Treating Back Pain in a “Do Something” Society

Don’t do nothing, do something.

David Coombes,  Healthcare Consultant

I used to work with David Coombes, a consultant trained in hospital administration.  We sought to put together hospital-physician organizations featuring bundled-bills in which the hospital, primary care physicians and specialists,  submitted fees they considered acceptable for a variety of hospital evaluations and treatments,  In his stump speech, David, sensing the economic crunch ahead for hospitals and doctors, would say, “Don’t do nothing, do something,”  another way of saying, “Nothing ventured, nothing gained.”

I thought of David’s  advice when I read the following abstract of an online article in the JAMA Internal Medicine.

Worsening Trends in the Management and Treatment of Back Pain,

John N. Mafi, MD¹; Ellen P. McCarthy, PhD, MPH¹; Roger B. Davis, ScD¹; Bruce E. Landon, MD, MBA, MSc

ABSTRACT

I"mportance Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.

Objective To characterize the treatment of back pain from January 1, 1999, through December 26, 2010.

Design, Setting, and Patients Using nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we studied outpatient visits with a chief symptom and/or primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain. We excluded visits with concomitant “red flags,” including fever, neurologic symptoms, or cancer. Results were analyzed using logistic regression adjusted for patient and health care professional characteristics and weighted to reflect national estimates. We also present adjusted results stratified by symptom duration and whether the health care professional was the primary care physician (PCP).

Main Outcomes and Measures We assessed imaging, narcotics, and referrals to physicians (guideline discordant indicators). In addition, we evaluated use of nonsteroidal anti-inflammatory drugs or acetaminophen and referrals to physical therapy (guideline concordant indicators).

Results We identified 23 918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P < .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3% to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P < .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.

Conclusions and Relevance Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care."

This seems straightforward enough.  If only doctors would treat low back pain conservatively  with ibuprofen and physical therapy, patience, and watchful waiting,  and stop using pain-killing narcotics, unnecessary referrals to back surgeons,  CT and EMR imaging, and surgery could be avoided.  Conservative therapy is what evidence-based guidelines call for.  Evidence indicates patient due just as well with conservative treatment as with more aggressive approaches.

Give this evidence, why do doctors defy evidence-based guidelines.

I  offer these reasons: 

1)      When you’re suffering from low-back pain, which can be excruciating and debilitating, you go to the doctor because you want him/her to “do something.”  We are an impatient, activist society, and we tend to be leery of doctors who do nothing in the short term.

2)      When we go to a specialists, we have high expectations that they “will do something” to relieve our pain.

3)      Specialists tend to do what they are trained to do rather than “do nothing.”

4)      Because of the malpractice environment, specialists do what they are expected to do to impress patients.

5)      Guidelines are 20/20 in retrospect,  but tend not to impress patients who are looking for immediate prospective relief.

I am not justifying physician treatment of back pain .  I am explaining  it

As Don Marquis of Archy and Mehitabel fame, said;

I suppose the human race

is doing the best it can

but hells bells thats

only an explanation

its not an excuse

 

Tweet:   Physicians overuse narcotics, imaging, and surgery rather than evidence-based guidelines recommending ibuprofen and physical therapy.

 

 

Obamacare:  If It’s for Them,  It’s OK,  If It’s for Them and Us, It’s Not OK

So it’s us v them

Over and over again.

Song Lyrics,  Us V Them

You hear it over and again.   Obamacare should cover all Americans. It’s a right.  It’s a moral imperative. It’s being a civilized nation.  It’s the compassionate thing to do.   We must do it for them.  It’s the right thing to do.  It’s the only thing to do. It’s universal coverage – even it if busts the budget.

As it turns out, however, it’s not one for all, or all for one.  It’s what in it for "us."

“Us” are 11 million government workers covered by FEHP (Federal Employee Health Plan) with a wide selection of health plans,    10 million  union workers with top-of-the line health plans,   1100 or so political allies who receive waivers who say they can’t afford Obamacare,  small businesses  with 50 or more employees seeking financial relief from $2000 penalties for each uncovered worker, and congressional lawmakers who learn their staff  may desert them if they are forced to  buy Obamacare coverage.

