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I had to quit my job because of the stress I had to endure was putting me at high risk for a stroke or heart attack and I couldn’t physically keep up anymore
I’m 56 years of age
My job was 32 hours a week
But because of Obama care my insurance was costing me $600 dollars a month for just major medical!
No dental no eye care no life insurance
So by the time I paid my rent, electric, water, sewer, garbage, car insurance, house insurance etc, I had enough money to put gas in the car to get to work and buy ramen noodles and some cheap hot dogs for food!
Over 60% of my net pay went to insurance that covered nothing!
Now I am unemployed with ZERO insurance
Its pretty damn sad when all the damn medicaide and dissabilty cheats are eating steak with perfect teeth and new glasses and are in perfect health while I have to bust my damn ass just to eat ramen noodles wityh bad teeth , basbasd eyes, and life threatening health problems!!
So here I am, no job, no insurance, no hope
Patient’s story as posted on Obamacare stories
The average household income in the United States is $51,000. From that you pay for our food, shelter, children’s education, and movie tickets. Oh, yeah, and $5000 for a health insurance policy. One of the things that Obamacare did was begin to put a cost on our insatiable healthcare consumption. Turns out, that cost is VERY high.
If you are an average American, boy are you ticked off. Half of all Americans spend under $400 a year on healthcare. Pretty much a round of antibiotics for a sinus infection and, for women, a year’s worth of contraception. Not only that but because of high deductibles (to keep the cost down by discouraging consumption) you are paying $5,000 to the insurance company AND paying cash for your sinus infection visit and medicine. Then there are the drug companies and insurance companies that are colluding to raise the prices of formerly cheap antibiotics to get even more of your household income.
About 1% of the people in this country account for about a quarter (27%) of the health care spending. In 2014, this was about $100,000 per sick person. Those in the top 5% of sick people were responsible for almost $50,000 in health care costs. These numbers are unchanged since Obama was elected. So what has changed? Before, the costs of these people were hidden. They would get the care for “free” at a safety net hospital who would get money in other ways to pay for it. Or a sick person would use an insurance card then the payment would be denied as a pre-existing condition and the hospital would eat the cost. More likely, the sick person would get on disability, suffer for 2 years, and become Medicare eligible so we the taxpayer would pay. The care still cost money but was hidden in taxes. Insurance companies kept costs low, in other words, by shifting them to the federal government. Now folks under 65 who are sick can pick up an Obamacare policy and get exceptional care. Also on Obamacare stories are ones like this:
Thank you President Obama thanks to your healthcare plan I was able to continue to see specialists, this resulted in a diagnosis of a rare intestinal infection and even more concerning, two stage three colon cancer tumors, one on each side on each side of the colon. This required almost total colon removal from a top notch physician that was able to do my surgery without having to have a bag.
Only problem is, this type of care costs A LOT more than $5,000. .
So, if you bought an Obamacare policy and feel ripped off, let me tell you what your $5000 paid for. It wasn’t eye glasses and dental work for poor people that jacked up your bill. You spent your $5000 on people under 65 with heart disease and lung disease. You purchased them a lot of expensive tests, some time in the hospital, and some expensive drugs. You paid for the person with breast cancer’s $300,000 tab whose $5000 premiums were paid by the cancer treatment facility. You paid for the person helicoptered in after rolling their car on Interstate 65 while trying to avoid a deer. You paid for some very expensive medication for people with mental illness to keep them out of a mental hospital.
Did you pay too much? Yes. Other countries can do the same thing better for half as much or less. Perhaps the new adminstration will look at this as an opportunity to further retool our expensive, not very effective care delivery system and reign in some of the profiteering. Or maybe we’ll just continue to blame the poor…
Are you going to provide free clinics for sick underprivileged children? Will you do in Alabama what you do on mission trips to other states and countries?
Senator Jim McClendon, explaining why he is sponsoring not one but TWO lottery bills
The legislature in Alabama is meeting in special session starting today to see if they can find more money for the General Fund budget. The budget passed in the regular session was about $100 million short for what was needed to maintain the Medicaid program at its current bare bones level. Medicaid and corrections are the major programs funded by this complicated and convoluted budget process and, as you can imagine, the constituency tends to be silent. The legislature comes back into special session today to determine whether Alabama will become the first state to reduce Medicaid funding below the threshold required for the match.The funding possibilities are as follows:
- Governor Bentley’s proposal- a $225 million lottery, with proceeds going to the General Fund. Would require constitutional amendment. Money not available for about a year.
