The ACP Advocate Blog
by Bob Doherty
Thursday, May 16, 2013
If having health insurance doesn’t matter . . .
Would you give your health insurance up and become uninsured? And cancel your loved ones’ policies?
Why do I ask? Because one of the principal argument made against ObamaCare—and specifically, the option for states to expand Medicaid to the poor and near-poor—is that having health insurance coverage really doesn’t matter very much. The argument pretty much goes along the following lines. The uninsured already have good access to care through free charitable clinics. Hospitals aren’t allowed to turn them away. Health insurance just gets inbetween doctors and patients. Health insurance really doesn’t ensure access and good outcomes. Offering the uinsured coverage will cost a lot of money. So it isn’t a good use of taxpayer dollars to extend coverage to the uninsured, they are doing okay without it.
Funny thing is, the people who argue that health insurance doesn’t matter are for the most part well-off people who have generous health insurance coverage for themselves and their families, usually through their employers. It is a big part of their compensation package and employee benefits. My guess is that they value having the peace of mind that health insurance gives them and their families. They and their employers have made a cost-benefit calculation that health insurance is worth it. But for the poor and near-poor (most of the uninsured), the same peace-of-mind and cost-benefit calculation apparently doesn’t apply.
Now, before someone accuses me of making a straw man argument—that is, my premise that many critics of ObamaCare believe that providing health insurance to the uninsured really isn’t that important—let me back it up. A new study that compares the experience of previously uninsured persons who won a lottery to be covered by Oregon’s Medicaid plan, to those who remain uninsured, has been seized upon by ObamaCare critics to argue not only against expanding Medicaid—but against the very idea that having health insurance really matters that much when it comes to better health outcomes.
The Washington Post’s Sarah Kliff posted an excellent (as she always does) blog explaining how the study’s principal finding—that the Oregon expansion didn’t result in better health outcomes on cholesterol, blood pressure and blood sugar levels for the new Medicaid enrollees (after two years) compared to the uninsured—has been seized upon by opponents of ObamaCare’s Medicaid expansion. But although it is true the study didn’t find any improvements in these three common measures of outcomes, it did show one huge benefit—the people who were able to join Medicaid no longer had to worry that getting sick would result in a financial calamity, as Jonathan Cohn explains in his New Republic post:
“The big news is that Medicaid virtually wiped out crippling medical expenses among the poor: The percentage of people who faced catastrophic out-of-pocket medical expenditures (that is, greater than 30 percent of annual income) declined from 5.5 percent to about 1 percent. In addition, the people on Medicaid were about half as likely to experience other forms of financial strain—like borrowing money or delaying payments on other bills because of medical expenses.”
The same study also found a substantial reduction in reported incidents of depression—which (I am just speculating) might have had something to do with recipients no longer having to choose between paying rent or getting health care!
So on one side, you have conservative critics of ObamaCare’s Medicaid expansion concluding that the new study validates their view that it is a big waste of money because putting people on Medicaid won’t improve health outcomes. On the other side, you have liberals who argue that the study shows that putting people in Medicaid protects them from financial catastrophe and is well worth the cost, even if it doesn’t result in immediate gains in health outcomes.
If the argument was just about Medicaid, that would be one thing—surely one can make a credible argument that there are better ways to provide coverage to the poor than expanding Medicaid (although I have yet to see a plausible conservative alternative), but some conservatives are citing the study to argue against the very idea of providing health insurance coverage (not just Medicaid) to the poor.
The Washington Post’s Robert Samuelson opens his latest column, Why ObamaCare is Oversold, with this provocative statement (citing the Oregon Medicaid study):
“It’s the great moral imperative behind the Affordable Care Act (“Obamacare”): People should not be denied health care because they can’t afford insurance. Health status and insurance are assumed to be connected, and opponents have often been cast as moral midgets, willing to condemn the uninsured to unnecessary illness or death. The trouble is that health status and insurance are only loosely connected. This suggests that Obamacare may result in more spending and health services but few gains in the public’s health.”