 Obamacare may be OK for “them”, most Americans, but not for “us” who like the plans and doctors we have   

The moral, perhaps I should say the morale for the “us” crowd,  is: We are not an either/or society – government-endorsed v  private plans.  We want multiple options, and we want full-time jobs.

Here is how Kaiser Health News reports the dilemmas facing organizations who want to retain the status quo, many of  Obamacare allies, and how they are confronting the problem. 

"Lawmakers' Aides Fret Over Requirement To Buy Obamacare Coverage" (Kaiser Health News, July 30, 2013)

The New York Times explores how congressional staffs are anxious about a health law provision requiring them to buy coverage in online insurance markets because the fderal government may no longer pay a share of their premiums. Meanwhile, The Hill reports on a request to audit Enroll America, a nonprofit that is encouraging people to enroll in new coverage.

The New York Times: “Wrinkle In Health Law Vexes Lawmakers' Aides”

As President Obama barnstorms the country promoting his health care law, one audience very close to home is growing increasingly anxious about the financial implications of the new coverage: members of Congress and their personal staffs (Pear, 7/29).

CQ HealthBeat:  “Definition Of Full-Time Worker Continues To Roil Health Care Law”

White Castle might stop making full-time hires because of costs associated with requirements in the health care overhaul, an executive with the hamburger chain recently told a House panel. The testimony from Jamie Richardson was one of the latest examples of an employer citing the law’s definition of a full-time employee as a major problem, and highlighted an ongoing debate over whether a revision is needed (Attias, 7/29).

The Hill: “Watchdog Requests IRS Review Of Group That Is Promoting ObamaCare”

A watchdog group is asking the IRS to review the tax-exempt status of an organization crucial in helping to promote ObamaCare. Cause of Action has asked the IRS to investigate Enroll America, a nonprofit that is encouraging people to enroll in new coverage options under the healthcare law (Baker, 7/29).

Contra Costa Times: "Half Of Affordable Care Act Call Center Jobs Will Be Part-Time"

Earlier this year, Contra Costa County won the right to run a health care call center, where workers will answer questions to help implement the president's Affordable Care Act. Area politicians called the 200-plus jobs it would bring to the region an economic coup. Now, with two months to go before the Concord operation opens to serve the public, information has surfaced that about half the jobs are part-time, with no health benefits -- a stinging disappointment to workers and local politicians who believed the positions would be full-time (Gafni, 7/25).

Fox News: “Workers At ObamaCare Call Center Angry After Being Offered Jobs Without Health Benefits”
A soon-to-be-opened call center meant to help teach the public about ObamaCare is under fire for offering many of its new employees part-time positions — in turn denying them benefits under the very law they are helping to implement. The Contra Costa Times reports the call center, which is set to be opened Oct. 1, attracted about 7,000 applicants for 200 jobs after the county won the right to operate it earlier this year. Many workers and local politicians say they believed that the majority of the positions at the center would be full-time with benefits (7/29).

These news items raises questions;  Is Obamacare turning us into a part-time nation?   Should federal workers and Congessional staffs be exempt form Obamacare?  It is fair  workers for the Obamacare sign-up campaign  be denied benefits?  Who should receive Obamacare waivers form the health law?

Tweet:   Should  government workers, union members, Obama campaign employees, small business with low wage workers be exempt from  Obamacare?

 

 

Opinionated Predictions about Berwick’s Eleven Monsters
 

What a chimera is man! What a monster, what a chaos, what a contradiction, what a progidy! Judge of all things, feeble earthworm, depository of truth, of uncertainty and errors, the glory and shame of the universe.
 

Blaise Pascal (1623-1662), Lettres Provincciales (1656-1657)

Have you noticed is one man's "achievement, " is  another man’s “monstrosity” or “monster”? Such is the case with Obamacare,  its proponents and opponents.   

In one of my blog posts,  I characterized Obamacare as a cookie monster.  I closed with this paragraph;
 

“What a cookie monster is health reform! It is like a big baby- an alimentary canal with a huge and growing appetite at one end and no end in sight at the other. It keeps saying ,”Me want cookies!” The trouble is: its cookies are your cookies too.”
 

