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    A special place in Hell for Republican governors who eschew expanded Medicaid

    By jollyroger on Wed, 11/06/2013 - 4:28pm |

    A poignant letter to the New England Journal of Medicine should serve to focus our attention on the less sensational but more important component of Obamacare.

     

    While the media clucks over the feckless code writing that has sprayed egg over the collective faces of the administration hacks who are endeavoring to snatch efficacy from the jaws of a Rube Goldberg contraption whose very inception was tainted by obeisance to the "free market", the expansion of Medicaid will mean the difference between life and death for thousands of lower income Americans.

     

    As one who has come to despise that clown in a progressive costume, I must withal give him credit for at least trying to make Medicaid more widely available.

     

    That said, what punishment would a just god administer to the several Repugnant govenors who have found it politically expedient to refuse a torrent of federal funding, thus condemning to death uncounted innocent citizens of their states.

     

    And, then, of course, there is John "you can't force Medicaid expansion on the sacred states" Roberts.

     

    Given that the bill was atrociously drafted (Thanks, Max Baucus), this was still a gratuitous shiv in the progressive ribs.

     

    America-where it kills the powers that be to give the poor a chance at life.

    Comments

    Well put, Jolly.  Ever the Pollyanna, I'm hoping that ACA, even though it will be a screwed up program in some states, will demonstrate the possibility of good health care and will then whet enough appetites among the underinsured and uninsured that they themselves will become a voting force for a better system---raising the possibility of reverting to a single payer system.   


    by Oxy Mora on Wed, 11/06/2013 - 7:50pm

    a voting force for a better system-

     

    That would be a blessing...so may we hope that the newly deprived food stamp recipients will see their way clear to the same.

     

    I does seem to be working that way in NYC.


    by jollyroger on Thu, 11/07/2013 - 9:26am

    I agree with most everything you say. But I must admit I am nervous that the new Medicaid in many states will not be any better than the old Medicaid as far as access to providers and treatments is concerned. (Maybe worse if the increased volume of patients is not equaled by increased number of providers willing to accept Medicaid payment or willing to be in the network of the entity that is running the state's Medicaid program.)

    If that's the case, besides stories of unhappiness with long waits for treatment and/or poor care, you will have the promotion of stories along the lines of  "Medicaid patient denied treatment to life-saving this or life-saving that." Which could lead to things like: 1) more agreeing that the government is not the one to handle medical care, and 2) a belief among once-grateful Medicaid recipients that they are being targeted for poor care because of racism or similar reasons.


    by artappraiser on Wed, 11/06/2013 - 10:19pm

    I have only anecdotal evidence to offer in riposte, but, soit--fwiw:

     

    In San Mateo County, circa 2001, I had occasion to avail myself on the local county clinic to treat an emergency condition, with follow up antibiotics dispensed gratis from the in house pharmacy.  The care was free and top notch. Shortly thereafter, the clinic instituted a sliding scale payment schedule, but anyone with medicaid (not me) was covered in full.  Note: it's best to be poor in a rich county, if possible.

     

    My current clinician, in Brooklyn, who parenthetically was president of the Yale Med. Alumni Assoc in 2005, has been brought by frustration with private insurers and their ball-busting ways, to accepting only Medicare and Medicaid (!) as assignment, requiring privately insured patients to front the fee and seek their own reimbursement.\

     

    NB, Obamacare has raised Medicaid payment for general practitioners to equal  to the Medicare amount, which is in many cases more than the private insurers (hint, they have to extract their 20 % profit before paying the laborer...)


    by jollyroger on Thu, 11/07/2013 - 9:24am

    NB, Obamacare has raised Medicaid payment for general practitioners to equal  to the Medicare amount, which is in many cases more than the private insurers (hint, they have to extract their 20 % profit before paying the laborer...)

    My understanding is that many states have not had the direct pay Medicaid anymore for quite some time, but have turned Medicaid patients over to for-profit HMO's, in an arrangement similar to Medicare Advantage plans. Here is an example, New Jersey:

    http://www.state.nj.us/humanservices/dmahs/info/resources/care/

    Must say that I have no idea whether accepting the expanded Medicaid under Obamacare changes this. But I do know that the old arrangement was states were free to try all kinds of things and that many of them did this.


    by artappraiser on Thu, 11/07/2013 - 10:03am

    Yes, that is a wrinkle that I cannot parse (metaphor?).  OTOH, NY has a medicaid hmo set up as well, so maybe that means that my doc is in the hmo provider network, or similar.


    by jollyroger on Thu, 11/07/2013 - 10:13am

    Somewhat more systematic evidence:

     

    Contrary to the Union-Leader's assertion that Medicaid doesn't show "measurable health outcomes," a study of Oregon's 2008 Medicaid expansion published in the New England Journal of Medicine found that while certain health outcomes were not achieved -- such as lowering cholesterol and hypertension -- expansion had other benefits such as lowering rates of depression and increasing the rate of diabetes detection and treatment.

