If you follow my work via my blog or Facebook page then you may have noticed I like writing about fellow writers. I mean, beyond the natural affinity I feel for anyone who takes up the pen and sticks with it, there are myriad things about the writing life that are universal and singular to each writer I profile. There’s no single path to becoming a writer and every writer’s life around the work and separate from it looks a little different, sometimes a lot different. And then there’s the very different kinds of writing people do and the unique voices they express. The subject of this New Horizons cover story, Bud Shaw, is a medical doctor and writer who’s gained a measure of fame for training his inner eye and ear on his former life as a transplant surgeon through essays, several of them collected in his well-received book, Last Night in the OR. Though it took him until about a decade ago to finally write about his own personal experiences, he’s been writing since he was a child. It can take the better part of a lifetime to find one’s voice, especially that voice residing deep within the inner recesses and nooks and crannies of our subconscious. When Shaw finally did find his, he revealed himself to be a strong, spare writer in the style of his literary heroes. My profile of Shaw will appear in the May 2017 issue of the New Horizons, a free montly newspaper from the Eastern Nebraska Office on Aging. Beginning April 28, look for the new issue at area newsstands or, if you’re a subscriber, in your mailbox,. Order your free subscription by calling 402-444-6654.
Voyager Bud Shaw gives up scalpel for pen
©by Leo Adam Biga
Soon to appear in the May 2017 issue of the New Horizons
Before Dr. Bud Shaw gained fame as a liver transplant surgeon, first in Pittsburgh, then at the University of Nebraska Medical Center (UNMC), he was a writer. An adventurer, too. He’s a veteran small-engine pilot and hang gliding enthusiast and an avid bicycle trekker.
His wonderment with words goes back to childhood. It continued during his formal education – all the way through undergraduate and medical studies. Even during his surgical career he continued writing whenever he had down time. But since putting down the scalpel for the pen, his writing’s really taken off.
For decades he composed fiction but in recent years he’s turned to nonfiction. Some of his highly personal essays have won recognition. His 2015 book Last Night in the OR was a New York Times Bestseller.
His wife Rebecca Rotert is an award-winning poet, short story writer and essayist whose first novel Last Night at the Blue Angel was well-received.
Shaw leads writing clubs at the Med Center. He advocates students and professionals take writing courses to enrich their humanities education. He cites research showing the health benefits of writing.
“When you write something down as opposed to talking about it, it gets stored in long-term memory – with far fewer details but more indelibly – and it’s in an area where your brain keeps working on it. It’s like the thing where you write something and put it away and come back to it and you start editing it immediately when you couldn’t have done that the day before. But your brain’s been working on it.”
He said studies show that in “patients who wrote for three days in a row their brain did some processing that somehow also helped them deal with their illness.”
Reading and writing
Prose fed Shaw’s imaginative escapes as a youth.
“I read a lot. As a kid I got sick frequently and I’d end up having to stay home. We had bookshelves full of books. My mother bought a series of classics for kids: Black Beauty, Treasure Island, Bambi. I would pick them out and read them, and then I got into The Hardy Boys and when I read all that I even tried Nancy Drew.”
He became a familiar figure at the local library.
Family trips to Crystal River, Florida got him hooked on diving and his natural curiosity and affinity for reading found him hunting every book he could on the subject.
“My school projects were reports about the aqua lung and the difference between one and two stage regulators and how you could get the bends and prevent that. I knew the decompression tables when i was 12.”
Writing had already become an outlet.
“I began writing seriously in second grade, My mother helped me write a romantic adventure novel involving a boy and his pony. It filled 10 pages of Golden Rod tablet paper we bound with rubber cement and a cardboard cover. She died a few years later and I guess I’ve been looking for that kind of approval ever since.”
His passion for literature was stoked at Kenyon College a small liberal arts school near where he grew up in rural Ohio. There, he said, “reading and writing were paramount and literature became a limitless world for me – a world where anything could happen. I was a chemistry major, but I filled the other spaces with literature and creative writing courses. In the first two years of medical school, those intellectual pursuits were largely replaced with the drudgery of rote memorization. I found myself obsessively writing short stories and sending them off to Redbook, Playboy and Reader’s Digest. It was a useful diversion and the rejections hardly mattered.”
His literary favorites range from John Steibeck, Ernest Hemingway and William Faulkner to Kurt Vonnegut, Gunter Grass and Cormac McCarthy.
Finding his niche as a transplant surgeon
Though his father was a surgeon, Bud at first resisted following in his footsteps. He said the fact he eventually did was “probably because he didn’t push it on me.” Shaw received his MD at Case Western Reserve University, did general surgery training in Utah and completed a transplant surgery fellowship in Pittsburgh,
There, he made a name for himself as a talented maverick working under the father of transplantation in America, the late Tom Strazl. The two men shared a complicated relationship.
“Most of the advances going on at that time in transplantation were happening in Pittsburgh. I was working with Starzl, who then was by far the most important pioneer in transplantation. I would have stayed there happily and worked with him but it just became more and more difficult.”
Shaw left because he disagreed with the way certain things were being done that he felt hampered surgeons’ learning and endangered patients’ lives.
“I wanted to change the way we did things and I realized I wasn’t going to be able to do that there as much as I wanted. I realized I didn’t want to be part of a program that was chaotic and dangerous for patients.”
Prestigious hospitals coveted having this hot shot young surgeon come start a transplant program in what was a sexy new medical horizon making headlines.
“It was a brand new field. I had probably done more liver transplants in the previous two years than anybody in the world .”
Coming to Omaha and building a world-class transplantation program
UNMC recruited him. It didn’t have the cachet of other courters but it proved the right fit. It helped that the man pursuing him. Layton “Bing” Rikkers, knew him when Shaw trained in general surgery at the University of Utah, where Rikkers had taught.