“The most overlooked finding [from the Oregon study] is that the uninsured already receive considerable health care. On average, the uninsured annually had 5.5 office visits, used 1.8 prescription drugs and visited an emergency room once. Almost half (46 percent) said that they ‘had a usual place of care,’ and 61 percent said that they had ‘received all needed care’ in the past year. About three-quarters (78 percent) who received care judged it ‘of high quality.’ Health spending for them averaged $3,257. Much of this was known — or could have been surmised — during the debate over Obamacare. The Congressional Budget Office reported that the uninsured typically received 50 to 70 percent of the care of the insured. A study in 2007 of the 1965 creation of Medicare — insurance for the elderly — concluded that it had ‘no discernible impact on elderly mortality’ in the first 10 years but improved recipients’ financial security by limiting out-of-pocket expenses.”
And then this:
“ ‘Health insurance is a financial product that is aimed at providing financial security,’ the study says. On that ground, the expansion succeeded; by most clinical measures, it didn’t. Perhaps it is too early. The expanded Medicaid coverage was only two years old at the time of the study. Maybe greater health improvements will emerge. But maybe they won’t, and not only because the uninsured already receive care. Many uninsured are relatively healthy; insurance won’t make them healthier. For others, modern medicine can’t cure every health problem. Still for others, bad luck or bad habits are hard to change. About two-fifths of Oregon’s uninsured were obese or smoked; Medicaid didn’t alter that.”
And Samuelson concludes with this stunning attack on the motivations of those, like me and ACP, who support ObamaCare, arguing that is our sense of moral superiority (rather than concern for the poor) that motivates our support for universal coverage:
“Obamacare’s advocates ignored these ambiguities. They were too busy flaunting their moral superiority. Universal health insurance is a legitimate goal, but 2009 — in the midst of a major economic crisis — was the wrong time to pursue it. Predictably, it polarized public opinion and subverted confidence for what seem to have been, based on the available evidence, likely modest public health improvements. The crusade for universal coverage has been as much about advocates’ sense of self-worth as about benefits for the uninsured.”
Wow . . . “the crusade for universal coverage has been as much about advocates’ sense of self-worth as about benefits for the uninsured.” Really?
I would say that extending health insurance coverage to everyone, so that no one has to worry about a financial catastrophe because they get sick, is in itself enough of a benefit for the uninsured to explain my and ACP’s support for ObamaCare.
If protecting the uninsured from health related financial catastrophe wasn’t enough, I would say that the preponderance of evidence shows having health insurance will reduce tens of thousands of preventable deaths, notwithstanding the Oregon study—which by itself would be enough of a benefit for the uninsured to explain my and ACP’s support for ObamaCare. The esteemed Institute of Medicine in 2009 looked at all of the evidence on being uninsured, and found that there is a “chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death.”
I don’t support ObamaCare because of my own self-worth, but because I believe that the evidence shows that it will provide enormous economic benefit (for sure) and health benefits (most likely) to the 30 million or so uninsured (and mostly) poor who now have no access to coverage.
But don’t take my word for it. Listen to this interview with a real person who explains to Kaiser Health News reporter what being brought under Oregon’s Medicaid plan has meant for her:
Q: How did lacking insurance affect your medical care?
A: “At one point I needed some cortisone for my asthma and they wanted to do a complete heart work-up to make sure that my troubled breathing wasn’t congestive heart failure. You're always telling them, ‘No, no, no, this is the only thing I want.’ It's like trying to buy the burger with no fries at McDonald's. You have this resistance all the time, because doctors and nurses look at you with these big soft eyes and say, "But it would be so important to know your level of cardiac health, I'm really concerned. I'm sure the doctor there will work out something and make payment arrangements." And it sounds so good and you do it and it never works out. The discount isn't there or you fill out something wrong and all of a sudden you have a $300 bill in collections. So you have to make sure none of that happens to you.”
Q: How has your health changed since you went on Medicaid?
A: “Over the course of nine months or a year I was able to drop two different blood pressure medicines, which is nice because they had side effects I didn’t like. So I'm down to half a pill of one of the medicines and my blood pressure is still stable. For about a five-year period I thought my thyroid medicine was too low and I couldn’t afford the doctor visit to have the lab slip to get a new prescription. That whole procedure is about $300 so I just stayed with the same medicine. With Oregon Health Plan I was able to go back to the doctor and when she said wanted to check my thyroid levels I could say, ‘Yes, I'll go to the lab and get that done.’ They were low again. I was able to get that increased and that made a big difference in how much energy I had and how much better I felt.”
Q: If you had hadn't won the Medicaid lottery, where do you think you'd be financially and medically?