Donald Berwick, MD,  Obama’s first CMS Administrator,   founder of Institute for Healthcare Improvement,  now candidate for Massachusetts Governor,  and sweet voice of reason for top-down government reform and patient safety,  has his own set of 11 "monsters" facing the hospital industry.

He says these monsters can be conquered and brought into the hospital corral.

Here’s how to bring these monsters to bay.

1.      Instill confidence in science as a basis for action. Doctors and hospitals have triumphed in connecting medical decisions to science, and treat patients "according to facts, not according to myths or habits…But it's an incomplete triumph because we don't do it…We continue to allow quite senseless unscientific variation in practice to masquerade as autonomy."

Prediction – This isn’t going to happen on grand scale.  Patients have more confidence in their own judgment and that of their physician than in science, as set forth in government guidelines.

2. Use our global brains. While at CMS, Berwick says, he was told to never mention another country. "If you do, you'll take a cheap, demagogic shot from someone who questions your loyalty or says you're a socialist"

Prediction -   Americans are more likely to listen to their own healers and to adopt their own solutions, rather than mimic other country’s systems and solutions. Policy makers may think “global’ but they act “local.”

3.      Learn from large systems. Somehow, American healthcare's thought leaders must learn how to improve care by experimenting with change in real time clinical environments, not by researching or adopting what happened in the past. But they haven't sufficiently developed, nor have they widely accepted, new investigatory approaches and they will have to get over that.

Prediction - We would be wise to learn from successful clinical experiments from large organizations  But ie hasn’t happened yet, and it may not because, to paraphrase Tip O’Neil, “All health  care is local.”

4.      Name the excess. America spends 40% more on healthcare than it needs to. And that has been pushed by the argument that patients need more. "These claims are goodhearted…But it has been nearly impossible to claim what in our nation has become true, which is enough is enough. The particular monster here is very big and very scary. It's the scariest one."

Prediction -  When you or your relative is  sick, enough is never enough.  The best way to rein this monster is malpractice reform, including loser pays. Unless this is acknowledged by Berwick and Obama, not much will change.

5.      Distinguish profit versus greed. The American healthcare marketplace generates "energizing entrepreneurship and what I'll call proper competition," Berwick said. "But on the other hand, it has cynical, calculating greed in it. And we do not have methods in public policy or in private to tell the difference between entrepreneurship and greed and act on it."

Prediction -  As long as Obama and people like Berwick preach the gospel of entrepreneurship as equivalent to greed,  innovation will be stunted because “profit” is necessary for disruptive  innovations to occur.

6.. Resist innovations that don't help. At a major convention last year, Berwick was escorted through an exhibit hall with 6,000 vendors, one for each of the 6,000 participants. "There was fiber optic this and robotic that, ceramic this, and disposable everything. And I am absolutely sure that somewhere in the acreage of innovation there was something that could help patients that was definitely worth the money.

Prediction -  This is not helpful.  How do you know something will help unless you try it and it fails.   I predict government will be unable to stifle innovation through punitive regulations, as abandonment of the he medical device tax will show.

7. Expand roles and scopes of practice for non-physicians. "We need to support new models of care that provide expanded roles for non-physicians." However, he says, the legacy payment systems don't encourage these changes. We need help from the (professional) guilds, not their opposition," but he said, many "are fighting the change."

Prediction:  This is already happening , but it is a state-by-state process.   It depends not only on physician acceptance but public acceptance.

8. Defend the poor. This monster, Berwick said, is causing him to lose sleep because the nation fails to regard healthcare as a human right. "The social safety net is vulnerable and the will to protect" social services for the poor "needs constant reinforcement that government can't provide without hospitals' support.

Prediction – This is classic liberal position that somehow the rest of us are against the poor.  In the case of Medicaid, the truth is that the states say they handle Medicaid  better than the feds without going broke.

9. Palliative and end of life care. Berwick blasted what he called "cruel rhetoric" that equated sensible discussion of advance directives and preferences with "death panels." "But the rule in Washington favors never ever mentioning end-of-life or palliative care, or advance directives. Not in government. That is a tragic silence and it has to stop."