- Jim McClendon’s bill, which would include electronic lottery machines in four counties – Greene, Jefferson, Macon and Mobile – with a bond issue to pay for Medicaid in the coming year. Would require constitutional amendment.
- House Minority Leader Craig Ford, D-Gadsden, said he’ll bring a lottery-only bill that would set aside lottery proceeds for education. Another Ford bill would include casino gambling as well. Would require constitutional amendment. Money not available for about a year.
- The legislature may create a compact with the Poarch Creeks, allowing them to offer more types of gambling in exchange for an annual fee or a cut of the proceeds. Critics worry that under federal gaming regulations, a lottery could open the door to Creek expansion without a compact. Unclear how this would work. Likely would draw a lot of attention form the feds.
- They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
- They may, and possibly will, do nothing and allow Medicaid to become a non-compliant program
If they fail to act. the feds will do one of two things. Because the program’s recipients are disproportionately poor and of color, the feds may sue under the Fourteenth Amendment and require us to find $100 million to maintain a $6 billion program, maintain access to healthcare for ALL Alabamians, and not force the layoffs of tens of thousands of individuals who work in healthcare. Conversely, the Supreme Court has ruled that Medicaid is an optional program. The feds may just allow us to opt out and allow our natural experiment to continue. Let’s see how many folks will come to Alabama instead of Ecuador for mission work.
I will be appearing at a press conference on Friday, August 5th as a representative of the Alabama Academy of Family Physicians. Beside me will be representatives from the Alabama Academy of Pediatrics, the Alabama Hospital Association, and the community. We will share the following message. This message is being shared in across the state in a series of press conferences beginning Monday:
On August 1st (tomorrow), Alabama begins applying cuts to the state’s Medicaid system that will impact the quality of care all Alabamians receive. In Alabama, Medicaid:
- Provides health coverage for eligible children, pregnant women, and severely disabled and impoverished adults
- About 1 million Alabamians
- More than half the births in Alabama
- About 47 percent of Alabama’s children
- About 60 percent of Alabama’s nursing home residents
These cuts are devastating and dangerous. Because Alabama already operates a bare bones program, the following will occur:
- Reduction of payments per visit to primary care physicians by 50% beginning tomorrow
- Reduction of reimbursement rates for ambulatory surgical centers, all other specialty physicians, dentists, optometry, hearing and other programs
- Elimination of the prescription drug coverage for adults for the first time
- Elimination of adult eyeglasses
- Elimination of outpatient dialysis
- Elimination of prosthetics and orthotics
- Elimination of Health Home and Physician case management fees
- Consideration of a pharmacy preferred provider program
As a result of the Medicaid cuts put in place August 1, my colleagues in primary care are being put between a rock and hard place. Medicaid rates will not cover the cost of keeping the practice open. My primary care colleagues will either accept fewer Medicaid patients, limit the number of office locations, lay off staff – including nurses and other clinical staff. In some cases they will make the very tough decision of closing their practice and moving to a state that has a more hospitable practice environment.
So what? Turns out primary care doctors are the economic engines of small communities and provide economic vitality to all communities. Combined, we support 83,095 jobs and generating $11.2 billion in economic activity, according to a report by the Medical Association and the American Medical Association. Specifically:
- Jobs: Each physician supported an average of 9.5 jobs, including his/her own, and contributed to a total of 83,095 jobs statewide.
- Output: Each physician supported an average of $1.3 million in economic output and contributed to a total of $11.2 billion in economic output statewide.
- Wages and Benefits: Each physician supported an average of $758,744 in total wages and benefits and contributed to a total of $6.7 billion in wages and benefits statewide.
- Tax Revenues: Each physician supported $46,148 in local and state tax revenues and contributed to a total of $404.9 million in local and state tax revenues statewide.
When these cuts take effect, doctors will leave. Consequently it much more difficult for any patient in the state – including those on private insurance like Blue Cross/Blue Shield – to make an appointment with a doctor of their choice at a time convenient for their schedule. Jobs will leave these towns, towns will die.
Isn’t Medicaid full of fraud? Turns out, not. In fact state lawmakers recently conducted an extensive review of Medicaid’s funding and operations. Our program is one of the most frugal health plans available.
What needs to happen? In order to protect the state’s fragile healthcare system from collapse and ensure that all Alabamians have access to the doctor of their choice, legislators must find a long-term, sustainable solution to fund Medicaid, and shore up funding for the coming year.