“Once I got trained in transplant I always intended to go back to the University of Utah but they just didn’t seem to want to do it (start a transplant program).”
When Rikkers took the UNMC job he asked Shaw to join him but Shaw wouldn’t be persuaded – at first.
“I told him I want to go someplace with a seacoast or mountains or preferably both.”
Rikkers wouldn’t take no for an answer. He strategically brought Shaw in as a consultant on the ABCs of starting a transplant program. Shaw met a Med Center contingent, including Mike Sorrell and Jim Armitage, who, he said, were “incredibly enthusiastic about doing liver transplants.” “There was a stark contrast between the attitude here, which was one of ‘We understand we don’t know anything about how to do this – we need you to be the expert,’ and what I found elsewhere.”
Shaw said. “I realized this was a rare opportunity because I’d interviewed at much more famous, high-powered places. I’d told them the same thing I told UNMC – I can’t come alone, I’m going to bring a junior surgeon with me and I need to have an anesthesia team go to Pittsburgh and learn how to do anesthesia and a pathologist go learn how to read the biopsies of the liver. And all these places said, ‘No, we have experts, we’re sure they can handle this, and we have very precious faculty positions to maintain.”
He said other centers didn’t appreciate just what a commitment they needed to make.
“They said, ‘We want you to come start this and we’ll see how it goes,’ and I said, ‘See how it goes? This is a high risk sort of thing.’ That’s when I realized they were mainly interested in doing this not because they were interested in treating liver disease but because it was a cool thing to start doing and they didn’t want to be left out. This place (UNMC) was clearly different. It was one of the only places in the country thinking about this as a long-term prospect they could succeed in, and that’s why I came here.”
One of Shaw’s biggest contentions with the way things were done in Pittsburgh that he changed in Omaha was transplant surgeons not having responsibility for post-op patient care. Some patients get profoundly sick after transplant surgery and lax care can exacerbate already dire situations.
“On a typical Sunday morning I’d find three transplant patients in the ICU and two of them would be bleeding still and I’d have to take them back and fix them in the operating room. I’d go talk to the family and they’d say, ‘Nobody’s talked to us.’ So I found myself cleaning up messes made by other surgeons who weren’t being supervised adequately and hadn’t had enough training.
“I talk about this in the book,” Shaw said. “Tom Starzl never wanted to have a routine, he wanted to change it every time, and you just can’t teach other people what works and what doesn’t work very well if you’re changing it constantly.”
After coming to Omaha in 1985 with his first wife and establishing a world-class solid organ (liver, kidney, pancreas, heart) transplant program here, the city became their home.
“I came here with the idea we’d spend five years and then move to one of those places with seacoast and mountains, but at the end of five years we had a really good program going. We were still growing, we were doing innovative things.
“I got recruited to go look at a couple of jobs right around that time. I just realized it was going to be like starting over and the politics would be worse. There’s no advantage of going to those places other than geography and I can buy a plane ticket.”
Diversions by ground and air
He’s bought plenty of tickets over the years to make bike tours with friends in scenic spots around the globe:
Then there’s his life as a pilot. He got his license at 19.
“I bought a 1939 J-3 Cub and flew it back to college. I had another airplane in Utah where I also took up hang gliding. I didn’t have any aircraft in 1981 when I arrived in Pittsburgh, but by 1984 I bought a used seaplane that I also took to Omaha in 1985. I eventually sold it and joined two other guys in a partnership in several airplanes.
“I plan on getting my glider rating this summer.”
Shaw’s logged enough hours behind the controls to have had some harrowing moments in the air.
“Every pilot with that many years experience has many stories to tell, as do I. I’ve been scared several times when weather closed in on me unexpectedly while flying cross-country. I flew aerobatics for half a dozen years in the ’90s. That was always exciting but I never had any close calls doing that. I had a couple of close calls hang gliding. I describe one in the book.”
More often than not, his time in the sky has afforded sublime glimpses of beauty. He recalled a Utah ridge that provided “wonderful soaring” and close encounters with Bald and Golden eagles living in the rocky cliffs.
“They often came out and flew along with us, sometimes showing off their aerobatic skills.”
Then there was the 1973 coming-of-age flight he made in his little Cub with an acquaintance of his from Ohio, Scottie Wilson.
“The summer of ’73 was between my first and second year of medical school, which I hated. I’d restored an airplane I kept out at the local airport. Scottie had just gotten his wings for the Air Force. That summer we flew in my little Cub a lot together. Toward the end of the summer he had to get to Tuscon, Arizona for combat training. He was going to drive and I said maybe we should fly my Cub out there.
“There were multiple times during that trip where I was going to quit medical school and become a jet jockey.
When the whole thing was done I had to turn around and fly back by myself, and this was like two weeks before I was getting married. I had sort of abandoned ship and ran away.”
The event proved a crucible for Shaw.
“Right after I crossed the Continental Divide there was a storm up ahead I realized iI couldn’t fly around or above so I just landed on a road. As I was sitting there watching this storm go by I started crying. I had this deep sense of loss.”
Broke and out of fuel, he siphoned gas from every small plane on the line at the airport. Back home. he married. started a family and completed his studies. That summer interlude never left him but it’s only recently he
tried writing about it.
“I told Rebecca about it and she said, ‘There’s a romance there of a kind,’ and there really was. A closeness developed in a short period of time that was very different than any experience I’ve had with another guy.”
Intent on catching up with his old pal, Shaw happened to open a magazine to a story about Wilson restoring a 1938 Bugatti airplane presumed lost during World War II. The plane was rediscovered and Wilson, a retired Air Force officer, was building a replica.