Prediction – This is overstated.   The hospice movement will continue to grow, and so will palliative care.  To say otherwise is its own form of “cruel rhetoric.”    No one has a monopoly on compassion.

10. Create Authentic Prevention "Hospitals cure disease but they do not prevent it. And they can not prevent it," because they aren't set up to do that today. "Prevention doesn't have any cathedrals. The result is continuing misallocation of effort.”

Prevention -  Berwick is entitled to his opinion.  Due in no small part to his efforts,  hospitals are organizing to prevent infections, falls, and drug mishaps,

11. Creating Transition Models Berwick referred to Alaska's Southcentral Foundation "Nuka System of Care," a project that won the Baldridge award for its success in emptying hospitals and decreasing the need for specialty care, as a care transition model monster that is scaring hospitals.

Prediction -  I am all for creating “Transitional Models”.  Nuka is a model that  may work in the wilds of specialty-short Alaska, but  will fall short in urban and suburban continental America.

Berwick’s monsters are hardly monsters.   His monsters are  human beings under sickness and economic stress.  Hospitals and doctors are like most of us:  They want to pay their bills and creditors while doing the best they can under present medical-legal, financial, and regulatory circumstances. 

 Here is one’s reader comment on the 11 monsters,

“Dr. Berwick somehow forgot the number one monster that is threatening our healthcare system. That is a bloated, overreaching, hyper-political Federal government, populated by holier-than-thou political apparatchiks like himself…. Dr. Berwick sees everything through the eyes of government. In one breath, he says we must "defend the poor" by which I assume he means bankrupting the taxpayers through ever higher Medicaid expenditures, but in the next breath he decries end-of-life care, because it costs the government too much.”

Tweet:   Dr. Donald Berwick has identified 11 “monsters” bedeviling American hospitals, but they may be  more likely creatures of human nature.

Source:  Cheryl Clark,  “Berwick Names 11 Monsters Facing Hospital Industry,” Healtheaders Media,  July 29, 2013

Sixteen Imprecise Predictions about Obamacare ‘s Future

 The problem of predicting the future is that it involves the future.

Anonymous

No one knows with any precision about Obamacare's future.   There are too many variables and forces at work. I  make these uncertain predictions with the  certainty that they may be wrong.  This is not about exactitudes, but trenditudes

1.       The health law will remain in effect until 2016, as long as Obama is President.

2.       Republican repeal  or defunding  Obamacare is symbolic, since the President will veto any repeal.

3.       Certain ACA provisions, medical device taxes on revenues and obligatory coverage of businesses with over 50 employees, will be dropped or modified.

4.       The Obama campaign will spend more than $700 million to woe the young and healthy to sign up for exchanges with indifferent results.

5.       The nation’s one million physicians are an insignificant political force compared to 50 million seniors on Medicare.

6.       Physicians’ political power resides in  dropping out of Medicare because of low payments but physiian sare unlikely to exercise this power because politically physicians tend to be passive.

7.       The November 2014 elections are important in that they may return the GOP to power in the House and the Senate, but there will not be enough Republicans to override an Presidential  veto.

8.       Obamacare support among moderate and conservative Democrats and unions will continue to erode as its unworkability due to delays, glitches, missed deadlines, and skyrocketing costs becomes evident.

9.       More doctors, perhaps 10%, will opt out of Medicare, another 20% will cut back on seeing new Medicare patients,  and  50% will not accept Medicaid.

10.   More doctors in affluent areas,  in the 15% range,  will enter concierge and cash-only practices.

11.   Health savings accounts will continue to grow at 25% per year until they reach 60 million members by 2020.

12.   Patients will continue to flock to retail clinics, urgent care centers, and independent free-standing emergency facilities for convenince and lower costs.

 

13.   Specialty centers,  owned by hospitals, co-owned by hospitals and specialists, and owned by specialists, will proliferate, partly in response to accountable care organizations.

14.   Nurse practitioners will gain autonomy and primary care physicians will autonomy.

15.   Hospitals and integrated health systems will be the dominant providers in most regions with employed networks of physicians.

16.   Young physicians,  50% of whom will be women,  will gravitate towards employment and balanced life styles.

Tweet:  This blog post contains 16 healthcare imprecise predictions  about Obamacare and the future of medicine.

