Public Health and Pediatrics

Stan Musial, a Honda 70, and closed head injuries

The passing of Stan the Man a few months ago got me “musing” the other day.  When I was younger I was quite the baseball fan and I would imitate the various batting stances of the noted players of the day, and Musial’s twisted left-handed stance was prominent among these poses.

I also had a mean Joe Morgan, replete with the requisite flapping of the left elbow as well as a Willie Stargell windmill that was undoubtedly menacing (at least to my image in the mirror).  Heck, I even had a Mel Ott high kick in there for good measure.

At times I would leave the safety of the bedroom mirror and work on these drills outside, following through with a swing that in my mind should have been noticed by at least a few major league scouts in the area.  Alas, it was never to be.  But it wasn’t for lack of practice.

So it was that day that I was practicing someone’s stance outside by the shop behind our house.  About fifty feet away was my immediate younger brother, minding his own business as he was seated on an old blue Honda 70 motorcycle pretending, I’m sure, to be far away on some open road with his long hair flowing in the breeze.

That he was sporting the typical early 70’s buzz cut our dad gave us (these haircuts came in two styles- “short” and “shorter”) was totally beside the point.  In his mind he probably looked Peter Fonda-esque, to say the least. 

At any rate, I was taking my cuts with a 28 ounce Louisville Slugger when I had one of those moments of premonition that in retrospect should have been heeded.  However, a 12 year old obsessed with the perfect swing doesn’t always take the time to note what the “still, small voice” might be whispering.  What presented to my mind’s eye was a perfectly clear picture of me following through with a Ruthian whiff and the bat accidentally leaving my hands and whirling toward my brother, handle over end, and clocking him right on the forehead with a loud “Pop”!  What actually happened with my next swing was that I followed through with a Ruthian whiff and the bat accidentally left my hands and whirled toward my brother, handle over end, and clocked him right on the forehead with a loud “Pop”! 

I don’t recall what he did after the bat met his skull, but I’m sure he had at least a quizzical look on his face just before he passed out for a few seconds.  Needless to say, my batting days were terminated, at least for that afternoon.  I don’t know if the concussion my brother received has had any lasting affects; my siblings would have to chime in on this one.  I do know that many of us suffered concussions during our growing up years.  It was almost a rite of passage.  The concern for traumatic head injury has certainly changed how these cases are managed, from the local athletic contests all the way to the rarified air of professional sports leagues. 

It remains to be seen how this focus on closed head injury will affect the future of high school, collegiate, and professional sports.  Some have expressed that current iterations of the games we know and love may not exist in the not-too-distant future.  I do know that closed head injuries weren’t considered a public health problem way back when.  What seemed to be more problematic was how to explain to Mom how my brother got that goose egg on his noggin.  At least she had to believe my version of the events; he seemed to have trouble recalling much of that long ago afternoon…

Dr. K

Obamacare vs. Econ 101- there ain't no free lunch

When I was in high school, our sports teams traveled throughout southern Arizona to games and meets.  This travel often necessitated stopping at some fast food establishment for some after-competition sustenance, usually at the local McDonalds since the Golden Arches were the end-all and be-all of the fast food culinary arts in the mid-70’s.  I distinctly remember the coach standing outside the bus as we filed off, handing each one of us two crisp (or maybe not so crisp) $1 bills.  With this bounty in hand, I found out quickly that my two dollars would typically buy two cheeseburgers, a small side of fries, and a chocolate shake.  Every sports trip I took would end up with the same order; a bounteous feast to be sure. 

What strikes me now, after the passage of so many years and so much nasty McDonald’s burger consumption, is that neither I nor my teammates ever once presented ourselves to the counter and expected food to flow from the back of the restaurant into our ravenous mouths without the exchange of currency of some sort.  If we wanted another tasty Mcshake, or had a desire to top off the meal with a scrumptious apple pie, then we would be expected to produce even more of those little green bills with pictures of prominent Americans on them.  Apparently there was a mechanism in place to compensate the makers of the feast for their hard work and expense.  I suspect that otherwise this benevolent burger purveyor would soon have ceased to do business.  As we all know, that certainly didn’t happen.  Ronald McDonald (or at least his descendants) is still alive and well.

I’m reminded of this episode when I see recent news about what is lovingly known in some circles as Obamacare.  It would appear that insurance premiums are increasing yet again, while the Affordable Care Act was supposed to rein this in.  There are myriad reasons why, I suppose.  Might insurance companies be jacking rates in anticipation of future constraints to this sort of practice? 