“I tracked him down through Facebook and we ended up spending hours on the phone three or four different times over the space of a couple months. My plan was to go see him. He was in the process of starting to test fly this plane. I talked to him in May 2016 and in December I got an email from his brother that said, ‘I’m sure by now you’ve heard about Scottie dying…’ He’d taken the plane up again and was barely off the ground when it happened.
“He’d sent me some sample writing. He wanted me to help him write the story of this airplane.”
Wilson’s passing marked the latest of four recent deaths of important people in Shaw’s life. He feels compelled to write about what they meant to him.
“I have lots of starts in different directions in talking about the way your relationship with your mentors is more like a love affair than it is like a parenting relationship. It’s like seeking their love and approval more-so than maybe with a parent.”
Merging his personal, medical and writing lives
When Shaw was still doing transplants he was barraged by life and death events but so cut-off from them emotionally he didn’t write about them.
“I was so busy and chronically sleep deprived I rarely had time or inclination to write. Except on vacation. Once I got away from work, I inevitably started writing. It was always fiction. By the mid-’90s I had the starts of five novels. I took a sabbatical in 1996 to write and came away with a 180,000-word novel that isn’t yet worthy of publication. Of course, family and friends all thought it was wonderful but nobody else did. I was afraid of getting it reviewed by anybody.
“None of my writing then had any direct relationship to my work. I think it was largely a way to escape the stress of that life.”
Shaw’s real growth as a writer began when he confronted his own life on the page at the 2007 Kenyon Review Workshop.
“It was very educational and inspirational to actually have to write something and then to have people critique it. It was the first time I had valuable critique of what I’d written. I began to understand what I needed to do to improve things was to keep writing, to keep having people critique and then keep changing and writing.”
His next evolution came as a participant in the Seven Doctors Project that puts doctors together with writers.
Shaw was in the project’s first group of doctors in 2008 and he participated in several other sessions the next few years. One session in particular proved fruitful.
“I did get some wonderful stuff from the review of what I wrote that year. The most telling thing was from another writer there, Rebecca Rotert” (whom he ended up marrying after he and his first wife split).
“When it was my turn to read, everybody complimented how they liked this or liked that and then all of a sudden Rebecca said, ‘Okay, here’s the deal: I don’t know what this person’s motivations are. We’re missing some of the basic things of a story and by now we should know this.’
I started to feel defensive and then I thought, ‘Oh my God, she’s absolutely right,’ and I can fix that because I know what the answers to those questions are.”
All of it spurred him to explore his own life in nonfiction writing. The more he drew from his personal experience, the more he liberated himself.
“I was finally able to think about some of the experiences I had and to step back from them far enough to actually write about them without having a strong emotional agenda that kept me from doing it before.”
With each story he takes from his own life, he’s puts himself on the line.
“I suppose writing highly personal nonfiction stories is risky for anyone. I felt I couldn’t do it unless I found a way to be more objective about the most difficult and emotional experiences. I had to resist the temptation to ‘set the record straight.’ I had to discover instead the other stories within those moments.”
His first published essay, My Night With Ellen Hutchinson, is about a devastating personal and professional episode early in his career.
“As I sat down to write about it, I discovered just how stubbornly I still held onto a version of that story that blamed others, that let me off the hook for the death of a patient during a liver transplant. I had to revisit that night over and over again for weeks to reconstruct a view that wasn’t about the cause of the failure so much as it was about the results of it. It wasn’t easy.
“That was a very straight forward operation. In my mind, I’d done everything right. I got the new liver sewn into place and blood flowing into it and everything was just great when her heart stopped. And yet, the technical details of why the woman’s heart stopped and how we should have handled it and how today, I know she would not have died because of what we later learned to prevent the problem, none of that was a story worth recounting. I needed a fresh and far more human perspective, and that required me to do a lot of processing I hadn’t done before.
“Now I don’t seem able to stop.”
For years Shaw erected shields warding off self-reflection when people’s lives were in his hands.
“The protective mechanisms were about dealing with failure, where failure could be somebody’s death. After failure I felt it absolutely necessary to approach the next case with supreme confidence that everything is going to go well. There’s a lot of ways of getting to that point. Maybe the quickest way is to simply say, ‘That last problem – that wasn’t my fault.’ But that’s not the only way. Another way, but it’s not the one I took, is to think about it more and to recognize we’re fallible and I did play a role in that, and what can I do next time to make sure that doesn’t happen again.
“It would have taken the ability of being more mindful as they call it now.”
In his book Shaw reveals his own and others’ frailties as counterpoint to the God-like status medical professionals are held in or hold themselves in. His essays chronicle how he didn’t let things touch him, not the lives he saved or lost, not even his own bout with cancer, What opened the flood gates of introspection was the disabling anxiety that overcame him in 2006.
“I didn’t have any problems with social anxiety at all
until one day I was sitting in my living room and suddenly had a panic attack that eventually caused me to crawl into bed and cover up. I had no idea what was causing it. It just came out of the blue.”
Some days at work he couldn’t leave his office. He finally sought help. Drugs help regulate the condition. Writing about it has been freeing.
“What the writing has done is help me understand and accept the fact that I have this problem. It’s also helped me recognize I did have these protective things and the question in my mind is – what if I had been as self-aware and self-reflective when I was in the midst of this incredibly intense surgical career with all this risk?
Would I have been able to continue? I think the answer to that question is probably yes.
“The process of writing about my own experiences really did open up my writing in a way. That, and there were about three books I read around that time that made me become much more spare, to work harder on eliminating stuff. The big problem I had was my need to make sure you understood everything, explaining
everything. Being freed up from the idea that you have to explain everything was like a miracle. You can actually let people figure out stuff on their own.”
