigned from most of the panels and at that point made a moral and ethical decision that so I could see people who couldn't afford to come. I'd see them for free or I'd have a portion of my practice that would be pro bono. So I just want to tell you an anecdote that happened recently so I have nothing to do with insurance companies. But since my patients have insurance and mainly I think this is for you and me that if I write a script Now sometimes the pharmacy will call and say sorry doctor but you need to get pre-authorization Otherwise your patients are going to pay $200 a month for this med instead of $5 a month for this med.

Here's the number to call. So I call on the number and I get a computer voice that says to me what is your name. So I say my name. I have to identify my birthday too. And as I'm getting older I kind of wonder should I say the truth or not. And then I have to say the patient and their ID number and their diagnosis and then be in this computer voice said. This was 45 minutes of time which is not billable I won't bill anyone for that. The computer voice says Are you the authorized prescribing entity. And at the point that I decided I was not an entity. I said human being. And they hung up on me. So 45 minutes later to protect my patients I decided I was an entity and said yes and got through the whole thing. But then I finally got through and called again to find out what they do also is they'll ask three questions. The general medical questions not about the patient

not about the med and possibly not in any way related to being a safety net in terms of making sure the prescription is correct or that there's no harm done. So I called and got a human being at the insurance company and they I said why did you choose those three questions for this patient in this med and they couldn't explain. So what I'm worried about is that OK the good news is these people are covered by insurance. Somebody else is going to help pay for the med they need they're going to get the med but there are these layers of people who are asking questions that they don't know anything about and I'm sure they're collecting a salary. I'm being an entity and not a human anymore. I'm still sad about that. But anyway I'm worried that if that's what Phase 2 is so the punkin of the insurance coverage and that's great. But that includes this kind of extraneous stuff that isn't protecting anybody.

I don't even know how to protest. So my instant response is. Good grief yes we're trying to squeeze costs out of the system. Think of the waste that you just went through in addition to how incredibly fortunate your patient is that you hung in there for all that time. I think it's vitally important that we get rid of some of the administrative layers that add no value whatsoever to. And in fact as the case you've just pointed out take away the time that you have to spend with your patients. So I'm with you I think that's incredibly challenging. But I am hopeful that there is an opportunity to get rid of some of that just administrative waste and the hoops that you've had to jump through to be able to provide the best possible care for your patients. What I was worried about is these three questions were kind of Checklist Manifesto kind of narrowed down and in a distortion used in a distorted way or do you have power to do anything that is I'm certainly

going to carry the anecdote with me I will also say that health care for all has been very excited about The Checklist Manifesto however and not in that setting we've talked about the success that folks have had in using them in the O.R. and the number of mistakes and errors that have been eliminated based on the quick run through of these checklists. So we'll be talking quite a lot about that as a tool to improve quality. But I don't know about it. As far as screening folks and determining whether or not they are appropriate for specific prescriptions that's troubling and I applaud you I mean when I was with insurance companies I could at least bill for 15 minutes to speak and I could barely say hello in that amount of time so that I could just give the quick tale of two phone calls when I was my first pregnancy and to get Rodin when I called my insurance company. This is a routine medication and it took close to an hour of going around to get a standard

medication and I finally got it and then I had my dog lost her dog license so I had to call the New York City Department of veterinary service I thought oh no no go cities whatever. I called the phone I pulled out my tax form do my taxes a home on hold and a person answered the second ring and said Hello hello. I was so startled I said my my dog lost her license. Just put a dollar an envelope and mail it to us we'll send it back to you. So the dollar did yeah just mail it to us. I said OK and hung up the phone and I was startled the difference of these two phone calls that for my own health care I had to spend an hour finding a folder for my dog. It took two seconds and it cost me a dollar so maybe we can learn from our pets. Well there's I have the feeling that there's a fly in the

pointman or mainly it's the 600 pound gorilla in the room. And these metaphors I am referring to are the political forces that have kept us from universal health care since Hillary Clinton started it and started working on the project. Now we know that this 600 pound gorilla is the Republican Party except for the two senators from Maine. And we know how vicious devious how these people lie. And all that kind of stuff. And I just want to know how you think about that. I know you can't do anything about it. And I know you'd like to but you don't talk about it. I'm a little

hard of hearing so I may have missed some words about this subject but you don't talk about on it. And as they say. You're powerless against it. Parties people. But how do you think about them. Well I would say that health care for all is rabidly nonpartisan and that being said that it is vitally important that all of us reach out to friends and family and make them do it. I think we have not demanded that our health care system be reformed. I think we have not demanded that it was time to cover everyone. And I think the time has come. I think we are as close as we've ever been. I think we have this opportunity that we can't let pass us by again. So I think it's up to us. I think we are required to get involved and tell

folks that it's a simple phone call. Pass health reform or I won't vote for you. Do you have any thoughts from the inside. Well I guess what I would if I could face some of the Republicans I would want to ask them for an honest on a personal level what it means to oppose this and who would you want for your mother's doctor who would you want for your doctor and perhaps the percentage of Congress should do without health insurance you know comparable to the percentage of Americans who do without health insurance to anyone who works in medicine or to anyone I think who is a sentient being seems that health care should be a right not a privilege that we pay for. And how come we are happy to have police care for all fire protection for all roads for all but not health care for all I don't understand that as someone who practices medicine to give an explanation of why that wouldn't be the same. Same case for our health care.