How can you help? Visit IamMedicaid.com for more information and go HERE to contact state leaders to let them know how you feel. Encourage them to protect Alabama’s healthcare system by fully funding Alabama Medicaid. Let them know that you are concerned and you vote!
Q: How many magicians does it take to change a light bulb?
A: Depends on what you want to change it into.
Turns out, weekends are especially hard. On weekdays, I would get up, do chores (mostly dog and chicken related), go to work, then come home. Either Danielle would have supper ready or, increasingly, we would go out because it was too much hassle cooking for two. Then I would settle down to do a little work and Danielle would do her thing until it was time for bed. Our days would overlap mostly at supper. The weekends, though, would be when we did OUR thing.
Danielle: Remember, tonight is Art Walk Friday
Me: Ok, but I’ll be about 6 because I have patients
Danielle: Well don’t be late because we’re meeting folks at the Bike Shop for dinner at 7:30 and I have to see the show at the Skinny Gallery. And then tomorrow we have to go to the symphony, and then…
Even on days like this when I was on call, we would carefully plan our trips and errands around my rounding schedule.
Now I have had to change my weekend routine. Change, as they say, is inevitable.
Q: How many Marxists does it take to change a light bulb?
A: None. The light bulb contains the seeds of its own revolution.
Ranking things seems to be the new “news.” Almost everyone has put together a list of best and worst based on some criteria or another. My kids tell me these are called listicles. having the list without information in the title, so I understand, encourages folks to “click” ensuring more ad revenue. USA Today’s offering today was “The least healthy cities in America.” As everyone in America clicked to find out how their city fared, we in Mobile were (dis)honored to be #4:
4. Mobile, Ala.
>Premature death rate: 490.3 per 100,000
> Adult obesity rate: 36.1%
> Pct. adults without health insurance: 12.9%
> Poverty rate: 19.9%
The average Mobile adult feels in poor mental shape for five days a month on average, far longer than the 3.5 days the average American feels in such a state. Poor mental health outcomes in Mobile may be tied to multiple unhealthy behavioral and socioeconomic factors in the area.
Mobile’s 36.1% obesity rate and 29.6% inactivity rate are both far higher than the corresponding national figures. Additionally, nearly one-fifth of area residents live in poverty, and 7.0% of the workforce is unemployed, each some of the highest such figures in the country.
The results of that survey, Perkins said, made it clear that Mobilians suffer from poor mental and physical health in large part because the city’s built environment is not conducive to being active. Access to healthy foods in poor neighborhoods is also poor, he said.
If Mobile wants to work its way off these lists, it’ll take change (see figure). We’ll need to invest in infrastructure such as parks and bike lanes so people make healthier choices. Increase the minimum wage so folks have time to use these amenities to get and stay healthy. Expand Medicaid so folks are not one illness away from bankruptcy. Focus our care delivery system on health instead of on making money off of illness. In other words, while change may not be inevitable for Mobilians, it is the only way to get off of these lists.
Or, we could just double down on our football success:
HOW MANY SEC STUDENTS DOES IT TAKE TO CHANGE A LIGHT BULB?
At ALABAMA: It takes five, one to change it, three to reminisce about how The Bear would have done it, and one to throw the old bulb at an NCAA investigator.
[In response to increased dependence on oil from unstable countries] EEN began to create the “What Would Jesus Drive?” (WWJDrive) educational campaign in February 2002 to help Christians and others understand the relationship between our transportation choices and these three major problems – human health impacts, the threat of global warming, and our increasing oil dependence.
Remember those WWJD bracelets. Folks wore them as a reminder to act “right” when no one was looking. The letters stood for “What Would Jesus Do?” and the presumption was that in every given situation there was a “Godly” answer. Of course, placing yourself into the mindset of a person who lived 2000 years ago to establish a course of actions in a given modern-day situation led to some strange speculation. What Would Jesus Do when confronted with pork? Is veganism the established Jesus-like diet? This person can site scripture to say it is. It also leads to some creative marketing. On ETSY are several pages of handmade items embossed with the official WWJD query. One “ladies T” substitutes the letter “D” for the “J” allowing one to substitute The Donald’s thought process for those of the Other Big Guy.