He said a UNMC colleague objected to how much medical imperfection he revealed in his book.
“She said, ‘This is a huge mistake. Nobody should pull back the curtain and expose these sorts of things.’ I said, ‘Why, do you think people are going to come after us with torches?’ She said, ‘Well, they might,’ and I said, ‘Well, if they do, maybe we deserve it.’ I certainly got lots of positive feedback from surgeons outside of here. In fact, I’m still getting it.”
A notable exception was his old mentor Tom Starzl, who reacted strongly against the book. It strained the two men’s already tenuous relationship. As a show of respect and peace offering, Shaw attended Starzl’s 90th birthday celebration.
“I gave him a big hug and he started crying. It was very emotional.”
Starzl died a year later.
Before Shaw could get his book published, UNMC made him jump through hoops to change details so as to avoid privacy issues.
“A lot of the essays had been written with the names of the real people involved before I knew these stories were going to be part of a book,” Shaw said. “I had to start looking at how I could contact these people (for their permission). I knew I wasn’t allowed to look in the medical records for that purpose and I knew I couldn’t ask anybody else to do it for that purpose.
“I couldn’t remember some of their names. I was in the process of trying to sort out how to contact them when the privacy officer at the hospital called and said you can’t write about any of your experiences here.”
The decree made Shaw bristle. He resisted the blanket refusal, pointing out there was nothing in his contract or in UNMC’s HIPPA policy preventing him from doing it.
“Eventually I could not get them to allow me to contact the people. So I went in and changed enough of the details that there’s just no way anybody could recognize the real people.”
Doing what he has to do
Some of his writing does name names. His essay A Doctor at His Daughter’s Hospital Bed recounts the time he intervened in the care of his daughter Natalie, who was hospitalized with pneumonia and not getting the IV fluids he knew she needed.
“I know I shouldn’t be my daughter’s doctor. They taught us the problems with that during my first week in medical school. It’s a really bad idea, especially in high-risk situations. We doctors are also very superstitious that when dealing with family members … something is always going to go wrong. The more the Special Person hovers over the care of his or her loved one, the worse the complication will be. I’ve had conversations in which doctors feel they change their routine with V.I.P. patients, and it’s that disruption in routine that allows error to creep into their care.
“But right now, I don’t care about any of that. I’m the one with experience taking care of really sick patients, and if I know she needs more fluids, she’s going to get them.
I break into the crash cart … I pull out two liters of saline solution and run both into Natalie’s IV in less than 20 minutes. Natalie’s pulse slows and her blood pressure rises. An hour later, after the nursing supervisor and on-call resident finally arrive, I’ve finished infusing a third liter. Natalie finally looks better.
“This wasn’t the first time during Natalie’s illness … I broke my promise to just be her dad.”
It also wasn’t the first or last time he crossed the medical care barrier with a loved one.
My younger son, Joe, almost died … from septic shock. He became ill while I was out of town. I flew home and by the time I arrived at the hospital, he looked deathly ill to me. I told the nurse I thought he should be transferred to the intensive care unit, but she said the doctors thought he was improving. Joe stopped breathing during the night and I have blamed myself ever since for not insisting they move him.
“Over and over again during my dad’s last few years of life, I felt as if I should have just moved in with him so that I could prevent all the well-meaning doctors and nurses from killing him. Sometimes it was just because his doctors weren’t talking to one another and their conflicting prescriptions sent Dad to the hospital. In the end, he died about 10 minutes after receiving an injection I didn’t want him to receive.”
Shaw’s daughter did recover but, he writes. “I didn’t.” He explains in his essay:
“I stopped operating and taking care of really sick people two years later. I told myself I had become too distracted by my increasing administrative duties to be a safe doctor. I was glad to leave all that behind. Now I just want to sit on the sidelines and marvel as a new generation of doctors performs the miracles. I never again want to step in to rescue someone I love. But I will, if I have to.”
On a pedestal
He had occasion to operate on public figures or loved ones of celebrities. Such was the case in 1993 when he performed liver transplants on Hollywood icon Robert Reford’s son, Jamie Redford, in Omaha.
As is often the case, patients with good outcomes form an attachment with their surgeons that is one-part gratitude and one-part adulation. It was no different with Jamie Redford, who on Instagram recently posted a photo of himself and his life-saver with this caption: “My hero and good friend, Dr. Bud Shaw.”
Redford regained his health and produced a documentary, The Kindness of Strangers, raising awareness of the need for organ donation. Redford and Shaw saw each other just last year.
“Jamie and I did something at the Sundance Authors Series. I did a reading of my book and then Jamie came up and we sat on a couple stools and we did a kind of give-and-take with each other and people asked questions. Bob (Robert Redford) was there and Jamie’s sister was there. It was standing-room-only.”
But in his essay Real Surgeons Can’t Cry Shaw divulges how he didn’t cope well with the hero worship showed him. For him, surgery was a job to be gotten through, a task to be completed. The human dimensions of it sometimes escaped him or made him uncomfortable, and so he avoided those implications and interactions that required emotional investment.
Taxing times in the crowded OR give way to one-on-one writing-editing critiques
A transplant operation is always complex and requires a team of professionals/ But these were far riskier procedures in the 1980s and 1990s then they are today because there weren’t the techniques and drugs available then that there are now.
“The longest one in my experience was in Pittsburgh that was 27 hours,” Shaw recalled. “In that case it was a child. When we started out trying to open the abdomen it was like concrete. We had to go ahead and get the liver in there because its time out of the donor’s body was getting too high. We didn’t want it to die – the liver would be nonfunctional. So we put it in and then we had all this sorting out of stuff to do for hours and hours, trying to get the bleeding stopped.
