Medicaid – Page 3 – The Moral Healthcare Blog

Remarks on Medicaid Expansion

I had the privilege of testifying in favor of Medicaid expansion for Pennsylvania at a hearing of the PA House Democratic Policy Committee, chaired by Rep. Dan Frankel of Allegheny County. (Follow the link for the agenda and other speakers.)

Good morning. I am Dr. Chris Hughes, state director for Doctors for America, a nation-wide group of physicians advocating for high quality, affordable health care. I have been an intensive care physician for my entire career, now approaching 25 years, and within the past year I have also begun practicing hospice and palliative medicine. I am a former Trustee of the Pennsylvania Medical Society and Chair of the Patient Safety Committee. I have completed graduate studies in health policy at Thomas Jefferson University, and I am now teaching there as well in the Graduate School of Population Health.

I tell you this to let you know that I can get down in the weeds with you about the nuts and bolts of implementation of the Affordable Care Act, and I know a fair amount about health care financing, access, cost shifting, and all the rest. But you have a fine panel assembled here today who can do that for you, and I know you all know your way around these topics as well.

I am here as a physician and a representative of my profession. Every doctor you know, and every nurse and pharmacist and social worker and everyone in the front lines of health care, for that matter, can tell you stories of how our health care system has failed someone. Our system fails people regularly, and often spectacularly, and often cruelly, day in, day out.

I’ve had patients who work full time in jobs that fall far short of the American dream. They get by, but they can’t afford health insurance.

I’ll give you a few of my patients’ stories here, not just to point out the obvious- that we are mistreating our fellow human beings – but that we are misspending countless dollars on the wrong end of the system.

There’s the cabbie who recognizes his diabetes and determines to work harder and longer so he can buy insurance before he is stricken with the label even worse than diabetes: preexisting condition! He doesn’t make it and ends up in the ICU with diabetic ketoacidosis.

There’s the construction worker who has a controllable seizure disorder that goes uncontrolled because he can’t afford to go to the doctor. He ends up in the ICU multiple times.

There’s the woman who stays home to care for her dying mother and loses her insurance along with her job. When she finally gets to a doctor for herself, her own cancer is far advanced.

The laid-off engineer whose cough turns bloody for months and months before he “accesses” the health care system – through the ED and my ICU with already far advanced cancer.

These are people who are doing the right thing – working, caring for family members – and still have to go begging for health care. How many hours does an American have to work to “deserve” health care? 40? 50? 60? I’ve seen all of these.

Not long ago, expanding access to health care was a nonpartisan goal. As recently as 2007, a bipartisan group of U.S. senators, including Republicans Jim DeMint and Trent Lott, ( let me repeat that, “Jim DeMint and Trent Lott” ) wrote a letter to then-President George W. Bush pointing out that our health care system was in urgent need of repair. "Further delay is unacceptable as costs continue to skyrocket, our population ages and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for ‘free.’ "

Their No. 1 priority? It was to "Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage."

Medicaid expansion and the Affordable Care Act will get us closer to this than at any time in our history.

You will hear some physicians speak out against all of this. But what you generally will not hear is their leadership and organizations speaking out against it, except perhaps in the deep south. There is a reason for this. As leaders of our profession, we have to come to terms that we are not just in it for ourselves. We are in it for our profession as well, and that means we have to put our patients’ interests above our own, and that means we have to do our best to ensure that everyone has access to high quality, affordable health care. Don’t just take my word for it. The American Board of Internal Medicine Foundation and other organizations put together a Charter on Medical Professionalism about ten years ago, specifically making this part of our professional responsibility. If you go to their website, you will find that virtually every physician organization you can think of has endorsed it. That means the anesthesiologists and orthopedic surgeons as well as the pediatricians and the family practitioners.

For Medicaid expansion specifically, we should note here that the major national physician organizations, including the AMA, and the organizations representing internists, family practice, pediatricians, psychiatry and more, all endorse Medicaid expansion. On the state level, all of these organizations state chapters endorse it as well, with the exception of the Pennsylvania Medical Society, who have endorsed general terms of expansion only.

But this concept is really not controversial among physicians and health care providers. We see everything from the catastrophes to the small indignities. They are tragic, unnecessary, and we are on the road to ending them.

Some in the provider community have expressed concerns about Medicaid in particular as the way we are providing access, so I would like to take a moment to address the concerns we hear most often.