In 2002 a group of creative and and liberal soles asked themselves “What would Jesus drive?” This was a time immediately after the trade towers went down. The national narrative was being shaped and it was understood that our purchasing of oil from the Middle East was a proximate source of terrorist funding, bad for the environment, and bad for our health. Their solution? Drive smaller and more efficient cars. Not SUVs. Unfortunately, the opportunity to invade an oil rich country seemed much more the Jesus-like answer to some:
God told me to strike at al-Qaeda and I struck them, and then he instructed me to strike at Saddam, which I did, and now I am determined to solve the problem in the Middle East. If you help me I will act, and if not, the elections will come and I will have to focus on them“
Why the walk through memory lane? I was sent a copy of the Alabama Department of Public Health’s transportation survey (found here). Groups from every county in Alabama who care for the poor and underserved were interviewed and to a group they coalesced around a single theme -Transportation for poor people is terrible in Alabama. Agency after agency identified between 25% and 50% of their clients have to rely on friends, strangers, or don’t keep health care appointments at all because of a lack of affordable transportation. Most counties in Alabama have no public transportation; for example in Marion County:
The hospital is not aware of any other transportation entities available to patients in this area, with the exception of one called “Tommy’s Taxi Service,” consisting of one elderly man and his personal vehicle, which they have known patients to use to get back and forth from their dialysis appointments. These dialysis appointments represent one of the largest challenges to patients without reliable transportation access, due to the necessity of attending multiple times per week.
Multiple agencies including this “for profit” entity suggested that churches are the answer:
Finding a way to involve the churches and other faith-based organizations in this area with the issue of non-emergency medical transport would help a lot of people in this area, and could be done by scheduling specific pick-up points and times at regular intervals. However, issues with reimbursement and assumption of liability are most likely the largest roadblocks to developing this type of solution.
So, Jesus might drive a passenger van and make scheduled stops to keep Alabamians from having to budget tax dollars for transportation. Perhaps He would work on His followers in the legislature to create and fund an effective bus service. I’m betting He would just heal the poor, sick people in Alabama. Alabamians who drive SUVs could take their turn being sick for a while.
“It is one of the happy incidents of the federal system, that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”
The state of Alabama continues to deny its citizens access to expanded Medicaid. One of the arguments made by Alabama state Senator Tripp Pittman, a harsh critic of government in general and Medicaid in particular, is that the states are not given enough flexibility. He blamed the poor for the “excessive” cost of care, in fact, and suggested that if more control were given to the state the undeserving could be weeded out. Then, as one does with weeds, left in a pile on the side of the road to wilt I suppose.
An inside look of how the state of Alabama would REALLY handle this serious responsibility can be seen in the trial of our Speaker of the House, going on now. For those who don’t watch Rachel Maddow or read the New York Times, the state has its Governor under grand jury investigation and its Supreme Court Chief Justice under judicial review. These, however, are not the worst. Mike Hubbard, the Speaker, has been under indictment for 23 felony counts involving violations of the ethics laws he authored. It has taken two years for this to come to trial. In the interim he has been reelected to his seat and reelected as Speaker by his “peers.” Several of his peers have already pled guilty and are scheduled to testify. Others will likely plead the fifth.
It is an interesting set of charges. He is charged with taking money as a lobbyist (unregistered) from a gas company and then passing laws to push business in their direction. He is also charged with using his position as head of the Republican party to push business towards his formerly failing company. These are all your typical corrupt politician charges and his defense is one of confusion about the illegality of the actions (“I don’t know what he was talking about,” says defense attorney Baxley, it’s all “mumbo jumbo and gobbledygook.”) combined with the good-old-boy defense (“What he didn’t show was the parts of the ethics law that offers exceptions for friendships in business dealings,” Baxley said). Makes for fun theater.
The most serious charges and the ones that likely have gotten the feds interested are the ones regarding Medicaid. As a program that costs the state under a billion dollars and brings six billion dollars into the state, a bunch of money is available for folks to use for “bidness.” Speaker Hubbard, as documented in the New Republic, saw a huge opportunity. As the revenue stream for the general fund (which funds Medicaid) is diminishing and folks like Senator Pittman have no compunction to raise taxes, controlling medication costs seemed to be the natural course of action. Speaker Hubbard called a meeting and:
So three legislators, two lobbyists, and a handful of staff privately decided, after the briefest of deliberations, to enact a policy that would give a $20 million monopoly over the state’s Medicaid drug business to a corporation that had no experience running such a program, a move that would impact the lives of the 600,000 poorest and least powerful people in Alabama—children, senior citizens, people with disabilities.