    Moreover, the American College of Obstetricians and Gynecologists has argued that expanding Medicaid is a key strategy to improving women's health, as Medicaid "is the largest payer of pregnancy services, financing between an estimated 40% and 50% of all births in the United States, and family planning services, accounting for 75% of all public expenditures."

    Reimbursement rates under Medicaid expansion will increase as a result of the ACA, a fact the Union Leaderfailed to mention. As part of the law, provisions were included to raise rates so that doctors are more likely to accept new Medicaid patients. Rates will increase across the country by an average of 73 percent accordingto the Kaiser Family Foundation, and in New Hampshire, rates are expected to increase 50-99 percent:


    by jollyroger on Thu, 11/07/2013 - 4:41pm

    To clarify.

    With your San Mateo example you seem to be talking garden-variety emergency condition. And about primary care with your "current clinician."

    But when I said:

    If that's the case, besides stories of unhappiness with long waits for treatment and/or poor care, you will have the promotion of stories along the lines of  "Medicaid patient denied treatment to life-saving this or life-saving that."

    I was implying more this kind of scenario:

    His wife, performance artist Laurie Anderson, first disclosed the transplant in an interview with the Times of London newspaper published June 1. [....]

    She said that Reed had the surgery in Cleveland instead of New York, where they live, "because the hospitals here are completely dysfunctional.

    "Fortunately we can outsource like corporations. It's medical tourism. The Cleveland Clinic is massive. They have the best results for heart, liver and kidney transplants. Whenever I get discouraged about how stupid technology is and how greedy and stupid Americans are, I go to the Cleveland Clinic because the people there are genuinely very kind and very smart." [....]

    Where New York Medicaid is probably not going to cover a liver transplant patient's charges at the Cleveland Clinic, even if they manage to get there on their own dime. Nor do I think, say, a rural Kentuckian on Medicaid with a preemie with extra special problems, will be getting care equal that available to similar at Philadelphia Children's Hospital. Where they then make a video about the dying liver guy or the preemie and it goes viral, like in the olden days (late 80's, early 90's) when they might instead call up the local TV station to cover how "my HMO won't cover this special care I need and I am going to die" and it went viral. Or where the Feds wouldn't allow certain AIDS drugs to be used in this country and where ACTUP took it viral...that kind of stuff...

    And if all Bronze and Silver plans are as limited in network as they are starting to look like they are (who can know for sure?), and many Medicaid plans have very limited networks too, I fear them virals are going to start happening sooner rather than later. Where everyone starts agreeing "Obamacare sucks, it denies care by economic class" before all of its intended adjustment of the system functions can get off the ground.


    by artappraiser on Sat, 11/09/2013 - 3:33pm

    All because we don't have national medical licensure/NHS!

     


    by jollyroger on Sat, 11/09/2013 - 5:41pm

    It is coincidental that you wrote this.

    I have reviewed the entire two seasons of a TV show called HACK on Netflix, and there was this line that I included in some blog:

    Well, thank you very much.

    But you are still going to hell you know. It is just that you might find yourself in a nicer room down there.

    hahahahaha

    WE NEED TO STOP THE REPUBS FROM CONTROLLING ALL OF THESE STATE LEGISLATURES AND GUBERNATORIAL SEATS.

    the end 


    by Richard Day on Thu, 11/07/2013 - 12:59am

    I was real happy with Tuesday's election.  I liked who showed up to vote.  We will have to watch how the new Gov in Va pushes through the Medicaid expansion.  If he gets in there and fights real hard for it standing up for the working poor. Even if he can't get pass the state house but continues to pressure them.   Then we will see other states move to vote out GOP members from their states.  Right now many working poor don't think their vote matters because no one has been listening to them.  At least this is what I hear often at the grass roots. 


    by trkingmomoe on Thu, 11/07/2013 - 4:08am

     Right now many working poor don't think their vote matters because no one has been listening to them.  At least this is what I hear often at the grass roots.

     

    De Blasio for President, 2020 


    by jollyroger on Thu, 11/07/2013 - 9:29am

    They say all the best parties will be in hell...plus, you are allowed to smoke (how would they know?)


    by jollyroger on Thu, 11/07/2013 - 9:27am

    and this


    by jollyroger on Sat, 11/09/2013 - 12:01am

    To understand what the real deal is with what's in that article, you have to know about a dirty little secret (secret because it's so complex few ever wanted to figure it out) about how Medicare has actually been paying hospitals for inpatient costs since the 1980's.