Possibly. 

Might there be an increase in healthcare costs independent of the ACA? 

Perhaps. 

However, when a piece of legislation specifically prohibits insurance companies from actuarially accounting for pre-existing conditions, when the bill provides for the automatic inclusion of all children up to the age of 26, when the law states that no lifetime caps for benefits are to be instituted, then something has to give.  Did anyone expect that a business would be able to absorb such a mandate?  These increases were a foregone conclusion when the bill was passed, despite assurances to the contrary.  Someone will have to pay for this largess.  Will the insurance companies decide to pick up the slack?

It ain’t gonna happen.  It was never gonna happen.  As I found out years ago at the counter of Mickey D’s, there’s indeed no such thing as a free lunch. 

Dr. K

 

Medical marijuana- the Arizona scam

There appears to be a public health disaster looming of epic proportions, one that apparently will dwarf the impact of smallpox, HIV/AIDS, heart disease, or even bed bugs.  The statistics are startling, yet the American public seems to be blithely ignorant of the problem.  As a public health official in Arizona, I consider it my duty to warn folks of the impending catastrophe that may befall us if we do not take measures soon.  According to the Arizona Department of Health Services website, this concern afflicts fully 89% of the 33,633 successful applicants to the Arizona Medical Marijuana program.  I, for one, was not aware of the enormity of the problem.

What might this scourge be?  A horrible infectious disease?  An environmental health disaster?  Nah, nothing so prosaic.

Chronic pain. 

You got it. 

Chronic pain.

What is even more interesting from an epidemiological standpoint is that most of these afflicted with this dreaded chronic pain fall in the younger set; 46% of the applicants are 40 years old or younger.  A full 26% are younger than 30 years of age.  According to these figures there are seemingly hordes of young adults running around acutely suffering from chronic pain.  I would have thought that chronic pain would be something that increases with age.  Apparently not.  Well, color me skeptical, but I suspect that this set of numbers probably coincides with the percentages of each age group that light up marijuana currently.  Prior to the passage of the medical marijuana act in Arizona, the 18-40 year old demographic was far more likely to be smoking weed than your cuddly old grandmother-type with cancer.  Methinks this same group has just been transplanted onto the medical marijuana rolls, with a likely huge increase in the “chronic pain” diagnosis.  All this “new” chronic pain among our younger population is going to be such a heavy burden for society to bear!   

Is this a diatribe against the use of medical marijuana?  Not really.  I only decry the use of the rubric “medical” to promulgate the legal use of marijuana in my state.  I have somewhat more respect for those who were recently advocating the legalization of marijuana in Colorado, as there was a modicum of honesty in their presentation. 

Where will this end?  I have no idea.  However, given the likely rise in consumption of munchies in Arizona, I feel my portfolio could use a strategic Frito-Lay buy...

 

 Dr. K

 

 

A malpractice company and the golden egg

There once was a goose that had the proclivity to lay golden eggs.  Whether this was a genetic thing or a miracle is for others to decide.  All the goose knew was that out came an egg that was 24-carat gold, just about every day.  The goose’s owner thought this was a really sweet deal, but as is often the case, he decided to optimize his return by investigating the reason for this daily bonanza.  This scientific concern was likely well-placed, but also had the result of terminating the goose’s existence, and in turn the golden egg production was terminated.  Forever. 

 

In a similar fashion, I have two uncles who donate their surgical and anesthesia services as volunteers for the humanitarian organization Esperança .  Over the past few years they have traveled to Bolivia and Nicaragua and performed close to 1,000 surgeries for those who can least afford them.  My father, also a retired anesthesiologist, has joined them in Jinotega, Nicaragua the past two years and just this past month assisted in 60 operations over a 5 day span, including thyroidectomies, cholecystectomies, hernia repairs, and other procedures.  I was talking to my dad the other day and he told me of the adventures of working without an anesthesia machine (it broke) and the joys of monitoring the patients with just a blood pressure cuff, stethoscope, and a pulse oximeter.  Be it far from me to compare these men to a certain type of farm fowl, but these geese have been cranking out those eggs at a rapid pace, leaving a trail of hope and service in their wake.

Why would this sort of project be threatened?  It appears that the malpractice insurance company wants my surgeon uncle to pay the full active premium in order to continue to participate in the endeavor.  Currently he pays a much lower amount as he is retired and only assists occasionally back home in Tucson.  One wonders why the malpractice insurance company would want to charge this extra amount for this type of humanitarian work.  Is there an increased liability risk to the work he is doing?  Not likely, as I doubt the 32 year old female with chronic gall bladder disease who traveled 36 hours for her life changing operation is of a mind to sue him for his trouble.  I suspect that it is more likely that the insurance company is seeing this as an opportunity to gouge a subset of physicians that they haven’t noticed before. 