First, that Medicaid is “bad” insurance. What is bad about Medicaid is largely fixed in the ACA. Namely, it is very poorly reimbursed for providers. You’ve already heard [I assume] from HCWP why hospitals want it, but for providers in primary care, the frontlines of health care, they get a massive boost in reimbursement under the new law. Pennsylvania has historically had awful reimbursement in the Medicaid program, among the worst in the nation. Now, reimbursement will go to par with Medicare reimbursement, a huge incentive for providers to take on Medicaid patients whom they may have been reluctant to see previously. There are other new innovations such as Patient Centered Medical Homes and others, coming down the pike, that should really give people who previously had no chance at excellent care, a chance to avoid complications, avoid the ER and avoid the hospital.

I’ve also heard the strange claim that having Medicaid is worse than having no insurance. I suppose that in a vacuum where there is no good data, and where one sees, like I do, patients with no insurance or Medicaid, who don’t know how or aren’t able to access a doctor – you’d be amazed at how often this happens – you could look at patients who get very sick and attribute that to Medicaid, but we do have data now. In Oregon, due to a fairly bizarre set of circumstances a few years ago, Medicaid eligibility was determined by lottery, creating a natural experiment of haves and have-nots. In the first year, those who were enrolled were 70 percent more likely to have a usual source of care, were 55 percent more likely to see the same doctor over time, received 30 percent more hospital care and received 35 percent more outpatient care, and much more.

People often ask me why I am so passionate about this, and I always tell them, “I blame the nuns.” Growing up Catholic, there was nothing so drilled into me as Matthew 25. We used to sing a hymn based on it, “Whatsoever you do to the least of my brothers,” on a regular basis at Mass. And we went to Mass before school every day!

It turns out this is a pretty universal sentiment. I checked. Go to the websites of every mainstream Christian denomination in America and it will be in there somewhere: The Social Gospel and Social Justice. Dignity of the individual. Our duties to the less fortunate. It is a component of every major religion and philosophy in the world, with one notable exception – Ayn Rand’s. And I mention Ayn Rand and her most famous book, Atlas Shrugged, because it is perennially listed as the second most influential book in America after the Bible. A damning fact for us.

In spite of that, I am glad that social justice and a commitment to the fair distribution of our health care resources is integral to the sense of duty of my profession, the nursing profession and all health professions.

I encourage debate about how we get to universal health care, but I refuse to accept that America, alone among all modern nations, and Pennsylvania in particular, will reject the idea that we need to get there. And right now, Medicaid expansion, the Health Insurance Exchanges and many other components of the Affordable Care Act are our best hope. Let’s not squander it.

Thank You.

Ohio Right to Life comes out in ‘100 percent’ support of Gov. John Kasich’s proposed Medicaid expansion

After days of criticism from conservatives, Gov. John Kasich snagged a significant endorsement for his Medicaid expansion plan Friday from Ohio Right to Life.

The prominent anti-abortion group’s board agreed to back to back the proposal with "100 percent approval," President Mike Gonidakis told The Plain Dealer.

"Our mission is to support life from womb to tomb," Gonidakis said. "In this case minorities will benefit, the poor will benefit. It will cover the parents of young children."

He added: "I think what we’re seeing from this governor is a kind and compassionate approach. I would ask our friends in the Tea Party to read the full proposal and see it’s not only the most compassionate, but also the most fiscally responsible. You don’t have to be a Democrat or a Republican to support this."

Kasich, a Republican up for re-election in 2014, announced he favored the expansion Monday while unveiling his two-year budget proposal. Though he maintains that he is a staunch opponent of President Barack Obama’s Affordable Care Act, Kasich said the expansion called for under the law known as Obamacare provides coverage for those in need. With the U.S. Supreme Court upholding the law but giving states the right to opt out of the expansion, Kasich does not want to risk losing federal funds supporting the expansion to other states.

"Without this move Obamacare is likely to increase health insurance premiums even higher in Ohio," Kasich wrote in defense of his decision Wednesday on the conservative website RedState.com. "Worse, it takes $17 billion of Ohioans’ federal tax dollars out of our state and gives it to other states — where it will go to work helping to rev up some other state’s economy instead of Ohio’s."

http://blog.cleveland.com/open_impact/print.html?entry=/2013/02/ohio_right_to_life_comes_out_i.html

Take money for Medicaid

Valerie Arkoosh and Marc Stier in Philly.com

If we take the money to expand Medicaid, Pennsylvania will receive $43.3 billion over 10 years from the federal government. And if for any reason the money does not come to Pennsylvania, the governor can cancel the expansion at any time.

Taking federal money to expand Medicaid requires Pennsylvania to spend $4 billion over 10 years. But roughly $2 billion will be saved because federal money will replace funding for General Assistance-related programs. More than $850 million will be saved because the state will not have to compensate hospitals for ER care for the uninsured. And between $800 million and $1.4 billion will be available for county health services, where harsh cuts have already taken place.