“What would happen is the patient’s own body would start dissolving its clots. That was a pretty common feature of a liver transplant.”
The operating room is a collaborative, dynamic environment of high risk and high reward. Writing, by contrast, is a solitary experience whose rewards are more internal then external. Shaw values having a life partner in Rotert who is a fellow writer. They share everything they write with each other.
“We are our own best editors,” he said. “I think I take her criticism of what I write a lot better than she takes my criticism about what she writes, and I don’t know if that’s because her criticism is more gently delivered because she’s not very gentle with it. But for some reason whatever she tells me often rings so true.
“LIke with these initial essays I wrote, I wasn’t sure what they were really about and she helped me figure out what they were really about.”
He admires her craftsmanship.
“She really writes incredibly well. She writes some beautiful sentences. She also develops characters incredibly well, each with different voices. She’s really a master at that sort of thing.”
The couple live in a multi-story home on the edge of Neale Woods. Books, magazines, paintings (by her) and photographs (by him) adorn the rustic-chic living spaces whose large windows look out on the Missouri River basin and bluffs to the east and pristine forested land to the west.
Idyllic surroundings and professional accolades aren’t salves for the demons inside us as Shaw discovered. Even at the height of his career, politics and egos found him fighting external battles. He eventually became chairman of surgery at the Med Center and after 12 years in that post he headed-up a large point-of-care software development project that got canceled.
He’s felt a bit adrift since retiring from surgery and then having that software project killed.
“There’s almost nothing like having a really difficult job to do with a lot riding on it and you’re afraid going in about what might happen but you do it anyway and you succeed and everything’s okay. It just so happens that liver transplants is one of the best things like that. And so I lost that reward system. The other thing I lost was every day somebody telling me what to do. Even when i was chairman of the department. It’s not like I had to say what am i going to do today? There was always stuff to do and too much to do.
“Not having that and having so called free time to write and to do other stuff was initially fun and easy but the longer it’s lasted the more difficult it’s become
While a practicing surgeon he once thought of leaving that career to write full-time but he wasn’t crazy or brave enough to try it. “Doing liver transplants is easier.”
Ever the voyager, Shaw has worlds yet to explore in his travels and in his new vocation as author, Having finally given himself permission to write about his past, he’s embracing new adventures as source material for future tales. With so much to draw on, his creative well should never run dry.
There’s nothing like getting current, though it’s hard to do when you write for a monthly. Still, in this cover story I wrote for the March 2017 issue of The Reader (http://www.thereader.com) I think I mostly managed to stay relevant to the topic of health care coverage in America, the forces pushing and pulling for and against the Affordable Care Act and what the ACA has meant in terms of gains and what its repeal and replacement would mean in losses. For the piece I spoke to local professionals on the provider and insurer sides of the equation for their take on how we got here and where we might be heading. The story went to press with us knowing Congress was working to repeal and replace Obamacare, though no one knew what that entailed, and then just about the time our story got published that plan was unveiled. As you know by now, the proposed new plan was met with disdain from all quarters, especially consumer rights groups and elected officials, even conservative Republicans, who heard loud and clear from constituents that they they oppose the called for cuts that would cause many people to lose insurance. As the push back continues, town halls and debates ensue, and presumably negotiations, revisions and compromises will get made. Meanwhile, America still can’t get its health care system to work equitably and efficiently.
Who’s Going to Pay? Before & After the Affordable Care Act
©by Leo Adam Biga
Appearing in the March 2017 issue of The Reader ((http://www.thereader.com)
One accident, one illness could be catastrophic. Not just medically, but also financially.
Families stood to lose almost everything in medical bankruptcies when health insurance companies rejected those with pre-existing conditions and capped their policies with lifetime limits.
Uncovered costs helped health care expenditures soar, more than tripling in the last 20 years according to the federal National Health Spending Report. In 2015, the federal government was the largest payer of health care, covering 37% of the total cost through its two programs Medicaid and Medicare.
The curve was starting to bend.
According to the Kaiser Family Foundation, health insurance costs increased 63% from 2001 to 2006 and 31% from 2006 to 2011. That number dropped to 20% from 2011 to 2016.
Part of the reason was the Affordable Care Act and a landmark shift in how health care was being offered. Through a series of tax increases targeting high-income earners, the ACA was able to fund experiments in in- novation while subsidizing the cost of bringing almost 30 million Americans into the health insurance system.
With the end of Obamacare at the top of the national conversation, The Reader talked to the major stakeholders about life before and potentially after the Affordable Care Act.
It’s not just the $2 billion in federal revenues Nebraska passed up for health insurance, or the 275,000 Nebraskans with pre-existing conditions that could be denied health insurance, according to the Kaiser Family Foundation. It’s not even the estimated 165,000 Nebraskans that would lose health insurance, an increase of 111% of the uninsured, according to the Economic Policy Institute, leading to almost 3,000 jobs lost and $400 million in federal health care dollars gone that we subsidize.
It’s also about the way we take care of each other.
Quality of Health Care Over Quantity
America treating healthcare as a commodity helps explain its high delivery and coverage expense. Characterized by historic lack of incentives to drive prices down, providers and insurers dictate terms to consumers. Subsidies to assist low income patients who can’t pay out of pocket get passed along to other consumers. But affording care and its coverage is a burden even for the middle classes.
Amid runaway costs and coverage gaps, America’s clunkily moving from a volume to a value-based system as part of long overdue healthcare reform. The Affordable Care Act was passed in 2010 after contentious bipartisan debate. The statute’s full roll-out began in 2014.