A: “Financially, I'd be maybe $100 a month poorer. I would not be monitoring my blood sugar. I would not be paying as much attention to my cholesterol. I probably would have lost some weight but I don't think I would have lost so much, and I don't know if I would have been so good at keeping it off. I'd be much more anxious about what could go wrong. One of the things you get in Oregon is you get your teeth cleaned and X-rayed once a year. I hadn't been to the dentist in six or eight years except to have a tooth pulled. So it was really nice to have my teeth cleaned and find out I don't have cavities and don't need my teeth pulled. My father died of melanoma and there's a lot of melanoma in my family—one of my sons had skin cancer when was he was 15—and so that's a worry. Being able to go to the doctor and have my moles checked was a big weight off my mind. I'm a lot surer I'm going to be able to make it to 70 without being crippled or in a wheelchair and not being able to take care of myself.
And there's something about just feeling like you're part of regular life. There's a lot of emphasis on how everyone should be healthy and everyone should live longer, and you don't want to be a burden on society. If you don’t have medical insurance, you're kind of not part of that. It's hard to explain, but there's an element of participating in society that being able to go to the doctor gives you. Everybody always asks everyone how you're doing, and to be able say ‘My doctor says I’m doing really well,’ that's nice, instead of being in a group of people and saying, ‘Well, I don't really go to doctors.’”
Q: The Oregon study did not find significant health improvements for those who won the Medicaid lottery versus those who did not, with the exception of improvements in self-reported depression. Some commentators have seized on these findings to argue that having Medicaid does not lead to better health. Do you agree with that?
A: “ Some people have completely lost track of what health insurance is supposed to be. We're talking about somebody being able to get their broken arm fixed if they fall out of a tree. My blood pressure is still not perfect, but over the last two years I have stopped taking two different blood pressure medicines and am only taking half of a third. That is a health improvement but it doesn't necessarily show up in the study. My blood sugar is not perfect, but it's more consistently in the right zone. But according to the study, I haven't improved. Most of the people who are going to be on Medicaid are going to be working. What are you supposed to do if you're working at McDonald's 30 hours a week? You're working all the hours they give you. Why shouldn't they be able to go to the doctor? Why should they have to lose everything they own if they break their arm and have to go to the emergency room? Everybody can't go to college and get a good job. Somebody is always going to work in the nursing home. Somebody is always going to work part-time at JC Penney even though they want to work full time, because the store only wants them there on Saturday and Sunday. Those people need to make enough money to live on, they need to have enough food to eat and they need to be able to go to the doctor when they're sick.” [Emphasis added by me in italics]
So yes, I admit that I feel that it is a great moral imperative to extend coverage to people like this woman. Medicaid is by no means perfect, but expanding it to her and others who are “working at McDonald's 30 hours a week” will give them financial protection. Why shouldn’t they be able to go to the doctor? Why should they have to lose everything if they break their arm and have to go to the emergency room? Why shouldn’t they have enough money to live on, enough food to eat, and be able to go to the doctor when they get sick. Why shouldn’t they be able to feel like they are just part of regular life—like you and me who are fortunate to have health insurance for ourselves and our families?
So if you really feel that this woman, and the millions like her, don’t need health insurance, how about canceling your own insurance (and your family coverage, to boot) and see what it is like to depend on free clinics for your medical care? And to make it a truly comparable experience, try to go without health insurance while living on a minimum wage.
If you aren’t willing to make the choice of going uninsured for you and your family members, then is it too much to ask that you support extending health insurance coverage to everyone, and especially, the poor and near poor? (And if you don’t like Medicaid and ObamaCare, explain how else you would make coverage available to everyone?). If having health insurance matters to you, it matters to them, it matters to everyone, it is the right policy to pursue, and yes, it is a great moral imperative that we try.
Today’s question: If you oppose expanding health insurance coverage to everyone because health insurance “doesn’t matter” or it is too expensive, would you give up your own health insurance? Why or why not?
Monday, April 29, 2013
Does measurement improve performance?
Like it or not, measuring physician performance is now a key part of the conventional wisdom on improving our health care system. Borrowing from management guru Peter Drucker’s mantra “You can’t manage what you can’t measure” health care policy makers have embraced performance measurement as being central to managing our heretofore unmanageable health care system. But there is a small but seemingly growing group of Don Quixote-like dissenters who are tilting at the performance measurement windmill, arguing that these measures will not achieve the ends of improving quality and saving money and may instead do considerable harm.