Afterwards the group discovered to their surprise that one of the Speaker’s clients was involved in this Medicaid medication management scheme and would have benefited significantly.
The former chief of staff also urged Hubbard not to vote on the budget bill because it “looked bad,” but Hubbard said it would send up “too many red flags.” The language was later stripped in committee.
His current defense? “No harm, no foul” and/or “we stuck it to them city slickers.”
So in this one laboratory of democracy, even with significant federal oversight, Medicaid money seeps out around the edges to enrich a small number of folks. Imagine what’ll happen when the oversight is less. My prediction: It’ll be HUGE for some people, very few of those being the poor and the sick.
“Last year (2015), the Science and Security Board moved the Doomsday Clock forward to three minutes to midnight, noting: ‘The probability of global catastrophe is very high, and the actions needed to reduce the risks of disaster must be taken very soon.’ That probability has not been reduced. The Clock ticks. Global danger looms. Wise leaders should act—immediately.”
Bulletin of the Atomic Scientists, 2016 Doomsday Clock update
Here in Alabama, it is one minute to healthcare catastrophe. The legislature passed, the governor vetoed and got caught in a sex scandal, the legislature overrode and made law a bill which reduces Medicaid to a level not seen in any of the other 49 states. The program exists as a federal-state partnership and Alabama’s partner has every right to back out if we don’t hold up our end of the bargain.
So what, you say, I have Blue Cross.
As fellow Alabama physician Pippa Abston documents, everything is connected. Our doomsday clock has been inching closer and closer to midnight ver since 2003 when Governor Riley failed to pass a funding package to deal with the problem. In the interim we have cut mental health services to the bone, have reduced services that maintain the elderly in their home, have reduced payments such that eight rural hospitals have closed and another 2 dozen are on the critical list. The next tick of the clock spells disaster. Woman’s and Children’s Hospital in Mobile, 71% Medicaid. Children’s of Birmingham, 57%. Midnight is only a minute away.
In the cold war era we actually planned to survive the nuclear holocaust. Fallout shelters stocked with food, instructions on how to “duck and cover” and other propaganda gave us a sense of bravado in the face of certain annihilation. We were fortunate that the balloon never went up because our survival was never guaranteed. In fact, policy makers were well aware of the futility of their efforts.
Today and tomorrow are the day when we decide whether to let clock click to zero for health care in Alabama. Don’t believe in the false security of private insurance. Our system is built on Medicaid. Call your state senator and tell him or her you support using BP money for Alabama Medicaid.
Alabama is still poised to unleash the Death Angel. The night after we wrote that post I suffered a tragic loss. Danielle Juzan, my wife and silent collaborator of 33 years was stricken and died of a heart attack at the age of 55. As you can see from the attached article, she was a wonderful, passionate woman who pushed me to stand up and do the right thing regardless of the personal or professional consequences. She was also a marvelous writer and those who have read this blog over the years will never know how much she added to these posts.
She was a fixture in the local community and fought hard for improvements to Mobile, Alabama. Her attachment to our community was what made this work so important. Over the years I have looked at several jobs in places that are better positioned to provide healthcare for all citizens. Each time Danielle would give me the reasons not to leave our house (we just got the garden where it needed to be, we are getting a dog park, etc) and ask me if we couldn’t stay in Mobile a while longer. I would agree that we had a nice life despite the seeming callousness of the public officials and we would go back to tilting at the windmill that is improving the care of the underserved in Alabama.
As I grieve, I continue to check my e-mail and am thankful for the hundreds of expressions of sympathy that I have received. For those of you who read this, thank you so much. While nothing will make it better, it is comforting to know that Danielle has touched so many.
Immediately after her death we were challenged in a message as to accuracy of the position that Medicaid (not the expansion, access to Medicaid at all) saves lives. The commenter suggested that the evidence for improved health was wanting. He pointed out that before the passage of the ACA, Oregon randomly gave several thousand people who were uninsured Medicaid coverage and followed them and several thousand uninsured for a couple of years to see what would happen. The results were as follows:
Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk. Medicaid coverage also had no statistically significant effect on employment status or earnings.
The science is pretty clear, access to health insurance over a two year period for relatively healthy people improved some aspects of their lives but is no panacea. How these findings are interpreted depends on if you live in a red state or a blue state:
A great deal of controversy exists about reducing the number of uninsured people in the United States through Medicaid expansion. Advocates for Medicaid point to evidence showing that Medicaid has been an essential part of the nation’s safety net, providing access to comprehensive health care for the nation’s most vulnerable.