Nebraska Medicine CEO Daniel DeBehnke said, “The tipping point that brought the ACA forward is really the unsustainable growth in our country’s healthcare costs.”
The calculus of people not being able to afford care translates into real life implications. Untreated chronic diseases worsen without treatment. Early diagnoses are missed absent annual physicals or wellness checks.
Championed by President Barack Obama, who promised reform in his campaign, the ACA’s enacted consumer protections and mea- sures holding providers account- able for delivering value.
Nebraska Methodist Health System CFO Jeff Francis said organizations like his have “con- tracts and monies at risk for hit- ting certain quality items, not just with Medicare, but with some of our commercial insurers as well, Five or ten years from now,” he added, “we’ll probably have more at risk financially from a quality and outcome standpoint. Recent federal legislation changed the way physicians get paid by CMS (Centers for Medicare and Medicaid Services). Starting in 2019 they’re having potential penalties depending on whether they’re hitting certain quality metrics or not.”
He said the stick of such punitive measures works.
A new Standard in American Health Care
Aspects of Obamacare, such as the individual mandate and public health exchanges, have detractors. Federal lawsuits challenging it have failed. But its intact survival is in jeopardy today. A chief critic is President Donald Trump, who with the Republican controlled Congress vowed to repeal and replace, though that’s proving more daunting in reality than rhetoric. On February 16, GOP leaders shared a replacement plan with tax credits for buy- ing insurance and incentives for opening healthcare savings accounts, but no details for funding the plan or its projected impact on the insured and uninsured.
Debehnke said, “I don’t think there’s any question, regardless of where you land politically, there are components of the current ACA that require tweaking. Even Democrats will tell you it wasn’t exactly perfect – nobody said it was going to be perfect. It was understood there were going to need to be changes as things move along.”
There’s widespread consensus about the benefits accruing from the ACA. New subsidies allowed millions more people nationwide and tens of thousands more in Nebraska to be insured, in some cases getting care they deferred or delayed. Insurers cannot deny coverage for pre- existing conditions or cancel coverage when someone gets sick. Plans must cover essential care and wellness visits. Adult children can remain on their parents’ insurance until age 26.
Francis said, “A lot of good things have come out of this. We’re focusing on well- ness, we have fewer uninsured, we’re having better outcomes for patients. I think there’s satisfaction with the improvements. I just think there’s disagreement with how it’s occurring or being done.”
“You can’t believe the difference it’s made by setting minimum standards for health insurance,” said One World Community Health Chief Medical Officer Kristine McVea, “so that things like child immunizations and mammograms are covered.”
Since the ACA’s adoption, uninsured 18-to 24-year-olds in Nebraska dropped from 25.5 percent in 2009 to 12.4 percent in 2015, according to the Kids Count in Nebraska Report.
McVea said, “At One World people get assistance in enrolling for health insurance. Counselors guide them through the market- place. People are really becoming more savvy shoppers. Improved health literacy has been a result of this process, you can really compare for the very first time apples to apples in terms of different plans. That has been a tremendous boon to clients.”
Not everyone included – Nebraska drops the Kick- back
Healthcare disparities still exist though. In Omaha 24% of adults living below the poverty line
lack health coverage while 3% of adults with medium to high in- come are uninsured. Some 36% of Hispanic adults, 15% of black adults and 5% of white adults are uninsured in the metro, ac- cording to numbers reported by The landscape, a project of the Omaha Community Foundation.
McVea said, “The poorest of the poor are not eligible for the marketplace at all because that part of the Affordable Care Act carved them out thinking states would cover them with Medicaid. Well, Nebraska’s elected not to expand Medicaid, so there’s this whole gap of people not insured. Then there’s prob- ably another tier who do get assistance through the marketplace, but considering the economic pressures they’re under, even with the assistance, it still falls outside their reach to get good healthcare.”
The Kids Count Report found 64 percent of uninsured Nebraska children are low-in- come — likely eligible for but not enrolled in Medicaid or Children’s Health Insurance program (CHIP).
Past Nebraska Medical Association president Rowen Zettermen said, “In Nebraska we have somewhere in the neighborhood of 60,000 to 90,000 uninsured people that would have otherwise been eligible for Medicaid expansion. you find the highest percentage uninsured rates in rural counties. We still have 20 some million uninsured in this country. A number may have insurance but they’re underinsured for their various conditions. Ideally, everybody should be able to establish a healthcare proposition with their physician, nurse practitioner or physician’s assistant to access care whenever they need it.”
Then there are federal DSH monies to fund Medicaid expansion the state foregoes because the legislature’s voted against expansion. Gov. Pete Ricketts opposes it
as well. Disproportionate Share Hospital payments are subsidies paid by the federal government to hospitals serving a high percentage of uninsured patients. Nebraska hospitals write off uncompensated care cost while getting no money back for it.
Zetterman said, “We could expand Medic- aid and take advantage of the roughly $2 to $2.5 billion that’s failed to come into the state. It would have paid salaries for more people in physicians offices and a variety of things that would be taxed and bring in more revenue.”
DeBehnke of Nebraska Medicine said, “Being a large hospital health system that takes all comers, we have a Medicaid percentage of our business. We would be better off in a Medicaid expanded state. We would like to see more coverage for the working poor. That’s what Medicaid expansion is – providing coverage to the working poor. Those who don’t currently qualify for it would under an expansion.”
Proposed federal community block grants could expand coverage. DeBehnke cautioned, “We just have to be sure there’s good control around how those dollars are used and they actually go for healthcare coverage. Expanding coverage to all people is really the key.”
Nebraska State Senator Adam Morfield is the sponsor of lB 441, which would expand Medicaid in Nebraska. The bill is scheduled for a March 8 Health and Human Services Committee hearing.