Take money for Medicaid

Gov. Bobby Jindal’s administration reverses planned elimination of Medicaid hospice program – The Washington Post

BATON ROUGE, La. — Louisiana Gov. Bobby Jindal’s administration scrapped plans Wednesday to shutter the state’s Medicaid hospice program in February, meaning the state will continue to provide end-of-life care to people on their death beds who can’t afford private insurance.

Jindal’s health secretary Bruce Greenstein made the announcement as hospice program supporters were gathering for a candlelight vigil on the state capitol steps to protest the cut. Greenstein said his department will use grant funding to cover the hospice costs this year.

The stupidity, economically speaking, and the heartlessness, you know, human being-wise, of some of these self described “Christians” (ChristoRepublicanus Americanus?) is astounding.

The price of Medicaid expansion opt-outs: $53.3 billion

The Supreme Court decided way back in June that the health law’s expansion of Medicaid was optional rather than required. That decision, it appears, comes with a hefty price tag: $53.3 billion.

The National Association of Public Hospitals estimates that, in light of the decision, the United States will spend as much as $53.3 billion more on bills that go unpaid by the uninsured. Their analysis uses data from the Congressional Budget Office, which estimates that six million to10 million fewer Americans will gain insurance through Medicaid after the Supreme Court decision.

“Congress certainly didn’t foresee this level of uninsured and uncompensated care when it enacted the ACA,” says NAPH president Bruce Seigel.

Keep in mind, this isn’t necessarily $53.3 billion in new spending. It’s more like a cost shift. Those who would have had their bills paid by the federal government (under Medicaid) could now have the costs covered by local governments and hospitals, which tend to foot the bill for many of the health care services that go unpaid.

The Congressional Budget Office estimates that, over the course of a decade, states opting out of the Medicaid expansion – and not drawing down funds from Washington – will save the federal government $84 billion.

It’s also a cost shift to those with private insurance, as hospitals charge a bit more to clients with coverage to recoup their losses on the uninsured. One study estimated that cost shifting raises annual insurance premiums by as much as 1.7 percent, or $80 annually.

Medicaid on the Ballot – NYTimes.com

But one thing is clear: If [Romney] wins, Medicaid — which now covers more than 50 million Americans, and which President Obama would expand further as part of his health reform — will face savage cuts. Estimates suggest that a Romney victory would deny health insurance to about 45 million people who would have coverage if he lost, with two-thirds of that difference due to the assault on Medicaid.

….

So, about coverage: most Medicaid beneficiaries are indeed relatively young (because older people are covered by Medicare) and relatively poor (because eligibility for Medicaid, unlike Medicare, is determined by need). But more than nine million Americans benefit from both Medicare and Medicaid, and elderly or disabled beneficiaries account for the majority of Medicaid’s costs. And contrary to what you may have heard, the great majority of Medicaid beneficiaries are in working families.

For those who get coverage through the program, Medicaid is a much-needed form of financial aid. It is also, quite literally, a lifesaver. Mr. Romney has said that a lack of health insurance doesn’t kill people in America; oh yes, it does, and states that expand Medicaid coverage show striking drops in mortality.

So Medicaid does a vast amount of good. But at what cost? There’s a widespread perception, gleefully fed by right-wing politicians and propagandists, that Medicaid has “runaway” costs. But the truth is just the opposite. While costs grew rapidly in 2009-10, as a depressed economy made more Americans eligible for the program, the longer-term reality is that Medicaid is significantly better at controlling costs than the rest of our health care system.

How much better? According to the best available estimates, the average cost of health care for adult Medicaid recipients is about 20 percent less than it would be if they had private insurance. The gap for children is even larger.

Health care for all: Expanding Medicaid would save lives, suffering and money – Pittsburgh Post-Gazette – Printer friendly

My Piece on Medicaid expansion from the P-G:

Health care for all: Expanding Medicaid would save lives, suffering and money

One of the most common questions I get asked about the new health care law concerns how expanding health insurance coverage to millions of low-income families through Medicaid will affect those who already have insurance. “What will all of those new people with access to health care do to the rest of us? Will it make it harder to get access to our doctors? Will they clog up our emergency rooms and hospitals?”
As someone whose profession takes a strong position in favor of universal access to health care, I have a hard time saying anything but, “What a great problem to have!” It turns out to not even be a problem.
Massachusetts did this many years ago, as we are being frequently reminded, and the results are in. Use of emergency rooms is down, waiting times to see a primary care doctor are essentially unchanged and there has been a vast expansion in the use of preventive services: mammograms, colon cancer screens and prenatal care, for instance. Doctors and the people of Massachusetts overwhelmingly favor continuation of their program, and they are now proceeding to the really hard part: getting costs under control. Stay tuned!
An even more interesting experiment is being conducted in Oregon via an unhappy accident. Due to a shortage of funds, Medicaid eligibility was determined by lottery, creating a natural experiment of haves and have-nots. In the first year, those who were enrolled were 70 percent more likely to have a usual source of care, were 55 percent more likely to see the same doctor over time, received 30 percent more hospital care and received 35 percent more outpatient care, and much more.
Every doctor you know can tell you stories about how the lack of access to health insurance and health care has injured a patient’s health, life, limbs, finances or all of the above. I’ve had patients who work full time in jobs that fall far short of the American dream. They get by, but they can’t afford health insurance.
There’s the cabbie who recognizes his diabetes and determines to work harder and longer so he can buy insurance before he is stricken with the label even worse than diabetes: preexisting condition! He doesn’t make it and ends up in the ICU with diabetic ketoacidosis.
There’s the construction worker who has a controllable seizure disorder that goes uncontrolled. He ends up in the ICU multiple times.
There’s the woman who stays home to care for her dying mother and loses her insurance along with her job. When she finally gets to a doctor for herself, her cancer is far advanced.
So, for me and my profession, the most expansion for the most people is a best-case scenario. But others see expanding health insurance only through a short-term budgetary lens and consider covering nearly everyone a worst case.
For one thing, this view ignores the incredible deal states get when they accept Medicaid expansion. According to the Kaiser Foundation, by 2019 Pennsylvania would add about 482,000 new enrollees; another 282,000 who are eligible but don’t know it would come into the program. That’s more than three-quarters of a million people with access to care.
Critics point to the potential cost to the state of more than a billion dollars over six years. That’s a lot of money, but the federal government would pay more than $17 billion — over 94 percent of the cost. Furthermore, the additional billion would be only 1.4 percent more than Pennsylvania’s currently scheduled spending over that period. Even in a best-case scenario, with insurance for an additional 1.1 million Pennsylvanians, this figure would rise to only 2.7 percent.
One can choose to focus on the costs to the state and federal governments, but we spend many of those dollars already on the wrong end of the care continuum. Our governments already pay for patients who cannot pay for themselves, largely by cutting big checks to hospitals.
You can take care of a lot of diabetic cabbies for a lot of years for the cost of a stay in the ICU. Just because the costs don’t show up as a line item in a government budget — it could be labeled “Exorbitant Amounts of Money for Preventable Complications and Deaths” — doesn’t mean we don’t pay them.
A frequent talking point against expanding access to health care, “You can always go to an emergency room,” is actually dead on. Literally.
The law requires emergency rooms to treat and stabilize patients even if they have no means to pay. But no emergency room does cancer screening. Or prenatal care. No emergency room manages diabetes. Or congestive heart failure. As a result, many people don’t seek treatment until they are nearly dead.
Patients forgoing care or medicines because they can’t afford them simply shifts the costs from keeping people healthy to our extremely expensive system of “rescue care.” And remember, Massachusetts’ early experience and Oregon’s current experiment are showing the benefits to the entire system of getting people taken care of before they need an ER or ICU.
Not long ago, expanding access to health care was a nonpartisan goal. As recently as 2007, a bipartisan group of U.S. senators, including Republicans Jim DeMint and Trent Lott, wrote a letter to then-President George W. Bush pointing out that our health care system was in urgent need of repair. “Further delay is unacceptable as costs continue to skyrocket, our population ages and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for ‘free.’ “
Their No. 1 priority? “Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage.”
Medicaid expansion, as well of the rest of the new health care law, represents our best effort so far in reaching these once-bipartisan goals. Pennsylvanians deserve an expansion of health insurance and health care, a healthier state, a healthier workforce and to continue the journey toward my profession’s goal: excellent, affordable health care for all.
Christopher M. Hughes practices intensive care and hospice medicine in Pittsburgh and is the Pennsylvania director of Doctors for America (www.drsfor america.org).

First Published October 4, 2012 12:00 am

The Romney-Ryan Plan to Obliterate Medicaid | Mother Jones

The Journal of the American Medical Association

Romney’s Medicaid shell game – Boston.com

Mitt Romney is lambasting federal aid in his campaign for the presidency, including derisive comments against those who receive government assistance. But he pulled all the stops to pursue federal aid as governor of Massachusetts, even hiring “revenue maximization” contractors to scour federal programs for every possible penny — and using financial schemes to maximize and then divert the aid from his needy constituents.