Do I have hope that this will be reversed?  Not likely.  I do worry about the people in Bolivia and Nicaragua because I feel that if volunteers such as my family members can’t go on these trips anymore, then the people they serve are out of luck. 

Sorta like, I suppose...their goose is cooked…?

 

Dr. K

Building fences as physical therapy- a boy's memory...

As a fourth year medical student, I took an elective in Physical Medicine and Rehabilitation.  I also have a niece whose husband is a physical therapist, and a number of my friends are likewise.  I have also undergone three knee surgeries, so my exposure to the rehab field is fairly extensive.  But as in most instances, one’s attitudes towards most things are molded from early on and my perception of what constitutes proper rehabilitation dates from an incident from my early years.

I would preface this account with a disclaimer- though my father is a physician, most of what passed for medical care in our home growing up was surprisingly (or not) made up of a cursory exam to see if life or limb was endangered, and if not, we were sent on our way.  I will say that when one of us thirteen children had sustained significant trauma or a serious illness, Dad was there with a timely suture (albeit with the surgery performed on the kitchen table) or an I.V. pole set up in the living room (for my immediate younger brother, who, it must be stated, still gets woozy just looking at a merry-go-round) for a gastrointestinal bug that got out of hand.   I also must admit under duress from my lovely wife that my triage
interaction with my own kids has been of a similar variety; not a lot of time was spent nurturing a boo boo.  If they could walk and talk without too much blood loss, they were generally good to go.

We raised cattle on our farm, an enterprise that lent itself to many different projects (calling them chores would make these seem so…so mundane), not the least of these was building and fixing fence.  Poor fences led to the cows getting out, going down into the San Pedro River, and climbing out into someone else’s pasture which usually would generate a phone call to our house which in turn would lead to our tromping off to gather the cattle-which typically led to a lot of mumbling and cursing under our collective breaths.  Most of our venom was directed at the erstwhile free-range bovines, when it probably should have been targeted at ourselves, since we were the ones who had built the shoddy fences in the first place.  I’m sure our dad had no problem figuring out where to lay the blame. 

Granted, we were relatively young when we first started building fence, and by the time I was in sixth grade and my older brother in eighth, he was in charge of quite a motley crew of fence builders that consisted of me and probably two or three other younger brothers.  The youngest of these brothers will claim that he was an integral part of the team, but as he was only six or seven at this stage in the enterprise, he likely was just assigned to place the clips along the fence posts that we used to tie up the barbed wire.  Either that or he spent the time drinking all our lemonade.  At any rate, fence building was quite the big deal; it kept us busy with its seemingly never-ending construction and it kept the cattle busy working at ways to countermand our efforts.

And so it was that my older brother broke his ankle wrestling. 

Imagine the monkey wrench this threw into the gears of such a smooth fence-building operation.  Cattle would be roaming all over the San Pedro Valley with our brand affixed to their backsides and advertising for all to see whose farm had the lamest fence constructionists; we would surely be the laughingstock of all the farms along Airport Road.  We needed older brother to run this crew; pounding fence posts required some modicum of skill, but it mostly required someone with the brawn necessary to hoist a fifty pound post-pounder above his head and over the post and give it repeated whacks until the post is subdued and pounded into approximately two feet of the terra (really) firma of our dad’s farmstead.  As I said, I was only 12 or so and the prospect of pounding all those posts was not the first item on my to-do list that winter. 

Sometimes events in our lives line up just the way we would have them and so it was in mine.  Given my father’s predilection for eschewing unnecessary convalescence or rehabilitation (or perhaps believing that his prescription was better than anything a physical therapist could offer), my brother ventured out after a few days of recuperation with his ankle to knee cast intact, awkwardly wielding his crutches from one post pounding to the next.  We younger siblings gratefully hauled the pounder for him from post to post and solemnly held the post for him to resume pounding every six paces or so.  We weren’t going to mess up a really good thing by suggesting to Dad that perhaps it might be better if brother were allowed to recover back in the house, leg propped up with a warm cup of hot chocolate in hand, undoubtedly surrounded by a number of fawning sisters.

And so that fence was finished.      