The care-coverage-income gap may be more widespread than thought. Kids Count Report findings estimate 18.5 percent of Nebraskans are one emergency away from financial crisis.
Preventative Care is Long-Term Savings
Having coverage when you need it is a relief. Insurance also motivates people to get check-ups that can catch things before they turn crisis.
“A woman having symptoms for some time didn’t have any insurance and she waited
before she sought care,” McVea said. “By the time she came to us for diagnosis she already had a fairly advanced stage of colon cancer. She’s undergone chemo- therapy and surgery and is now living with a colostomy. That didn’t have to happen. We see things like that every day – people who’ve let their diabetes and other things go to where they have coronary artery dis- ease, and that’s not reversible. We’re trying to get them back to the path of health with treatments, but they’ve lost that opportunity to maintain a high quality of health.”
Zetterman said, “There’s good data to show patients with cancer who don’t have insurance tend to arrive with more advanced disease at the time of initial discovery because they come late to seek care.”
That pent-up need is expressed more often, McVea said, as “people have insurance for the first time or for the first time in a long time.”
“We’ve seen a lot of people come in as new patients saying, ‘I know I should have come in a long time ago, and I’ve just been putting it off.’ Many are middle-aged. They’ve been putting off chronic health conditions or screening tests or other things for years. We see people come in with diabetes or high blood pressure that’s out of control and within three months we get them to a point where everything’s in control, they’re feeling better, they have more energy, they’re feeling good about their health. We’ve maybe given them advice about diet and exercise and ways they can keep themselves healthy.”
More positive outcomes are prevalent across the healthcare spectrum.
“I would say overall the average patient is having a better experience and outcome now than they were five years ago,” Nebraska Methodist’s Jeff Francis said.
One World’s CEO, Andrea Skolkin, said, “We’ve been able to reach more people living on limited income so our services have been able to expand both in terms
of numbers of patients we care for as well as types of services and locations.” One World opened two new satellite clinics with help from ACA generated monies. “As we’ve opened new clinics we’ve seen a number of people that had never been seen or delayed being seen with very complex
medical and sometimes mental health issues – and it’s more costly. We grew from about nine or ten percent of patients with insurance to close to 15 per- cent. For newly insured patients it’s meant some peace of mind.”
Fewer insured people, Higher Costs
She and her community health center peers favor more afford- able coverage to increase the numbers of those insured.
Zetterman said high premiums and co-pays present obstacles that would be lessened if everybody got covered. “The financial burden on the individual patient and family for health- care right now is too high.”
DeBehnke said, “A lot of the
burdens of those premiums in terms of high deductibles and other things have been shifted to families. There has to be some degree of subsidization if we’re going to make this all work. Regardless of where we land with this, the financial burden on the individual patient and family for health- care right now is too high.”
For the poor, the last resort for care continues to be the ER.
“If you’re uninsured the one place you can go in this country is to the emergency room of a hospital because the laws say you cannot turn anyone away from there,” said Zetterman. “As a consequence the uninsured make use of the ER because it guarantees they’ll get cared for – at least at that moment. The ER is the most expensive place to go for things that could otherwise be handled in a healthcare office.”
Zetterman said America’s handling of its social contract and safety net means “we cost shift in the healthcare environment to pay for things.” “In Nebraska, where we didn’t expand Medicaid,” he said, “we cost shift from private insurance and healthcare providers to people who have private insurance. They help pay for the uninsured-underinsured. We’ve estimated that to be well over a billion dollars. We can’t control costs reliably until everybody is in the system with some kind of a paid healthcare benefit. That can include all the current federal and state programs as well as commercial insurance that’s out there.
“Once we no longer cost shift to pay for healthcare we can begin to address the questions where are we spending our money and why are we spending it in those areas. Then we have a chance to control the growth of healthcare costs.”
Skolkin said, “A lot of hands in the pot helps add to the cost. There’s a lot of system inefficiencies, particularly in billing and credentialing, that could be made a lot of easier. That would save resources.”
DeBhenke said, “As the healthcare industry, we have not been engaged to the degree we need to be to actually decrease overall cost of care because frankly from a pure financial standpoint it’s not been in our best interest. The health systems, providers and other organizations have to really get be- hind this whole idea of providing value, of decreasing overall total cost of care while improving outcomes for patients. That’s got to work in parallel with legislative and subsidization levels at the federal level.”
He said until there’s more buy-in from “young invincibles” – 20-somethings in good health – to broaden or balance the risk pool and thus reduce payouts, costs will be a problem.
“Certainly the pricing needs to be attractive to those individuals to broaden the pool. And frankly the benefits associated with products on the exchange need to be attractive so those individuals feel comfort- able and actually want to have coverage. Those least likely to go to the marketplace and buy individual health insurance plans are exactly the people we want to do that to broaden the pool. Healthy individuals that don’t utilize healthcare much soften the financial blow.”
Repeal Without replace is A mess, Why not repair?
The ACA’s meant adjustments from all healthcare stakeholders. Opponents have resisted it from the start and that fight continues. In early January the Republican-led Senate began reviewing ACA to try and garner enough votes to repeal it through the budgetary reconciliation legislative process.
“Unfortunately President Trump has focused on what he’s going to take away without have a plan in place,” said Kristine McVea, “I think that’s been harmful. There’s a lot of fear and uncertainty among our patients. These are people who struggled without health insurance who finally got a chance at taking care of their health and are now very afraid of the possibility that’s all going to be taken away. We hear this every day from people coming into the marketplace and coming into see us for care, I think the capricious statements made by this administration have fueled that.”