Thank you. Thank you. I do want to ask one last question that was a rousing And so I hate to bring it down but I do want to go back to these extra late years of bureaucracy that have been brought up. It seems from my outsider in positions that a lot of things fit the national debate has changed from health care reform reforming the system of health care delivery to health insurance reform. And that is actually a phrase that I've heard repeated in the media and repeated by legislators. We're not in reforming the health care system anymore we're talking about reforming health insurance and giving people access not to a doctor but to an insurance policy. And it sounds like that insurance

policy can be the source of a lot of cost a lot of layers of bureaucracy a lot of time wasted. Is this really the best way to go about it. Or is it only the expedient way to go about it. Do we have to reform insurance and then move on to reforming the health care system. Or is it possible to skip that step and move on to actually giving people access to care. My gosh I think that health insurance reform is part of health reform I think they're inextricably linked. And I think the examples that I talked about in Massachusetts our experience here showed that providing folks coverage up front made a tremendous amount of difference. And now we truly are talking about delivery reform. We truly are talking about making sure that patients have as much time with Doctor or free as is needed to be able to talk about

the ancillary issues and the presenting problem that takes you into her office. I think they are complementary and absolutely have to be approached together. What do you think. Probably have to agree it's hard to imagine how we're going to undo our health insurance system. But I spent all time working in an HMO based practice and my desk simply had probably 15 piles of forms from each HMO and for for one doctor required three administrators to work with me just to do all the paperwork because every health care company had different requirements and I was wondering Can there just be one form for all the companies at least so I don't have to have three secretaries to support one doctor so I think it's going to have to be it's going to have to be both. OK. The idealist few is too ideal one. Does anybody else have a last question. If not going once going twice. Stand up.

Just curious. And then is this universal health care bill. It's I think it's really 2000 pages something. And just wondering is there anything about it which is sort of potentially threatening to the MSA choose its system. Is it really impossible to tell simply because of the the weight of the bill. You know like these things often contain little time bombs. I think first of all I would invite people not to be overwhelmed by the length. It is a big bill and it makes sweeping changes. And it's worth a read it's actually readable. And there are also some wonderful summaries available around online so you can go to health care for also web site you can also go to our sister organization community catalyst which works on national reform with in 44 states around the country like Massachusetts. I think the most important thing for us right now is to know that if we don't pass

national health reform we will spend the next name the amount of time but at least three years playing defense trying to maintain the gains we've made in Massachusetts. I think if we don't pass national reform the next thing to go will be the work that we've done here in Massachusetts because they'll be a perception that we don't have to have it. So I urge all of you to think about your investment in having national comprehensive national reform and to get involved. It simply will not happen unless we demand that it it happen. So if it doesn't pass at the national level that's what's threatening in mice which I think if we don't take advantage of this opportunity I don't believe it comes again in a lifetime. And for those of us who are residents of Massachusetts I think we spend an awful lot of time playing defense and trying to maintain the gains that we've made rather than what I'm asking for is the opportunity to do phase two of health reform which truly is improving the delivery system and the

experience that patients have with their providers. We have that opportunity here in the Commonwealth. And I believe we would lose out if we don't have national reform upon which to build it. There's actually in the other thread through an article in the paper just the other day that a number of other states are actually organizing against compulsory. Yes. So there are many states that don't want this system like Massachusetts. I mean the whole number of reasons for it but that in itself is threatening if people don't fully understand what we've done here I think we've had some misstatements about what it's cost the Commonwealth. I think there have been some misperceptions about the gains that we've made. So certainly part of health care of Paul's mission is talking about the facts of health reform in the state. And imagine if you were living in one of those states to have leadership talking about not only getting on board to reform the health care system

but frankly not caring about the fact that you are living without access to the system I think is wrong. OK thanks. OK. Thank you Daniel. Free and thank you Amy Whitcomb Slemmer. This has been encouraging conversation by and large and I look forward to reading reading the whole book. And there were also there are on the back table some examples of the Bellevue Literary Review. So when your nose isn't to the grindstone you you actually are more are you. You write yourself but you are also the editor of this journal. What what do you get out of writing. Just briefly working in medicine is very minute to minute second to second

experience with very little time for reflection. Writing is such a slow process by comparison so I think it's the time to think about what we do and not just do it. Editing the literary journals another way to put more of a creative spin reading poetry fiction and nonfiction that get Also think about the experience of Medicine illness health a disease without just crunching numbers so it's hard to imagine being at Bellevue every day I'd probably end up in Bellevue so I need to have this other part of my life. OK thank you Danielle ovary. And again thank you Amy Whitcomb Slemmer. Thank you.