      Most Medicare patients are under the illusion that their individual inpatient hospiltal bill is submitted to Medicare and that it gets paid, but maybe the goverrnment negotiates or gets a discount. Naw, there is this giant complex entity called the Prospective Payment System (PPS) that pays hospitals in big clumps for Medicare patients, which I tried to understand once but the instruction and rule books were just beyond my capacity. I got only the basics: the Medicare patients are assigned diagnosis codes and by those codes they are put into diagnosis-related groups and then the hospital gets some kind of per capita payment for each diagnosis group and they have to make ends meet with what they get from that (or make gravy profit if they can.)

    Then the key provision here with PPS since the 1980's; the community hospitals that are willing to treat the uninsured (and things like the gunshot victims dumped out of cars at their door,) they got a much higher PPS per Medicare patient than the other hospitals! So they could use the extra leftover money on other things. It was really a sorta workaround by lawmakers, to snitch money from Medicare to handle the uninsured problem a tad. Few understood the system, so nobody screamed about it.

    Now from the NYT article it's not real clear (to be more understandable on this it would have to be much longer) but it sounds like contingent with Obamacare, there have been cuts to Medicare payments to all hospitals and maybe even phasing out of the current PPS system? The article does suggest that here

    The cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020.  The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally.

    The cuts are just one of the reductions in government reimbursements that are squeezing hospitals across the country. Some have already announced layoffs

    This goes in line with all we have read about Medicare the last few years trying to make hospitals more success oriented, and to be penalized for readmissions, things like that. And for those community hospitals, again, it's not real clear again, but even if the state is one that has accepted Medicaid expansion, they will start to see cuts in the PPS for Medicare? Because with ACA they should expect to be getting more from increased Medicaid payments and far fewer uninsured?  All part of the plan as ACA starts to kick in.

    The NYT article does note a possible big glitch in the related ACA goals even if they are states that have accepted Medicaid expansion:

    Some experts say the cuts in hospital subsidies are part of a larger problem: government programs like Medicaid do not pay enough to cover the actual costs of care. The cheapest private insurance on the new health care exchanges, the Bronze Plan, covers just 60 percent of costs, leaving low-income people who buy it with a lot of out-of-pocket costs that hospitals worry the patients will not be able to pay.

    In that this does not help the problems like the examples in the article! If Donna Atkins had an ACA Bronze plan, she would go to the doctor with the sore throat and then he would tell her to go get a $2,300 imaging scan of her neck, and she wouldn't do it because she wouldn't be able to come up with the 40% co-pay. And she would probably have to come up with a lot more, up to $6,300, to get all the things the doctor recommended. With a Bronze plan, she still needs a community hospital or another provider willing to do tests and procedures for free.

     


    by artappraiser on Sat, 11/09/2013 - 11:49am

    as I understand it, the flip side (the subsidy sliding scale) of the three tiered plan structure is shockingly small subsidies, indeed, mere trifles, as income rises even marginally over the poverty multiple that defines the upper limit of medicaid eligibility.

     

    The whole structure is so preposterously and obviously an attempt to obviate the simple and efficacious way that every other developed nation handles the problem, you might almost think it was the bastard child of some Heritage think tank toady....oh, wait...


    by jollyroger on Sat, 11/09/2013 - 11:54am

    On the subsidies, FWIW, I saw some great state-by-state charts somewhere (maybe Kaiser Foundation?) that clearly showed (without pointing it out, you could just see it in the charts) that subsidies are heavily skewed to cover the higher rated costs of older insured. I.E. the subsidy within the same income group: for a 20-something is like $8 on a $140 premium, but for a 50-something is like $275 on their $400 premium. The subsidies are not easily parsed is what I am sayin'. (Yes we are still dealing with Rube Goldberg, like it or not. Everyone should've known that when they saw how much paper it took to print ACA out.)

    On the whole system, I should have noted in my comment this quote from the NYT article:

    “We were so thrilled when the law passed, but it has backfired,” said Lindsay Caulfield, senior vice president for planning and marketing at Grady Health in Atlanta, the largest safety-net hospital in Georgia.

    That means they were fully on board with the hopes that Medicaid expansion and low-income insured contingent would cover the cuts they knew were coming via lower Medicare PPS payments.


    by artappraiser on Sat, 11/09/2013 - 12:29pm

     how much paper it took to print ACA out

    Per contra, I suppose Britain's NHS might be printed thus:

     

    "You get sick, we treat you."


    by jollyroger on Sat, 11/09/2013 - 1:14pm

    In response to your comment above @ 1:14

    I am very partial to the NHS model myself.