 

 

Is Ending Fee-For-Service The Key to Lowering Health Care Costs?

If Medicare is to have a secure future, one has to move away from fee-for-service medicine, which is all about incentives to spend more and has no incentives to keep patients well.

Howard Dean, MD, “The Affordable Care Act’s Rate Setting Won’t Work,” Wall Street Journal, July 28, 2013

Doctor Howard Dean joins a chorus of policy types  calling for  end of fee-for-service. The chorus includes the National Commission of Payment Reform and a host of medical organizations – The American Medical Association, American College of Physicians, the American College of Physicians, and the American Osteopathic Association. 

All call for some sort of staged process gradually replacing FFS and the present coding system with new value-based payment models.

Dean posits that the Independent Payment Advisory Board (IPAB) a provision  of the health law The job of the IPAB i s to regulate Medicare fees, won’t work,  because price controls have always failed.    Instead, Dean  maintains, only ending FFS will do the job of bringing down costs in concert with implementing the Accountable Cae Act.  

Dean's premise is that doctors charging FFS have an incentive to be greedy, to order unnecessary tests, to do unnecessary procedures, and to avoid preventive care measures.

As I see it, there are four big problems with ending FFS. 

1) Human society and human nature - FFS is how the world does business in every other economic sector, including shelter and food, which are less inflationary than health care.

2) The basic problem with health costs may not be physician fees at all, but a variety of other factors – trial lawyers, insurers, government, drug and device manufacturers, and hospitals. To date, physician hospital employment has raised fees, not lowered them.

3) Introducing preventive measures on a broad scale involves changing American cultural, economic, and patient behaviors and paying doctors more for prevention than treatment, and there is little evidence that these measures have had any signfican effect. 

4) According to surveys of doctors,  the advent of electronic medical records, quality and safety data as the main criteria for physician payment, and bundled and fixed fees so far have done little to bend the health cost curve downward, or to change their practice behavior.

In his John Goodman’s March 28, 2012 Health Alerts blog, Greg Scandlen, an independent health analyst who espouses more consumer choices, argues that fee-for-service is not the basic problem Indeed, he says, if we let FFS rule the economic roost, and ended third party intervention and monitoring, health care would cost less not more.

Scandlen asks: Is fee-for-service the problem? 

“Almost everyone involved in health care will tell you that the greatest problem in our system is that we pay on a fee-for-service basis. Almost everyone is wrong.”

“The logic is obvious – paying a fee for a service encourages providers to get more fees by providing more services. Ergo, we consume too much and spend too much. Ipso facto, getting rid of fee-for-service would result in fewer services and less spending. Case closed.”
 

“Well, maybe not.”
 

“In fact, almost everything we do in the course of our economic lives, we do on a fee-for-service basis. When we go to the movies, get our oil changed, have our roof replaced, buy a computer, get a haircut, hire a baby sitter, buy a steak dinner, get someone to do our taxes or defend us in a suit, we do it on a fee-for-service basis. None of it is particularly inflationary.”
 

“Yes, the providers of these services would like to sell us more units of service. But we have good reason to resist – we don’t want to waste our money on services we don’t need.”
 

“What is unique about health care is not fee-for-service, but third-party payment.

Only in health care is there someone else picking up the tab for our spending.”
 

Scandlen and others, including conservative health economist, John Goodman, believe ending FFS and replacing it with value-based purchasing is not the answer, The answer is incentivizing patients, through health savings accounts with high deductibles, to pay-of-pocket for routine health services and to have physicians compete for the cost-conscious consumer. Goodman says ending fee-for-service would simply drive physicians and loyal patients into concierge practices, free of third parties and government. In thse pratices, patients would pay a fixed fee for convenience, access, and routine preventive services.

Tweet. For every complex problem there is a clear, simple,  answer that is wrong answer. For health costs, that wrong answer is ending FFS.

Obamacare – Will It Collapse of Its Own Weight?