Dr. Bob Centor, author of DB’s Medical Rant blog, is one of them. (Disclosure: Dr. Centor is chair-elect of ACP’s Board of Regents, although the views he expresses in his blog are his own, not ACP policy). One of his posts, titled “What has performance measurement wraught?” calls them madness:
“Most readers know that I am obsessed with performance measurement and why it not only rarely works but often causes negative unintended consequences. As I have pondered this question recently, computers cannot replace physicians as diagnosticians. And the same misunderstanding of medicine that would advocate such a position drives the performance measure movement.
Physician decision making requires a complex weighing of disease severity, number of diseases, social situation, cost of medications, the patient's desires and willingness to address issues and more that you can imagine. To think that we can apply simple rules to such decision making represents an unjustifiable conceit that patient care is simple and can therefore be broken down into RULES.
The unintended consequences of this movement are many. We now have nonsensical report cards and, here the author gasps, public reporting. If we could define excellence, then public reporting would make sense. But we cannot define excellence through rules that cover only selected diseases and only one aspect of doctoring.
How do we stop this madness???"
In an earlier post, he cites a commentary in the Journal of the American Medical Association (JAMA) which suggests that poorly-designed performance measures can cause harm to patient care. “Too often we have measures based on a religious belief (e.g. lowering HgbA1c is always the proper goal) and not based upon good prospective data,” he writes. “Whenever we have to struggle to meet a performance goal, we run the risk of unexpected consequences. This irresponsible process likely harmed patients. Let me repeat that sentence. This irresponsible process likely harmed patients. The reasons now are clear. Some, including the authors of this commentary complained bitterly back in 2006. We allow organizations to establish performance measures without expecting the same rigorous testing that any other intervention must have prior to approval. We would not approve a new drug without careful testing for both efficacy and safety. Should we not hold performance measurement to the same standard?”
But is it possible to improve clinical performance without measuring it? The Institute for Healthcare Improvement, formerly headed by ex-CMS administrator Don Berwick, MD, says that “Measurement is a critical part of testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement.” In 2008, Dr. Berwick co-authored an article published in Health Affairs that presented the Institute’s now widely accepted Triple Aim of improving individual patient outcomes, improving population outcomes, and lower per capita costs. He writes that “in general, opacity of performance is not a major obstacle to the Triple Aim. Many tools are in hand to construct part of a balanced portfolio of measures to track the experience of a population on all three components. At the Institute for Healthcare Improvement (IHI), for example, we have developed and are using a balanced set of systemwide measures closely related to the Triple Aim. A more complete set of system metrics would include ways to track the experience of care in ambulatory settings, including patient engagement, continuity, and clinical preventive practices.”
Measurement for the purpose of helping groups of physicians assess how well they are doing in achieving the triple aim may be challenging enough, paying based on performance measures raises a whole host of other issues. All payment systems create a mix of potentially good and potentially bad results. Fee-for-service achieves the potentially good outcomes of creating incentives for physicians to actually see their patients and not undertreat them, because FFS pays them on how many patients they see and how many procedures they do, but it can also have the undesirable outcomes of “rushed” assembly line visits and over-testing and over-treatment. Capitation achieves the potentially good outcomes of encouraging physicians to be more efficient and not over-treat their patients, since they are paid the same amount per patient no matter how many procedures or visits provided, but it can also have the undesirable outcome of incentivizing physicians to not see patients enough, not treat sicker patients, or undertreat them. Payment systems linked to performance measures can have the desirable outcomes of creating incentives for physicians to organize their care to achieve better outcomes for their patients, better care of the patient population they see, and maybe, lower costs (the Triple Aim), but also the undesirable outcomes of “treating to the measure” (paying attention only to things being measured, and less to things not being measured), and creating disincentives for physicians to take care of sicker patients and those with lower socioeconomic status because such patients may adversely affect their performance “score.”
Performance measures though could help level out the potentially undesirable incentives existing in FFS or capitation: FFS tied to performance measures could help counter the incentives for over-treatment because physicians who over-treat with no improvement in outcomes wouldn’t score as well on measures of individual, population or per capita cost outcomes. Capitation tied to performance measures—if accompanied with appropriate risk adjustment-- could help counter incentives for physicians to under-treat patients, since under-treatment would result in poorer “scores” on individual and population-based health outcomes and patient experience with the care provided.