Critics of Medicaid, on the other hand, believe Medicaid has put a tremendous strain on state budgets and increased dependency on government programs. They argue for state-based solutions that place more emphasis on subsidizing enrollment in private insurance for the low-income uninsured. The findings from the Oregon Health Insurance Experiment are cited by both sides as evidence in support of their positions.
Oregon did not take away coverage from required populations. This was coverage provided to folks who would not have been Medicaid eligible otherwise. Alabama is poised to take coverage away from patients on dialysis, patients with complex seizures, and premature infants. It will be a different experiment.
Kaiser has synthesized the evidence on Medicaid’s contribution to the health of the population and it is as follows:
- Consistently, research indicates that people with Medicaid coverage fare much better than their uninsured counterparts on diverse measures of access to care, utilization, and unmet need.
- Children with Medicaid and privately insured children compare quite closely in their access to and use of preventive and primary care. The uninsured do not have access to such care due to expense
- As distinct from access to primary care, access to specialty care has emerged in some research as a weakness in Medicaid relative to private insurance.
- Compared with both privately insured people and the uninsured, Medicaid beneficiaries have much higher rates of ED use. However, a substantial body of research investigating this disparity more closely indicates that poorer health and access challenges in Medicaid both play important roles in explaining Medicaid’s higher ED visit rates.
- Research investigating the quality of care received by Medicaid beneficiaries is limited, but two new analyses, one focused on health center care and the other on hospital care, indicate that the care received by people with Medicaid coverage tracks closely with benchmarks for high quality.
- One study found statistically significant but small differences at the national level between the shares of Medicaid and privately insured adults who received perfect hospital care which was more related to regional differences.
Their conclusion is as follows:
In its totality, the research on Medicaid shows that the Medicaid program, while not perfect, is highly effective. A large body of studies over several decades provides consistent, strong evidence that Medicaid coverage lowers financial barriers to access for low-income uninsured people and increases their likelihood of having a usual source of care, translating into increased use of preventive, primary, and other care, and improvement in some measures of health. Furthermore, despite the poorer health and the socioeconomic disadvantages of the low-income population it serves, Medicaid has been shown to meet demanding benchmarks on important measures of access, utilization, and quality of care.
For you, Danielle. Continue to help me keep fighting the good fight.
When asked about folks possibly dying from lack of access if we fail to maintain a Medicaid system that meets federal requirements:
“We all die sometime,” Trip Pittman (R-Montrose) said. “We’re all mortal. We all have a finite period of time on earth. I think sometimes we confuse saving lives with extending lives.”
Wow! The state of Alabama has passed and overridden the Governor’s veto of a budget that, per the Medicaid commissioner, does not allow us to meet the federal requirements to stay in the “voluntary” program. There was a hearing on the impact of the budget on Thursday. In the lead-up to the hearings (found here) Senator Pittman was quoted as saying that the reason was that “I think there are legislators who need to more fully understand the workings of Medicaid.” A fair statement; as I have as I previously explained (here) the funding of Medicaid in Alabama is incredibly complicated. The hearing included a very informative presentation by the Medicaid Commissioner that can be found here.
Highlights of the Commissioner’s presentation are:
- Counties with the highest unemployment have the highest Medicaid enrollment
- Administrative costs are only 4%
- Cost per enrollee have remained the same but the number of enrollees has increased by 30% since 2008 because of Alabama’s sluggish economy
And, the part that got Senator Pittman’s attention:
- 1% of enrollees account for 30% of costs with 35 tragic cases accounting for almost $40,000,000 in cost to the agency
Senator Pittman’s response (heard here starting at 4:39 and accompanying article by Glynn Wilson here) would have made international news had this been one of Obama’s surrogates. Many of the federal requirements he finds onerous provide healthcare to the “undeserving.” For example, the Feds require Medicaid to cover those who are receiving Social Security disability checks:
“[The eligibility rules]may be too liberal,” Trippman said, and “not discerning enough on whether somebody is really eligible.”
Giving to deserving people, it seems is OK. It’s just that those who could get out and work, in the Senator’s estimation, need to get off their disabled rear ends and find jobs that provide health insurance.