    But if I am very honest with myself, I know there is evidence that it only ranks middling in cost and life expectancy when compared against more Rube Goldbergian systems of other countries:

    The Two Obamacare Charts That No One's Talking About
    By Dan Munro, Forbes.com, Nov. 7, 2013

    [....] All of which brings us to one final chart. Of all the ones I’ve seen – and used – this one (with OECD data from 2011) still represents (at least for me) the best graphic representation of our continuing national healthcare crisis.

    We are currently way worse than all of those countries. But one should take us out of the picture then and look at what's working best elsewhere. I try to keep an open mind that maybe something different than what the NHS-type systems do is what is required for the future where we are assured costs are going to rise astronomically as population ages and more and more procedures become status quo. If you delve into their system, you find it is having lots of serious crises. Maybe just maybe it does need to be more complex than that. Japan, Italy, Spain, Korea, Israel: cheaper & better results than NHS? (Interesting that Canada is more expensive but not getting much better life expectancy results than NHS.)


    by artappraiser on Sat, 11/09/2013 - 2:01pm

    ooh, I just lucked out on a search and found the 2011 figures applicable to that chart, for what we in the U.S. spent all that on, from cms.gov:

    Historical NHE, including Sponsor Analysis, 2011:

    • NHE grew 3.9% to $2.7 trillion in 2011, or $8,680 per person, and accounted for 17.9% of Gross Domestic Product (GDP).
    • Medicare spending grew 6.2% to $554.3 billion in 2011, or 21 percent of total NHE.
    • Medicaid spending grew 2.5% to $407.7 billion in 2011, or 15 percent of total NHE.
    • Private health insurance spending grew 3.8% to $896.3 billion in 2011, or 33 percent of total NHE.
    • Out of pocket spending grew 2.8% to $307.7 billion in 2011, or 11 percent of total NHE.
    • Hospital expenditures grew 4.3% to $850.6 billion in 2011, slower than the 4.9% growth in 2010.
    • Physician and clinical services expenditures grew 4.3% to $541.4 billion in 2011, a faster growth than the 3.1% in 2010.
    • Prescription drug spending increased 2.9% to $263.0 billion in 2011, faster than the 0.4% growth in 2010.
    • As a share of total health spending, households (28 percent) and the federal government (28 percent) accounted for the largest sponsor shares.  From 2010 to 2011, state and local government (17 percent) shares increased by about 1 percentage point while households and the federal government shares dropped by a percentage point.  Shares of private businesses (21 percent) remained constant from 2009 to 2011.

    For further detail see NHE Tables in downloads below.

    There you have one of the problems right at the top, Medicare spending grew the fastest, followed by hospitals & physician & clinical.

    Note also how Medicare and Medicaid spending adds up to $962 billion while private health insurance spending is $850.6 billion, 36% and 33% of total respectively. It's pretty clear that they are not the only culprit causing that.

    Just looking at this, it is hard to see how private insurance profit could be the only problem causing us to spend 17.9% of GDP.

    It is also interesting about state and local government share increased and household and Feds share went down; have no idea what that's about.


    by artappraiser on Sat, 11/09/2013 - 5:42pm

    Just looking at this, it is hard to see how private insurance profit could be the only problem causing us to spend 17.9% of GDP

    Its not the only problem by a long shot.

    The drug companies with their government enforced monopolies profiting from NIH research are a biggie, the device manufacturers are insanely avaricious, and of course the doctors insist on grossly outsized incomes (cf Cuba...).

    We really need to begin with vastly expanded medical education subsidized by the state...I still like the Ben Nelson autobody and medical school chain.


    by jollyroger on Sat, 11/09/2013 - 5:46pm

     In 2005, Cuba had 627 physicians and 94 dentists per 100,000 population. That year the United States had 225 physicians and 54 dentists per 100,000 population;


    by jollyroger on Sat, 11/09/2013 - 5:48pm

    [edit]

    According to the World Health Organization, Cuba provides a doctor for every 170 residents,[53] and has the second highest doctor-to-patient ratio in the world after Italy.[54]

    Medical professionals are not paid high salaries by international standards. In 2002 the mean monthly salary was 261 pesos, 1.5 times the national mean.[55] A doctor’s salary in the late 1990s was equivalent to about US$15–20 per month in purchasing power.


    by jollyroger on Sat, 11/09/2013 - 5:49pm

    My open mind on the issue has closed a little bit more after seeing this chart: UK's NH is far more popular with its users than many other systems; Canada for example, looks pretty lousy in comparison:

     

    From a Nov. 18 WaPo Wonkblog post.


    by artappraiser on Wed, 11/20/2013 - 11:35am

    Besides the quite convincing level of satisfaction evinced by the Brits, what to make of the striking 75% of US consumers who want to toss "the world's best medical care".

    With that sort of popular groundswell, how can it be that the best achievable reform was such a caricature?


    by jollyroger on Wed, 11/20/2013 - 7:03pm

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