Now in building of chaises, I tell you what,
There is always a weakest spot, –
In hub, tire, felloe, in spring or thill,
In panel or crossbar, or floor, or sill,
In screw, bolt, throughbrace, — lurking still,
Find it somewhere you must and will, –
Above or below, or within or without, –
And that’s the reason, beyond a doubt,
That a chaise breaks down, but doesn’t wear out.

All at once the horse stood still,
Close by the meet’n'-house on the hill.
First a shiver, and then a thrill,
Then something decidedly like a spill, –
And the parson was sitting upon a rock,
At half past nine by the meet’n'-house clock, –
Just the hour of the earthquake shock!

What do you think the parson found,
When he got up and stared around?
The poor old chaise in a heap or mound,
As if it had been to the mill and ground!
You see, of course, if you’re not a dunce,
How it went to pieces all at once, –
All at once, and nothing first, –
Just as bubbles do when they burst.

Oliver Wendell Holmes (1809-1894),  The Deason’s Masterpiece The Wonderful One-Hoss Shay

Critics of Obamacare are betting that it will collapse of its weight into a heap and a mound because of  imperfections in its structure.  Its wheels, they assert, are already coming off – the abandoning of its long-term care CLASS program,  demise of the medical-device tax,  imminent  death of the Medicare Independent Advisory Board (IPAB), revolt of the unions(AFL-CIO, Teamsters, IRS, et al), opting out of states from Medicaid expansion, and delay of the employer mandate for a year.  

The final wheel,  lack of ability to sign up enough young uninsured to bring down premiums for the rest of us,  may come off by January 1, 2014.

Predictions of a sudden collapse are wishful thinking. Obama and the Democrats have too much political capital invested to let that happen.

But Obamacare is in trouble  because of doubts on these fronts.

Does the Obama administration have:

·         The technologic competence  to put together a “hub” linking 7 federal agencies to  judge  who should qualify for federal subsidies?  Despite assurances by Obama and  Kathleen Sibelius that all systems will be ready by October 1, 2013,   doubts exist in all quarters – federal and private - that the administration can meet the October deadline. 

·         The necessary collaboration among those entities – states who have  chosen to opt out and let the feds do it,  health plans who must participate to offer choices, and  uninsured and underinsured who must sign up in adequate numbers to make the whole thing work? 

·          Sufficient  capital  to fund the implementation of health exhanges in face of Republican plans to defund Obamacare, i.e., where will it get the money to put Obamacare in motion?   HHS estimates it will cost $4.4 billion to help states set up exchanges, more than twice the original estimate because 34 states have to let the federal government do the job.  HHS  does not have the money. It  has asked Congress for $1.5 billion more , but may not even get even that.

Should Obamacare falter and collapse, comes the ultimate question:  what are the alternatives for health reform? 

Tweet:   Does Obamacare have technologic competence, enough collaboration among participating entities, and capital to implement the health law?

Obamacare: Those For and Against

The phrase "you're either with us, or against us" and similar variations are used to depict situations as being polarized and to force witnesses, bystanders, or others unaligned with some form of pre-existing conflict to either become allies of the speaking party or lose favor. The implied consequence of not joining the team effort is to be deemed an enemy.

Wikipedia

 

Those For
 

President Obama, advisors, and supporters

Minorities and people of color

Academia

Teachers unions

Mainstream media
New York Times

Female bloggers

Majority of women

Comedy website, “Funny or Die”

Washington National’s mascot, Teddy Roosevelt
Silicon Valley

Hollywood and showbiz  celebrities

Upper West Side residents

Residents of Washington, D.C. and suburb

Upper crust ideologues

Blue State residents

Inside Beltway residents

Advocates of wealth redistribution to achieve equality

Those Against
 

Republicans

Conservatives

Most Independents

Public at large
Two-thirds of state governors and legislatures

Seniors

The young uninsured
The working and nonworking middle class

Majority of men

Talk radio hosts
Wall Street Journal

Citizens living outside Beltway

Labor Unions – AFL-CIO, Teamsters, IRS Unions

Congresspersons and staffs

Small and Medium Businesses

Most practicing physicians

Red State residents

Advocates of economic growth to lift all boats
 

Tweet:  Those for and against Obamacare fall into categories of skin color, color of politics, gender, business, union status, place of  residence