I suppose my brother’s ankle healed nicely.  I assume to this day that he has full range of motion in the ankle.  I can’t detect any discernible limp.  I'd like to think that the cattle were chagrined at the fact that yet another expanse of fence was built in time to thwart any further exit strategies.  Though I’m sure they managed to find a way out a few weeks later anyway.      

Dr. K 

An Arizona gunfighter and Dengue fever

I admit it.  I have a fondness for the history of my home state of Arizona.  The trick is to figure out a way to work this penchant for history into a blog about public health and pediatrics.  It’s not always easy, but it can be done with a bit of imagination and ingenuity.  And thus I will regale the reader with the story of one Jefferson Davis Milton.  How this has anything to do with public health? 
 

Wait for it…. 

Jeff Milton was born in 1861 on the Florida estate of his father, the Confederate (thus the name Jeff Davis) governor of Florida who committed suicide towards the end of the Civil War.  Jeff left home when he was 15 to seek his fortune as there appeared to be no future on an estate with no slaves and little prospects.  He landed in Texas and at 17 joined the Texas Rangers (lying about his age to qualify).  Four years later he moved west and spent the 1880s and 1890’s throughout Arizona, Texas and New Mexico working as a deputy U.S. marshal, sheriff’s deputy, customs inspector, police chief and in other law enforcement roles.  One of his more famous escapades as the police chief in El Paso involved backing down the infamous John Wesley Hardin.  As Hardin rode into town, Milton met him face to face in the street and asked him for his weapons.  For one of the few times in his life, Hardin decided against drawing against a man who had developed a reputation for a fast draw.  Hardin meekly gave up his guns to the police chief and was killed a short time later in an El Paso gambling saloon.  Milton famously stated once that "I never killed a man who didn't need killing, and I never shot an animal except for meat." 

By 1900 Milton had moved into Arizona and was working as a railroad guard when the Burt Alvord gang attempted a train robbery in the Cochise County train stop of Fairbank.  Not expecting Milton to be working that day, the gang opened fire on him in the railroad car and received a blast from Milton’s shotgun for their efforts.  One outlaw eventually died from the wounds delivered by that firearm.  Even still, Milton was shot in the left shoulder and left for dead.  He did have the foresight to hide the keys to the safe, however, and the gang left with a total of 17 Mexican pesos.  His left arm was never the same and it left him with a significant disability the remainder of his life. 

His story doesn’t end here in Fairbank, though, and we find out that he was hired
as an agent for the federal government under the Chinese Exclusion Act.  He spent the next 28 years traipsing all over the Arizona-California border with Mexico looking for smuggled Chinese aliens and others who might be fleeing the law.  He retired in 1932 at the age of 71 and is remembered today by officers of the U.S. Border Patrol as “America’s First Border Patrolman.”  He was 85 when he died in Tombstone, Arizona.

Well, with all this as preamble, our border with Mexico remains today a hot-button issue as well as a political minefield.  What people may not realize is that not only are there gripping stories and human tragedies along the border counties, but public health issues as well.  Should county, state, or federal monies be spent on immunizations for children who may be illegal aliens?  Should illegal aliens be treated with U.S. taxpayer dollars for conditions such as tuberculosis?  What of the emerging diseases that are creeping up from Mexico, such as Dengue fever?  We know the border to be a very fluid place.  We might think to vigilantly patrol the border as did our friend Mr. Milton, but communicable diseases, sadly, do not lend themselves to being controlled by an arbitrary line drawn across a multicolored map.  

No matter how tough the lawman.  

 

Dr. K

My dad, the doctor, vs. the bees

Dad kept bees.  I’m not sure he liked bees, or if this was merely another one of those “let’s do this so the boys (I am the second oldest of seven brothers) can learn the merits of hard work” gambits.  Or maybe he liked honey as mesquite honey does have its plusses.  Whatever the reason, Dad kept bees and that’s why I found myself overseeing an ill-fated operation in the middle of August approximately 31 years ago in southern Arizona.  That’s right, I said southern Arizona, in August.  For those not in tune to the typical weather patterns in that part of the world, let’s just say that the monsoon weather pattern brings a tad of humidity to the usual triple digits enjoyed during the summers there.  So we were hot.  And muggy.  Not to mention what this weather does to the bees’ disposition.

But I’m getting ahead of myself.  I was ramrodding an operation.  Of beemen.  At least what could be loosely termed an operation, in that my crew consisted of two of my least eager (at least in relation to their enthusiasm for bee-wrangling) younger brothers.  Dad had entrusted me with this job, probably because I was the oldest at home at the time.  