My sense is that the performance measurement genie is out of the bottle and isn’t going away. We live in an era where just about everything and everybody is being measured and held accountable for getting better results as efficiently as possible. Health care is so damn expensive that the public (through government) and insurance company shareholders will want to know if physicians are achieving the best possible results and the lowest possible cost—how can they know what results they are getting without measuring it?
But as measurement becomes increasingly imbedded in our health care system, we should pay attention to potential unintended consequences. We should insist on meaningful measures that are based on the best available science through a transparent process, not measurement for the sake of measurement. We should test measures whenever possible before they are widely adopted, just as we do for new drugs, and withdraw measures that turn out to be harmful, just as the FDA withdraws newly approved drugs if they are found to have unforeseen harmful side effects. We need to be very careful as we design payment models that incorporate performance measure so that what is best for the patient, not what is best for the measure, always comes first. All of these, and more, safeguards are called for in ACP policy on performance measurement.
And rather than starting with measurement as the be-all and end-all goal, we should begin by defining how best to organize care to achieve the best possible results for patients, through models like Patient-Centered Medical Homes, then determine a payment model that best supports those models, and then build and incorporate measures that actually help the physicians in these systems monitor and achieve the best possible outcomes for their patients—not the other way around.
If we really believe, as ACP does, that a well-trained internist, in a system of care designed to achieve the best outcomes for patients, will be shown to be the best bargain in American medicine, then performance measures can be our friends—but only if they are the right measures, measuring the right things, for the right reasons, and with the right oversight. And we should always keep in mind the cautionary note from sociologist William Bruce Cameron, sometimes misattributed to Albert Einstein, “That not everything that can be counted counts, and not everything that counts can be counted.”
Today’s question: do you think performance measures will improve or harm health care outcomes?
Thursday, April 18, 2013
What the Senate Gun Vote Says About Washington . . . and About Us
Many experts predicted that the unspeakable murder of dozens of children and adults at Sandy Hook elementary school would be a “game-changer” that would cause Congress to enact meaningful controls over firearms. How wrong they were.
Yesterday, the United States Senate rejected every single legislative proposal to make it harder for people—including convicted felons-- to obtain and use firearms to inflict harm on themselves and others. Because of Senate rules requiring 60 votes to get just about anything passed, a minority of U.S. Senators were able to block a bipartisan plan for universal background checks offered by two Senators with “A” ratings from the NRA, despite the fact that 90% of the public supports expanded background checks.
Proposed bans on the future manufacturing and sale of military style weapons and high capacity ammunition magazines didn’t even get a majority of Senators to vote for them. These are the weapons of choice of mass murderers, used to gun down children and adults at Sandy Hook; college students at Virginia Tech; a member of Congress and others standing near her (including the murder of a young child) outside a grocery store in Tucson; movie theater patrons in Aurora, Colorado, and so many more people who have been killed or injured, in so many places, by assault weapons loaded with high capacity magazines. But banning such weapons and ammunition was too big a political lift for most U.S. Senators.
The background check proposal had a much more modest purpose, closing existing loopholes to keep guns out-of-the hands of convicted felons, persons with domestic violence restraining orders, and violent, mentally-disturbed persons under court order (while exempting most sales among family members), but that was also too much of a lift for politicians cowed by the NRA’s opposition and a passionate but small minority of gun owners who oppose expanded background checks. Support for background checks among gun owners is about the same as the general public, with 88% of them supporting background checks for all gun owners according to recent polls.
I am deeply disappointed that Senate rules allowed a minority to again block the will of the majority of the Senate and the will of an overwhelming majority of the public. I am deeply disappointed by the effectiveness of the NRA’s deceptive, cynical “slippery slope” argument that universal background checks would create a federal registry of gun purchases that later could be used by the government to take legal guns away from law-abiding owners, when such a registry is expressly prohibited by the background check bill as well as by current law barring the FBI from retaining records of persons passing background checks.
I am also disappointed that organized medicine didn’t do more to support the Senate bill. ACP did its part: we wrote letters of support for the background check bill and asked our 8,000 plus ACP Advocates Network members to urge their own Senators to vote for it. The American Academy of Pediatrics did at least as much as we did. But from what I can tell, most of the other national physician membership organizations and state medical societies sat this one out. They either didn’t engage at all prior to the Senate vote, or limited their engagement to a letter of support, without backing it up with grass roots lobbying, direct lobbying on Capitol Hill, and the other elements one would associate with a high priority campaign. In my blog post immediately after the Sandy Hook massacre, I asked “Is the Medical Profession Doing Enough About Gun Violence?” Regrettably, the answer for much of organized medicine, appears to be no.
