Medicare AmbulanceThe Affordable Care Act, although complex, had a simple premise. If everyone is engaged in our very expensive healthcare system, then we all are motivated to improve the care. Medicaid was to be the floor but a funny thing happened on the way to health care nirvana. To quote an article in Health Affairs:

The original dream of a seamless, streamlined, no-wrong-door Medicaid, CHIP, advance premium tax credit, and cost-sharing reduction payment application and eligibility determination process has become a much more difficult reach with the Supreme Court’s still shocking interpretation of the Constitution’s spending clause, permitting the states to decline participation in the Medicaid expansion.

So, we are now into the implementation and we have 25 states who are convinced, if they just hold their collective breath long enough, something really good will happen. People in these states are being told, after they apply, “You are too poor to qualify for health insurance.” I guess we’ll teach those poor people a lesson.

The Atlantic decided to show the other side of the policy fight in an article published earlier this week. You know the side, the one where poor people get sick and die from lack of access to health care. In this article they follow several people who happen to live in Texas, make less than 138% of poverty, and thus are not granted front door access into the “greatest healthcare system in the world.” If we were playing Jeopardy (and who doesn’t love Jeopardy) and the answer was, “This large state has refused to expand Medicaid, a program that would give 1,000,000 citizens access into the health care system that they currently are denied,” you might say, “What is Texas?” and you would be correct. Then you might say, “One million, Alex? Really?”

This lack of coverage will lead to people who choose not to seek care or are denied needed care. Most of these people will merely suffer excessively. Some will die prematurely. Across America, it will be 27,000 deaths. Over 60 percent of these deaths will occur in either blacks or Latinos, the result of denying  access to what almost every other country considers a basic right. Texas researchers estimate that 9,000 folks will die prematurely in Texas.  The faces of these people shown in the Atlantic article include Claudia (who almost dies of a surgical misadventure) and Mark (who is dying from throat cancer, in part because no physician will provide the appropriate care).

The John Davidson of Texas Public Policy Foundation has some ideas about how to handle this situation. He thinks we need to focus on access and not insurance, and that well-meaning citizens can provide such access. For example, he cited the CareLink program run by the University Health System in Bexar County, which provides payment plans and sliding-scale rates for families who make less than 300 percent of the federal poverty level. Couple of things about that; It only serves one county, and while  it provides for a “sliding fee” of payment, the amount of the bill (at cash rates, not negotiated lower insurance rates) is not adjusted. So the poor are not required to accept demeaning charity; instead, if they are lucky enough to live in Bexar County, they are required to pay an outrageous bill over time, no matter how long that takes. Turns out that 143 counties have a similar programs. Unfortunately Texas has 254 counties.

The Texas Public Policy Institute has a policy paper full of good ideas for how red states can provide care for our unfortunate too-poor citizens. Mostly, their big idea is that doctors will likely volunteer to see those one million people free of charge. I can see how that might seem appealing.

So, the next time “repeal and replace” comes up, I think the “red state doctors see poor people for free (or at least on a sliding scale)” ought to be explicitly part of the legislation. It might not be “seamless and streamlined” but it will at least make the Medical Society meetings more interesting.