By way of background, I had just returned at twenty one years old from a two year mission for my church to Chile four days prior, and was slated to speak in church the following day.  It most certainly would not do for me to receive any bee stings to my youthful visage at this stage in the game.  But again, I’m getting ahead of myself.

We had the assignment of collecting the frames from the supers that were typically full of bees from the top to the bottom.  In order to drive the bees down into the stand, we would place a lid on top of the stand that was impregnated with butyric anhydride, euphemistically known as “Bee-Go”.  Well, sometimes they do, and sometimes they don’t.  Especially in the summer heat which makes the bees grumpy.  I maintain to this day that my one brother, who was eighteen at the time, didn’t leave the lid on long enough.  He maintains otherwise.  At any rate, when this didn’t work and we opened the lid, hordes of the little fiends came roaring out of the hive.  The puny smoker, filled with the best smoke that matches and high-grade cow manure could provide, couldn’t hold a candle to the territorial instincts of this host of insects bent on protecting their turf.

We hastily closed the lid, leaving it somewhat askew, allowing the bees to stream out at an even faster rate.  Faced with this dilemma, a pow wow of the assembled work staff could not come up with a better idea than to grab the whole hive at once, place it in the truck and hope that the wind would chase most of the tiny offenders away.  I’m sure I was vociferous in my protestations, but I most likely was out-voted by my two younger siblings, who probably wanted to just head home from the San Pedro Ranch as soon as they could so they could go back to reading Hardy Boy mysteries while pretending to watch the irrigation overflow the ditch banks back at our family farm.  What we forgot to take into account was the fact that a hive with four supers full of summertime mesquite and cat claw honey probably weighs over two hundred pounds.

With this fact glaringly missing from our decision tree, the three of us, decked out in full beekeeper’s regalia, proceeded to hoist the hive up a few inches.  Upon doing so, I realized in that instant that the majority of the 100,000 bees had NOT been streaming from the top of the hive, but had been cunningly waiting for some useful idiots to do just what was being done-that is, provide them with an opening from the bottom.  At this moment, two thoughts came to my mind.  First, beekeeping gear does not guarantee 100% success in repelling the critters, and second, I was a running back/defensive back in high school.  Knowing the first point led me to quickly ascertain the advisability of a speedy retreat and the second gave me the assurance of my ability to outrun a linebacker/tight end and an offensive lineman.  To paraphrase an old line- I don’t have to outrun the bees, just outrun my companions.

Which I did.  May it also be noted that the linebacker/tight end was faster than the offensive lineman.  So it was that my sixteen year old brother caught the brunt of the bees’ fury and I can still remember him to this day, stumbling down the path away from the bees, futilely swatting at the mass around his head as he lumbered toward us.  Not wanting him to bring the spectacle any closer, we frantically pointed at a huge metal water tank that would serve as a refuge from the marauding hordes.  He blindly stumbled towards the tank, climbed the eight feet or so to the edge and tumbled in.  As he sank towards the bottom, there was a trail of bees that followed him to the bottom of the tank.  He eventually resurfaced, with bees and unattached stingers still clinging to his face, head, and neck.  Summoning our utmost bravery, we chased the stragglers away and put him into the truck. 

The ranch was about 10 miles away from our house and by the time we were a few miles from the scene of the incident, younger brother was starting to lose consciousness.  I promptly applied an even hastier retreat in the old farm truck and arrived at the house emergently hoping that Dad was home.  He was, and as younger brother stumbled out of the truck and passed out on the grass in our front yard, Dad walked over to the truck and pulled out a vial of epinephrine (who knew?) and a syringe.  He calmly injected the erstwhile beekeeper who was up and about in a few minutes.  To me this was nothing short of miraculous, as it was likewise to the gaggle of congregated sisters standing on the front porch with their mouths agape and curlers in their hair, readying for the Sabbath on the morrow. 

Which reminds me.  My sisters may or may not have looked good the following day.  My younger brother certainly didn’t, swollen up like a beach ball.  But my face, when I spoke in church the next day, why, it was as pristine as that clear, mesquite honey.  And twice as sweet.  And having a father who was an anesthesiologist prepared for the unforeseen, even more so.

Dr. K    

Teenage pregnancy prevention redux

My last post regarding the New York City school system and its provision of Plan B contraception was met with a number of replies that took issue with my characterization of the problem. Perhaps I have been less than artful in my explanation of this issue.