But my disappointment over the Senate’s failure on guns pales to that of Gabby Giffords, the member of Congress who was grievously injured in the Tucson shooting. Read what she said in today’s New York Times:
“Senators say they fear the N.R.A. and the gun lobby. But I think that fear must be nothing compared to the fear the first graders in Sandy Hook Elementary School felt as their lives ended in a hail of bullets. The fear that those children who survived the massacre must feel every time they remember their teachers stacking them into closets and bathrooms, whispering that they loved them, so that love would be the last thing the students heard if the gunman found them.
On Wednesday, a minority of senators gave into fear and blocked common-sense legislation that would have made it harder for criminals and people with dangerous mental illnesses to get hold of deadly firearms — a bill that could prevent future tragedies like those in Newtown, Conn., Aurora, Colo., Blacksburg, Va., and too many communities to count.”
“I watch TV and read the papers like everyone else. We know what we’re going to hear: vague platitudes like ‘tough vote’ and ‘complicated issue.’ I was elected six times to represent southern Arizona, in the State Legislature and then in Congress. I know what a complicated issue is; I know what it feels like to take a tough vote. This was neither. These senators made their decision based on political fear and on cold calculations about the money of special interests like the National Rifle Association, which in the last election cycle spent around $25 million on contributions, lobbying and outside spending.
Speaking is physically difficult for me. But my feelings are clear: I’m furious. I will not rest until we have righted the wrong these senators have done, and until we have changed our laws so we can look parents in the face and say: We are trying to keep your children safe. We cannot allow the status quo — desperately protected by the gun lobby so that they can make more money by spreading fear and misinformation — to go on.”
My deep disappointment with the Senate’s failure on guns can’t come close to that expressed by the heartbroken father of his beloved seven year old son murdered in Sandy Hook. Mr. Barden spoke last night at the White House of his anguish at the loss of his son, his disappointment with the Senate vote, and his determination to press forward:
“We'll return home now, disappointed but not defeated. We return home with the determination that change will happen -- maybe not today, but it will happen. It will happen soon. We've always known this would be a long road, and we don't have the luxury of turning back. We will keep moving forward and build public support for common-sense solutions in the areas of mental health, school safety, and gun safety.”
(Click on this link to watch his remarks followed by President Obama’s statement).
I know that some readers of this blog argue that background checks and bans on assault weapons and high capacity magazine’s won’t work in preventing all or even most firearms injuries and deaths, and that may be true, although the best available studies and simple logic suggest that they would help.
Despite gaping loopholes, the current background check system resulted in some 1.5 million persons with criminal records being turned down when they try to buy guns. Logic tells us that a system that closes the loopholes would keep guns out of the hands of even more convicted felons. Logic tells us that limiting access to certain guns that are designed to kill as many people as possible would result in fewer people being killed when someone tries to obtain them to inflict harm on us and others.
Some of you may also point out that the issue is more complicated than simply regulating firearms purchases—that mental health, culture, substance and alcohol abuse, and other societal factors also play a role—and with that I would agree. But the need to examine other factors contributing to firearms-related injuries and deaths isn’t a valid argument for not doing what we can now to keep guns out of the wrong hands and to limit their killing capacity.
Listen to more of what Gabby Giffords had to say about the Senators who voted against background checks:
“They will try to hide their decision behind grand talk, behind willfully false accounts of what the bill might have done — trust me, I know how politicians talk when they want to distract you — but their decision was based on a misplaced sense of self-interest. I say misplaced, because to preserve their dignity and their legacy, they should have heeded the voices of their constituents. They should have honored the legacy of the thousands of victims of gun violence and their families, who have begged for action, not because it would bring their loved ones back, but so that others might be spared their agony.
The should have, but they didn’t.
Today’s question: What is your reaction to the Senate’s rejecting of expanded background checks and a ban on assault weapons and high capacity magazines?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
- If having health insurance doesn’t matter . . .
- Does measurement improve performance?
- What the Senate Gun Vote Says About Washington . ....
- What does ACP have to say about . . .
- An Honest Assessment of Obamacare at Age 3
- Casting Aspersions
- In Honor of my Irish Heritage
- The Privatization of ObamaCare’s (Only) Public Opt...
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- Time is on My Side
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