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“Nobody knew that health care could be so complicated”  @realDonaldJTrump

We are 341 days and some change away from the presidential election which will determine the fate of healthcare in this country. The current president, Donald J Trump, campaigned in 2016 on the “repeal and replace Obamacare” platform. Although there was a flurry of activity which threatened to bring back the fear of preexisting conditions and the creation of an Obamacarelite product (perfect for those not planning on being sick) for the most part Obamacare remains intact. In fact one of the key components, Medicaid expansion, actually seems stronger than it did under president Obama.

As we gear up for the next election it seems that healthcare is once again getting the politician’s attention. The Republicans are still of the mind that “Obamacare doesn’t work” although they are unable to come up with anything better. The Democrats have pushed out seemingly hundreds of ideas. Though somewhat of a moving target, it seems that the ideas can be coalesced into “Medicare for All” (Sanders and Warren), “Medicare for some more” (most folks), and “Better Obamacare for some” (Harris and Buttigeig). What piqued my interest today was what I thought was an arcane mental health discussion. Senator Harris called to:

Repeal the Institutions of Mental Disease (IMD) exclusionThe IMD exclusion precludes Medicaid funding for adults receiving care in psychiatric facilities with more than 16 beds, and has also exacerbated a severe shortage of acute psychiatric care beds nationwide. Repealing the IMD exclusion will reduce the number of Medicaid patients who end up in already strained general hospital emergency rooms when they need acute psychiatric care.

I thought “This makes sense” until I saw this Vox article:

But on Monday, when Harris’s campaign rolled out its mental health policy plan, it had not been nearly so thoughtful. Harris seems to have gone all-in on attacking the freedom, dignity, and privacy of people with mental health conditions. People like me.

I have to admit, although I know little about the Senator, she does not strike me as THAT evil.

As it turns out, back in 1965 when Medicare and Medicaid were being designed, there were a lot of people in mental institutions that were being imprisoned for their mental illness. Congress, fearful of states using the new Medicaid money to build bigger insane asylums, created a mental illness exception for inpatient treatment. Any facility with more than 16 beds that exclusively treated mental illness was ineligible for Medicaid funding. Although there have been some attempts to repeal it, this exception has stuck over the years. In part because of fears of mental health advocates such as those expressed in Vox. In part because of fears of increased cost. From a demonstration project which included Alabama where the exception was waived:

“Overall, we found little to no evidence of MEPD effects on inpatient admissions to IMDs or general hospital scatter beds; IMD or scatter bed lengths of stays; ER visits and ED boarding; discharge planning by participating IMDs; or the Medicaid share of IMD admissions of adults with psychiatric EMCs.

Available data suggest, however, that increased access of adult Medicaid beneficiaries to IMD inpatient care would likely come at a cost to the federal government.

In short, we are likely to find ourselves where we have always been. Folks suffering from serious mental illness (including substance abuse) only able to use their Medicaid for treatment if they are not too sick. This is in part due to a fear that those who are functional have that they will be locked away rather than treated in the least restrictive environment. This is also reflects the reality that the feds fund “healthcare,” not the prisons and underpass encampments where folks with intractable mental illness are now found.

Nobody knew mental health care was THIS complicated…

Resident: The patient is a 45 year old black male…

Me (interrupting): I really don’t like identifying people by the color of their skin. What else do you know about him?

Resident: The patient is a 45 year old automobile mechanic who is here for a recheck of his diabetes…

Me (interrupting): Who lives where?

Resident: I don’t know, Mobile. Can I please just finish?

Me: Not until you tell me where he lives and why it’s important

Resident (whispering to another resident): is there another attending I can talk to?

Our current mayor, when he was elected, established an outcome for his “mayorship.” He stated, unequivocally, that he wanted Mobile Alabama to be the safest, most business and family friendly city in America by 2020. Well, OK, in my objective writing classes we were taught to focus on SMART objectives. That is, they had to be specific, measurable, achievable, relevant, and time oriented. For example: We want to to be the most family friendly city based on the “family friendly poll” that is administered by the governor’s office twice a year and includes a scientific sample families in Mobile, Huntsville. Montgomery, and Birmingham. Yeah, forgot that step, I’m afraid.

What should it mean to be the most “family friendly” city in Alabama? Mobile is a geographically large city. Bordered by a river on one side, the city stretches 12 miles in one direction and almost 10 miles in another. Does “family friendly” mean parks? We got some, but not a lot. Does it mean churches? We got a lot of those. I bet it is neither one of those. I would bet, if you ask people, they want it to mean a good life for their children. I bet people would say “I want my kids to be happy, healthy, and successful.” How are we doing with that?

Turns out, the federal government keeps statistics on the “healthy” part at the neighborhood level. You can use a tool (such as this) to find out if you live in a healthy neighborhood or an unhealthy one. If you live in an unhealthy one not only are you doomed to a likely premature death but so are your children, In Alabama the healthiest neighborhood provided it’s denizens with a life expectancy of 88 years (an affluent suburb of Birmingham) to 63 years (an area of Montgomery that Martin Luther King marched through 50 years ago). Mobile’s neighborhoods range from a high of 81 to a low of 63.

The neighborhood with the lowest life expectancy in Mobile is not that far from my house. I treat several patients who live there. What sets the neighborhood apart? The people are poor. They work, just not at affluent jobs. One in four are uninsured. One in five report poor mental health and/or poor physical health. A baby born in this neighborhood can only expect to live to 65. A baby born in the mayor’s neighborhood? 82.

