Daily Healthy: Matt Goldenberg

The People’s Advocate at the Supreme Court Bar

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<tr><td class="tr-caption" style="text-align: center;">H. Bartow Farr, III, Esq. </td></tr>
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The Patient Protection and Affordable Care Act (PPACA) has finally met its challengers in the highest Court in the land and following the three days showdown, there’s nothing left but watchful waiting for the Supreme Court to hand down its final decision. All media outlets from left, right and supposedly middle are covering the events and hundreds of experts are ready to make predictions based on the inflections in one Justice’s voice. I made a point to not read any of that, and if you are an informed citizen who still insists on making his/her own mind, the very impartial <a href="http://www.scotusblog.com/2012/03/scotusblog-health-care-and-a-few-things-you-might-have-missed/" target="_blank">SCOTUS blog</a> is the place to go for links to the audio and transcripts of all oral arguments and all briefs submitted to the Court. By this logic you should probably not read what follows below either, but if you do, this is an unorthodox (neither left nor right) look at the proceedings from a citizen's point of view, a perspective that struck me as lacking in the proceedings themselves. 
 
The main contenders were the Republican Governments of 26 States against a Federal Government controlled by a Democratic administration. There were also some private plaintiffs with a strong Libertarian argument, but their contribution to the subject is not clear to me, and is probably just a largely inconsequential sideshow. Generally speaking local governments were wrestling with central government in an outdated Federalist argument, where the people themselves have no standing. 
 
The <a href="http://www.supremecourt.gov/oral_arguments/argument_audio_detail.aspx?argument=11-398-Tuesday" target="_blank">main event</a> took place on Tuesday, March 27, where the constitutionality of the individual mandate, requiring every American to buy health insurance or pay a penalty, was argued, with the Federal Government arguing that its power to regulate interstate commerce includes the right to mandate that everybody buys health insurance, and if not, then the penalty should be viewed as a tax. The State Governments argued as expected that this gives the Feds unlimited power and a penalty is not a tax. The lively debate came complete with broccoli, burial insurance and babies being denied care at the hospital, hypotheticals. But here is what I found interesting: at the heart of the Federal Government argument was the contention that the uninsured are basically offloading their health care costs on the insured and society in general, therefore we must mandate that they buy insurance and pay their fair share. The States on the other hand, argued that forcing healthy people who don’t want to buy insurance to subsidize the sick is really not fair. Most Americans, as everybody agreed, are already purchasing health insurance, so who are these freeloading uninsured? 
 
Well, it seems that 68% of the <a href="http://www.statehealthfacts.org/comparecat.jsp?cat=3" target="_blank">uninsured</a> are under 140% of the Federal Poverty Level (FPL), and 95% of them are below 400% FPL. A full 45% of <a href="http://www.statehealthfacts.org/comparetable.jsp?ind=131&cat=3" target="_blank">poor adults</a> and 17% of <a href="http://www.statehealthfacts.org/comparetable.jsp?ind=128&cat=3" target="_blank">poor children</a> (under 100% FPL) are uninsured. Are these our freeloaders? Are these our interstate frequent travelers who impose huge uncompensated expenses on States where they don’t live? Are these poor people without insurance seeking out States that enacted guaranteed-issue and community rating insurance laws and move there en-masse? Is anybody else doing that? Do we even know what problem we are trying to solve? 
 
Another pearl from the March 27 arguments was the realization that the States concede that the Federal Government has the power to require that people pay for health care with insurance. They only differ on the timing of buying the necessary insurance instrument, with the State Governments insisting that a free citizenry should have the right to purchase insurance en route to the ER, if they so choose, and the Feds arguing that they must buy insurance the day they are born. Does that mean that one cannot pay for health care with cash, or chickens? Will they check to see if you have insurance and if so, cash payments will be disallowed? What do you do if you’re one of the penalized? Do you get to pay cash, or do you get some services in return for all those penalties you paid into the system? 
 
As interesting as the constitutionality arguments were, I found the session on <a href="http://www.supremecourt.gov/oral_arguments/argument_audio_detail.aspx?argument=11-393" target="_blank">severability</a> to be most enlightening. On Wednesday, March 28, the Court grappled with the next steps, if the individual mandate is by any chance found to be an unprecedented and unlimited expansion of Congress powers and thus ruled unconstitutional. The 26 Republican governed States argued that the Court should throw out the entire Obamacare legislation with the mandate, because everything else in the PPACA is either hinging on the offending mandate or is unimportant. This is not surprising, since the war on the individual mandate, which is the brainchild of an ultraconservative foundation, is just a battle in a much larger war to remove the current Democratic President from office. The Federal Government began its arguments by mentioning the millions of citizens that are not standing before the Court and how the Court should nevertheless give them consideration. That was beautiful, but it didn’t last long, because eventually it became clear that the Federal Government is asking the Court to strike down both guaranteed-issue and community rating clauses along with the individual mandate, if found unconstitutional. 
 