He was then asked to reflect on the 35 most expensive cases:
“We’re spending more than 40 percent of the money on children in their first year of life,” Pittman, said, and added: “We’re spending a lot of money on the elderly, at the end of life. I think as a society we need to debate and look at all of these things. If not, you’re going to get into rationing.”
He then proceeds to outline possible solutions, beginning by referencing Bernie Sanders (8:30 on the video):
“[Bernie Sanders] said 80% of the costs are for elderly and for people in this state in the last few months of their lives and for people with chronic illnesses and the elderly. The reality is that we have to have some discussions about quality of life, about the expenditure of money, and about the cost. You know in this country the transfer of wealth from working to non-working, for every dollar you transfer from working to non-working you are transferring $7 from young people to old people. That’s a moral debate and that’s something people need to start talking about.”
He goes on to say that the cuts will be made, the impacts will be felt, and people will react to what ultimately happens.
There you have it. Willing to turn away $5,000,000,000 and dismantle a state’s care delivery system , so we can find out in our own little laboratory of democracy just how people will react. Again, wow!
About 10 years ago, Mobile County landed one of the last large pre-recession “smokestack” projects. Competing against multiple states, the state and the county ultimately gave a lot of money in anticipation of “29,000 jobs during construction, and 2,700 jobs paying an average of $50,000 to $65,000 annually once the plant is operational in 2010.” One of the more controversial aspects of the corporate welfare was the amount paid by Alabama and Mobile County ($1 BILLION) as compared to the benefit accrued. Many of the skilled construction jobs were filled not by locals but by a nomadic group of people who traveled from places like North Carolina and Virginia, lived in campers for several months, and left to go to the next big construction job. Our corporate welfare went not to Alabamians but to people from all over the south who sought employment by “voting with their feet.”
Our legislature is electing not to spend $85 MILLION on adequately funding Medicaid. They are going to begin holding hearings on the budget they just passed next week, focusing on finding out why healthcare is so expensive, where the waste and fraud is, and finding out how to “fix the program.”
State Rep. Paul Lee, R-Dothan, said he believed a part of the Medicaid issue might be that the system does more “handing out” than “handing up.”
“We have children in need and elderly in need. …We need to start encouraging those that are able and willing to go to work rather than sitting and waiting for a check to come in,” he said.
“We can fix Medicaid in 24 hours if we could make our own rules (versus federal regulations) and do it the way it should be done.”
The first person to suggest that states should be given much greater leeway to “fix programs” was Ronald Reagan. Pointing to the migration of blacks to the north during World War II and to the migration to the energy belt in the 1970s, he suggested that America was not composed of static folks tied to a community, but was instead a moveable army of workers and others who would move from their current state to another if services were inadequate. Like the construction workers were drawn to Alabama. Or perhaps like poor, sick folks might leave Alabama
Do poor, sick people move from a low-service local to a high-service one? Do wealthy folks move to areas with low taxes? Are we finally entering a Reaganesque utopia to which the Ayn Rand capitalists will move after we eliminate Medicaid funding, creating a little Somalia right here?
As it turns out, the great migration of poor sick people to blue states after Obamacare never happened. Folks it seems are content to stay put and use the Emergency Department near their family rather than move to an expansion state. The exception are the chronically homeless, as it turns out that up to 40% are rather nomadic and identify service availability as a reason to relocate. This is about 40,000 people nationwide.
What about the converse? Are wealthy entrepreneurs leaving for the promise of lower state taxes? Despite what the moving company “data” reveals, the truth is nope. In a very well done study by the Center of Budget and Policy Priorities using IRS data which combined income and address change information, it turns out:
- 70% of folks never leave the state in which they were born
- The income tax status of the state does not correlate with the movement of people in or out in general
- If anything, poor people are MORE likely to move to a low tax state, which probably correlates with lower housing costs
- Old people are more likely to move away from snow
People move for two reasons, jobs and family. Well, warm weather as well for old folks.
Reagan’s belief was based on a theory by Charles Tiebout, a rather obscure economist, as well as personal observations about blacks moving north and and Houston’s energy-sector driven growth. Tiebout’s theory was based on faulty assumptions, and Reagan’s observations were not really contextual (the reason for the black diaspora was a little more complex).
Folks that vote with their feet, it seems, are nomadic. They come to either work on large construction projects or to seek out services to substitute for their lack of a permanent residence. It is probably more realistic to fully fund services such as Medicaid rather than fight the federal government and hope for an influx of wealthy Ayn Rand followers. I do not think this will come out in the hearings.