How can the mayor improve the health of this neighborhood? There are some simple fixes that could happen tomorrow. An effective bus route through the neighborhood, for example. A find a way to subsidize a source of fresh vegetables and fruits that is less than two miles away. Offer community support services at the neighborhood elementary school.

I believe that family friendly means that our children, who have not yet made any choices, have an equal chance at success. By that metric we have a ways to go by 2020/

 

Today, Mobile has set its sights beyond historic racial inequality, social inequity, and environmental disasters. Residents, local government, and community-based organizations are forging a consensus on what Mobile’s future should look like, from building an economically strong downtown to providing more easily accessible options for physical activity. Increasingly, community engagement and cross-sectoral partnerships are having a visible impact.

RWJF Culture of Health Sentinel Community Snapshot Mobile Al November 2016

I have to admit when I saw this I was a little taken aback. Tied up with the implementation of a new Electronic Health Record and planning a move to a new space, I figured I must have missed an e-mail or something. Mobile was one of 30 cities chosen by the Robert Woods Johnson Foundation from around the country. They were going to watch us as we developed “a culture of health.” I thought to myself “this is great” and “wow, what a big job.” I only hope that someone has been put in charge that is up to the task.

Because, as it turns out, a “culture of health” doesn’t just mean that we have good doctors and hospitals:

Think of social determinants as the root-causes of health and disease.

Imagine a bucket full of health. This bucket has a hole in the bottom and the health is dripping out (disease). We can mop up the floor below every hour, maybe even squeeze some of the health back into the bucket from the mop. But eventually, the health will be lost because we are not addressing the root of the problem. Instead, we can look for ways to prevent the hole and stop the leak from occurring.

And per the report we have a ways to go:

  • The median household income in Mobile is $38,644 per year, compared with $43,511 for Alabama and $53,482 for the United States (Figure 1).3 Inequality between the city’s black and white residents is striking, with black residents earning about half the median income of white ones. If you are poor you cannot afford good food, educational activities, or safe housing. These all are associated with poor health outcomes.
  • While more likely to have some college education or an associate’s degree in 2014 than they were in 2010 (Figure 2), the percentage of black residents who had a bachelor’s degree or higher in 2014 declined from 2010, despite increases in higher education among white residents. Educational attainment is always associated with better health outcomes. 
  • Teen pregnancy rates in Mobile County are 57 per 1,000 for women aged 13 to 19, compared with 47 per 1,000 in Alabama and 20 per 1,000 in the United States. Teen pregnancy is associated with a lack of knowledge regarding contraception and a lack of access to effective long acting contraceptive methods.
  • The county’s mortality outcomes are higher than the national average for preventable noncommunicable diseases, such as heart diseases, cancer, and diabetes. This reflects limited physical activity, limited opportunities for physical activity, and a very high level of obesity.
  • The city has an uninsured rate of 17%, which is more than 2% higher than the national average.

The report is very complementary of the Mayor’s “One Mobile” initiative and the Three Mile Creek park development.

Unfortunately, the community piece that was cited as most important in transforming our community was “Live Better Mobile.” From the press conference in 2012:

A “Live Better Mobile” program was unveiled today during a news conference. It’s aimed at creating public awareness focusing on three efforts – achieve healthy weights, prevent teen pregnancy, and quit tobacco.

The focus for the 37 community partners participating in the program is on prevention, nutrition and exercise.

“If we’re going to have a significant impact on health and well-being of our citizens, it’s going to take a community effort,” Dr. Bert Eichold of the Mobile County Health Department, said.

The group’s website is now dead. Their FaceBook page hasn’t been updated in a year.

So, Mobile, RWJF and the country are watching us. For the next five years they will be following the health of Mobilians. Are we up to the scrutiny? From the comments:

Talk from the fat cats is cheap. Want to encourage people in Mobile to Exercise? Give them a place to get out and exercise. Spend $70,000 on a weekly Ciclovia event. Pave that Rails-2-Trails from Prichard to Citronelle. Spend a money to construct Exercise Trails instead of spending money constructing Airbus Roads which don’t even have bicycle lanes.

 I just hope someone is in charge…

 

The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those “people” were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 “person,” in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing

In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.

The county is in a region of the state known as the “black belt”, named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the “citizens” of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama’s population. In the words of one Percy County resident

“The only reason people come to town now is for funerals, and they leave as soon as they’re over ’cause there’s nothing to do and nowhere to stay,” said Walker, 64, the son of sharecroppers

For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.

The poverty rate among [Wilcox] county’s white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county’s much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.

Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.

So why worry about these folks? Can’t they continue to vote with their feet?

“The Black Belt is a road map,” said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. “That’s what’s so tragic and so compelling. It’s an endgame depiction of what happens when you have social and structural inequalities. It’s the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities.” Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.

Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:

“Nothing happens without Medicaid,” Waits said. “It is the No. 1, the No. 2, it is the top 10 solutions.”

I’m beginning to think this is about something other than partisan politics.

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
  6. 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.

Wow. For those with a memory for these things, in 2013 Business Insider tagged us the 3rd most miserable city in 2013. At the time I pointed out

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.

8802-figure-1

[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.

Evangelical Environmental Network

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

George W. Bush. 2005

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.”

Justice Louis D. Brandeis

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.

 

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