The Federal Government, true to form, was arguing on behalf of its insurance companies patrons. Unless the Feds can guarantee a certain number of customers, there is no way that insurers will agree to sell their wares in a non-discriminatory manner, because discrimination is how insurers make money, and no government should infringe upon basic rights of corporations. It fell to an attorney independently appointed by the Supreme Court to argue for the people, and (very eloquently) make the simple point that the purpose of the PPACA was not to provide customers to insurers, but to make health care affordable to all Americans, including poor and sick ones. The individual mandate is just one tool in an arsenal of tools to accomplish that end. It may be a very useful tool, but it’s not the only tool, and therefore if it is found unacceptable, it should be severed from the legislation and removed without throwing out the baby with the bathwater. 
 
So the People finally got their 15 minutes in Court, represented by Court appointed counsel, as paupers usually are. Whatever the Court decides in this case, I will forever be grateful to the Supreme Court of the United States, the nine unelected Justices, who saw fit to solicit someone to speak for the People, something that neither States nor Federal Governments seemed to be too terribly inclined to do. And I am grateful that the Court chose H. Bartow Farr, III, Esq. to represent us in this matter, since his oral arguments were second to none, and may God grant the Court the wisdom to do what Mr. Farr advocated that they do, and the People shall prevail.</div>

H. Bartow Farr, III, Esq. The Patient Protection and Affordable Care Act (PPACA) has finally met its challengers in the highest Court...

Spreading Hope!