More recently, talk of flat-out repeal has given way to amend or modify in acknowledgment of the gains made under ACA and the difficulty of dismantling its far-reaching, interrelated tentacles, absent a ready-to-implement replacement. The political fallout of taking away or weaken- ing protection people have come to rely on would be severe.
“Once leadership has really started to
dig into what it would mean to repeal this outright and try to replace it they’re finding it is not a simple thing to do and the health and coverage of millions of people are at stake,” said James Goddard, an attorney with the public advocacy group Nebraska Appleseed. “So things are slowing down with the recognition they need to be careful with this, and of course they do.
“I think the change in the way it’s being discussed is a reflection of the reality that this is a dramatic thing you’re discussing altering and they need to do it the right way. Much of the ACA hangs together and one thing relies on another and if you start pulling pieces of it apart, you have the potential for the whole thing to fall down.”
Zetterman said he and fellow physicians favor a cautionary approach.
“Most of us would say the Affordable Care Act should be maintained and improved. There are dangers in taking it away and replacing it because it’s now in so many different places.”
Nebraska Appleseed attorney Molly McCleery said total repeal would affect many. “Initial Congressional Budget Office projections show 18 million people would lose coverage, and then in the out years, 32 million would lose coverage – both private and public. The Urban Institute’s state-by- state impact study found 200,000-plus Nebraskans with a pre-existing condition would be impacted if that consumer protection would be taken away.”
Jeff Francis said, “The new ‘r’ word I’m hearing is repair. The consensus seems to be to keep what’s popular and working and change what’s not.”
EDITOR’S NOTE: Details of the recently proposed GOP replacement had not been released as of this printing.
Daniel DeBehnke said of the current climate, “I think it’s extremely confusing because it’s complicated. It’s like a balloon – you poke in one area and something bulges out in another. I think people are frustrated, and rightly so, they pay a lot for healthcare. It’s not just as simple as I-pay- a-lot-for-my-healthcare, ACA is bad, let’s get rid of it.’ There are layers of complexity. We may not like exactly how things are funded or how some components are dealt with. We may not agree totally with all the tactics to get there, but at the end of the day we’ve got more people covered.
I don’t think anybody has the appetite to change that back.
“We just have to figure out how to incrementally lessen the financial burden while maintaining the real goal – more people covered and providing value for the money being spent.”
He said the best course of action now for providers is to “just take really good care of patents and decrease unnecessary utilization and duplication of services,” add- ing, “It’s what everybody wants anyway.”
Fixing the marketplace
Meanwhile, on the insurers’ side, some carriers have left public health exchanges after incurring major losses. This state’s largest healthcare insurer, Blue Cross Blue Shield, opted out of the volatile marketplace.
“Since we started selling on the ACA marketplace we’ve lost approximately $140 million,” executive vice president Steve Grandfield said. “We have a responsibility to all our members to remain stable and secure, and that responsibility was at risk
if we had continued to sustain losses. The public marketplace is unstable, which has driven increased costs and decreased com- petition and consumer choice. The higher premiums go, the more likely people, especially healthy people, drop their coverage. That means the majority of people remain- ing on ACA plans are sick, with increasingly higher claims, which drives premiums up even further.”
He cited instances of people gaming the system by buying plans when they need care, then dropping them when they longer need it.
Granfield said Blue Cross supports a well modulated ACA overhaul.
“It’s important to put in place a smooth transition. We would like to see regula- tory authority for insurance returned to the states, including rate review and benefit design and closing the coverage loopholes that lead to higher consumer costs.”
He has a long wish-list of other changes he wants made.
The leaders of two major Nebraska health provider systems say they haven’t seen any impact from the BCBS defection because there are many other insurers and products on the market. The executives were not surprised by the move given the fluid healthcare field.
Nebraska Methodist’s Jeff Francis said, “There were a lot of unknowns. I think it takes several years through the insurance cycle to be able to correct those kinds of unknowns, especially the way the federal government handles the bidding and setting of rates That’s why you won’t see craziness or changes in the rates in the years to come because they now have several years of experience with this new population and they’re then able to price accordingly.”
Daniel DeBehnke of Nebraska Medicine said, “Regardless of what happens in Washington, if the exchanges are kept in place there will be some changes made either in the pricing or pool that will help organizations like Blue Cross perhaps get back in that business.”
Quality Health Care Starts with Collaboration
Collaboration is key for containing costs in a system of competing interests. More U.S. healthcare decisions are happening outside silos.
Francis said, “A big change in the last 10 years is opportunities to work more collaboratively. In the past it would have been much more stand-alone. Now the hospitals and physicians are working more closely. Nebraska Methodist is part of an account- able care organization – Nebraska Health Network, along with Nebraska Medicine and Fremont Health. We recognize the importance of learning better practices from each other so we can pass that along to make healthcare better for the community and for employers paying for their employees insurance.”
One result, he said, is “less antibiotics pre- scribed by our family doctors at Nebraska Medicine and Methodist Physicians Clinic.”
Alexander Payne: His Journey in Film
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Author-journalist-blogger Leo Adam Biga resides in his hometown of Omaha, Nebraska. He writes newspaper-magazine stories about people, their passions, and their magnificent obsessions. He's the author of the books "Crossing Bridges: A Priest's Uplifting Life Among the Downtrodden," "Alexander Payne: His Journey in Film" (a compilation of his journalism about the acclaimed filmmaker) "Open Wide" a biography of Mark Manhart. Biga co-edited "Memories of the Jewish Midwest: Mom and Pop Grocery Stores." His popular blog, Leo Adam Biga's My Inside Stories at leoadambiga.com, is an online gallery of his work. The blog feeds into his Facebook page, My Inside Stories, as well as his Twitter, Google, LinkedIn, Tumblr, About.Me and other social media platform pages.
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