Public health is at its core a preventative specialty. As many know, prevention can be of a primary, secondary, or tertiary nature. In most areas of medicine, primary measures of prevention are lauded as the most beneficial, and tertiary measures are considered a failure in a population context. As a simple example, hypertension and its complications can prevented in a primary fashion by proper diet and exercise, in a secondary way through medications, and finally, the complications of hypertension, such as heart disease, can be treated in a tertiary manner through more invasive means such as surgery. Traumatic brain injury due to firearms is another example. Tertiary means of prevention such as treatment of brain injury by the neurosurgical crowd is certainly not the ideal. Secondary prevention such as gun safety education is not considered adequate by some segments of the population.  The true primary preventative intervention would be to ban guns altogether, and, again, certain voices in and out of medicine advocate for that as well.

Why should prevention of teenage pregnancy be any different? Would it not be better to facilitate a primary prevention model for the problem? Because it doesn’t work? The same thing could be said for the obesity problem, yet millions of dollars are spent in figuring out how to provide the health education necessary to convince millions of us to adjust our diets and eating habits (including the banning of certain sizes of sodas in a particular jurisdiction), clearly a primary prevention model. If the current model of primary prevention of teenage pregnancy is ineffective, then it would seem that there should be a push to find a model of primary intervention that does work and not be satisfied with secondary and tertiary results. Our profession doesn’t accept this in most other areas of medicine.

The point is, this continuum of preventative measures is found all throughout medicine, and in my opinion, the New York City school system’s move to provide Plan B is an example of secondary or even tertiary prevention, and could be construed as a failure in the public health context as outlined above.

Dr. K

 

 

 

 

The failure of sex ed in NYC

The mantra of the sex education crowd for years has been that if we only taught these sweet little cherubs the intricate details of sex and the downside of teenage pregnancy that they would catch the vision of proper precautions and the teen pregnancy rate would decrease.  Well, the enlightened ones got some sort of come-uppance the other day.  It seems that the New York City school system has been handing out “Plan B” emergency contraception for the past year, in an attempt to decrease the teen pregnancy numbers afflicting the system.  Plan B is a “backup” plan that consists of one tablet of levonorgestrel that helps prevent pregnancy after unprotected sex or birth control failure.  It seems that over 7,000 teenage girls became pregnant last year in New York alone, with the majority dropping out of school.  Sixty four percent of these pregnancies ended in abortion. 

The New York City school system had to do something.  What they did seems to me to be a tacit admission that sex education programs don’t or can’t deliver on their promises.  If they did, then there wouldn’t be a need for this Plan B. 

What’s next, RU-486 (the abortion pill) prior to gym? Or a walk-in abortion clinic after chemistry class?  And why even have sex education at all, if this is where it is going to lead?

 

Dr. K

Trolls, Obamacare and the land of make believe

Make believe.  It has a nice ring to it.  Living in such a land can be fun.  Enjoyable.  Enchanting even.  We all wish we had a visa to this country.  Because if we did, we would want to stay there forever.  However, the hard truth is that when we visit this land, eventually we have to go back to the reality of everyday life.  Where things do not always happen for the best.  Where things we want must be worked for and paid for. 

 

Such as some of the goodies that were promised in the euphemistically named Obamacare.  They tend to be the most popular of the provisions in the bill.  We all like the idea of our kids being carried by our insurance until they are 26.  We mostly seem to be amenable to the idea that pre-existing conditions should be covered.  What we tend to miss is that both of these are essentially a de facto expansion of the insurance rolls that will need to paid for somehow, by someone.  And this has already occurred; it isn’t one of the provisions that will strike in 2013, 2014 or beyond.  We also neglect to notice that these items don’t come cheaply.  The reason that pre-existing conditions typically aren’t covered is because these types of policies are so expensive that insurance companies couldn’t sell them anyway.  So now they are magically added to the insurance pool?  One of the major touted benefits of Obamacare was the money savings that would be found.  Adding these sorts of patients to the rolls of the insurance companies has to mean that premiums will of necessity rise for all.  I don’t believe this aspect was explained very well to the country, if at all.  Or maybe there was a willful blindness to the cost of these goodies.  Because they sounded so...good.  We wanted to make believe they wouldn't carry any cost.      

It must be nice to live in the land of make believe.  But we should realize that this land is not always just a frolic with fairies and unicorns; sometimes there is a big hairy troll.  With a club.  And sometimes, just sometimes, we could get hit over the head with it, which would bring us back to reality.  That certainly hasn't happened yet.  Some say that we'll cross that bridge when we get to it.  But you all know what might be lurking beneath that bridge...

Dr. K