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By Matt Goldenberg D.O. <o:p><span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;">@docgoldenberg </o:p> “You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.” <o:p></o:p> <div class="separator" style="clear: both; text-align: center;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGAuBL1SprzxDOE6jkkG1n5lpnddYDCnow2P4Jmhh0WvdglAt7K0fztqvqHWmTcmrLFYSiE9TP9dtiYVDhR_Qc-RsMERORHontoEuZrMJO3PBZt_0nUdWMIvc9ewQ0mvQFzJPe9_7XQQrL/s1600/patch-adams-553248l.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGAuBL1SprzxDOE6jkkG1n5lpnddYDCnow2P4Jmhh0WvdglAt7K0fztqvqHWmTcmrLFYSiE9TP9dtiYVDhR_Qc-RsMERORHontoEuZrMJO3PBZt_0nUdWMIvc9ewQ0mvQFzJPe9_7XQQrL/s1600/patch-adams-553248l.jpg" width="133" /></a></div> <div class="MsoNormal" style="margin: 0in 0in 10pt;"> I whole-heartedly agree with that statement. However, I cannot take credit for those words. Those are the words of Robin Williams, or more specifically, the words of his character in Patch Adams. I want to discuss the disease called depression. I will start by first discussing the diagnosis and the signs and symptoms of depression. I will then follow up with my thoughts on the various treatment options for depression and the strategies I employ with my patients to improve their outcomes. None of my thoughts and suggestions should serve in place of a formal consultation with a mental healthcare provider. However, I hope shedding light on mental health diagnoses like depression will lift the veil and social stigma on these chronic diseases that impact so many people. Psychiatry has come a long way in the last decade. This is a time of continued discovery and increasing public awareness. The leaders of our professional organization, the <a href="http://www.psych.org/File%20Library/Advocacy%20and%20Newsroom/Presidents%20Messages/Summergrad-2014-AM-Opening-Speech.pdf" target="_blank">American Psychiatric Association (APA), have suggested that we as mental health professionals are under a microscope</a>. I agree that we are and I also strongly believe that we are up for the challenge. School shootings and celebrity suicides and overdoses have increasingly put a focus on mental health. Psychiatry has significantly improved the outcomes, treatment options and the prognosis of patients with mental illness. However, we still are unable to decrease the prevalence of the diseases we treat or prevent them. We know that the brain changes during an episode of depression and our treatments help it to return to normal (see the image below). Although we are getting closer, we still currently do not have widely accessible blood or imaging tests that can confirm our diagnosis or localize the area of disease.<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjHTc9LL0rGLMe7XKQOE8onH6uIwnyX6cgVdFxYuMOOK1kosrLV8_KrIZMITeThL099IFIRdkdOdeJqk2Sbs7JghO9ow0WjeSCGtMJqHRlL5SHn0oZaHKcSi2ho1Li_6dMsMZi_SZLZFKY/s1600/Manbrainimgae.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="160" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjHTc9LL0rGLMe7XKQOE8onH6uIwnyX6cgVdFxYuMOOK1kosrLV8_KrIZMITeThL099IFIRdkdOdeJqk2Sbs7JghO9ow0WjeSCGtMJqHRlL5SHn0oZaHKcSi2ho1Li_6dMsMZi_SZLZFKY/s1600/Manbrainimgae.jpg" width="200" /></a></div> <div class="MsoNormal" style="margin: 0in 0in 10pt;"> I can say with certainty, however, we are able to accurately diagnose patients. We are able to identify medications, psychotherapies and other treatments that patients with a specific diagnosis or cluster of signs and symptoms often benefit from. There is strong evidence that our treatments decrease symptomatology and disability and improve quality of life, clinical outcomes and a patient’s prognosis. Psychiatrists are trained to view the patient as a “whole person”. Psychiatry is a field of medicine whose assessment by definition includes all of the biological, psychological and social aspects of a patient’s life. We listen for the psychological and social factors that can contribute to disease. Oftentimes, the “whole story” can be more telling than only focusing on specific symptoms of a given disease. There is a saying, throughout all fields of medicine, that “most patients have not read the textbook.” In other words, patients usually do not present exactly as the textbook says they should. Stress and psychological factors can mimic chest pain, shortness of breath, gastrointestinal problems and a whole host of other diseases. If we do not step back and get the whole story, we can miss the root cause or the exacerbating factors of many manageable diseases which are of the mind. Many of the diseases we treat, such as depression, are chronic illnesses which require lifelong treatment. Our treatments can improve a patient’s mental health and coping skills and decrease their symptomatology and substance use. We know through decades of research that these are modifiable risk factors for suicide. Therefore, Psychiatrists have the training and tools necessary to decrease a patient’s risk of attempting suicide. Our treatments have the potential to not only significantly improve the lives of our patients, but also the lives of their families and everyone who comes into contact with them. Anyone who tells you otherwise is misleading, misinformed or both.</div> <div class="MsoNormal" style="margin: 0in 0in 10pt;"> <span style="font-family: "Calibri","sans-serif"; font-size: 12pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"> <span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">I hope this information and the blogs to follow will give you hope. Mental illness can include symptoms which can be devastating and complications which can be <a href="http://psychiatry.org/suicide" target="_blank">life-threatening</a>. However, it is important to state again, these are treatable diseases. If you or someone you know, would like to talk to someone, call your primary care doctor or your insurance company for a referral to a Psychiatrist. A true multi-disciplinary team also includes therapists, psychologists, nurses and social workers. You are never alone. You can call the national suicide helpline 24 hours a day, seven days a week (1-800-273-TALK (8255) or visit <a href="http://www.suicidepreventionlifeline.org/">www.suicidepreventionlifeline.org</a>). There are also local crisis lines likely available in your area and are an internet search away. If you are ever feeling unsafe, or fearing for the safety of a loved one, you can call 911 or go to the nearest emergency department.</div> It is time for everyone to understand that there is no shame in getting help for depression, much as there is no shame in getting help with diabetes or high cholesterol. Even if you have never suffered from depression, there is a lot you can learn. <div class="MsoNormal" style="margin: 0in 0in 10pt;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtFwzBHqAnEjwkZBsUAwCX-AeHgooaLfCwYGVJTaTLFY1jGr8SovFrHlaH083SEvR7Lwdjpcj-C-7URLPVGLz-iMW8ZaLkr-NFOcnzW-xK90YoP7ZtPsgqqt6keYsGc4psxnedLQPpzON9/s1600/Depressed_NotDepressed+brain+image.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtFwzBHqAnEjwkZBsUAwCX-AeHgooaLfCwYGVJTaTLFY1jGr8SovFrHlaH083SEvR7Lwdjpcj-C-7URLPVGLz-iMW8ZaLkr-NFOcnzW-xK90YoP7ZtPsgqqt6keYsGc4psxnedLQPpzON9/s1600/Depressed_NotDepressed+brain+image.jpg" width="200" /></a></div> Together we can raise awareness and spread truth and hope. I know that if we spread knowledge, and ignore the misinformation, we will overcome the complacency and ignorance that is so pervasive today. That is how we can best honor those we have lost. That is how we can best prevent the next death from mental illness and addiction. <o:p></o:p> <div class="MsoNormal" style="margin: 0in 0in 10pt;"> </div> <a class="twitter-share-button" data-count="horizontal" data-related="APAPsychiatric" data-via="APAHealthyMinds" href="http://twitter.com/share">Tweet</a><script src="http://platform.twitter.com/widgets.js" type="text/javascript"> </script>

D.O. depression Matt Goldenberg mental illness psychiatrist Robin Williams treatment Spreading Hope!

By Matt Goldenberg D.O. @docgoldenberg “You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no mat...

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The People’s Advocate at the Supreme Court Bar

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