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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!

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'I hate it when people vote with their feet'

‘I hate it when people vote with their feet’

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.

 

 

From al.com, italicized  comments mine:

Lawmakers appropriated $700 million from the General Fund for Medicaid next year, $85 million short of the governor’s request.

From an Urban Institute paper about Alabama published in 2004:

An overarching issue is the defeat of the tax reform proposal, which implies that the vast majority of Alabamians prefer lower taxes to improved government services or possibly even maintenance of the current level of services.

In other words, we have been crying wolf for a long time and have always found a work-around. This crisis has been precipitated by past loans from other accounts, one-time payments such as the BP settlement, and other work-arounds coming due and not by Obamacare. 

 

But for the first time they said one option could be to eliminate prescription drug coverage for adults, which would save an estimated $50 million to $60 million in state dollars.

“If we have to live within our means, then we have to make some very tough decisions,” the governor said.

The estimated savings on the prescription program do not take into account increased medical costs that would result from people not getting their medicines.

Wow! Words fail me…

Azar also said Medicaid would not be able to proceed with the plan to begin providing managed care through regional organizations, a move intended to slow the growth in costs and improve health outcomes.

“Together with the Alabama Legislature, we have made significant progress in the way the Alabama Medicaid Agency operates, making it more effective and efficient,” Governor Robert Bentley said. (February 9, 2016)

What a difference a month makes!

The Centers for Medicare and Medicaid Services earlier this year approved a waiver to allow the change and could provide up to $747 million over five years to help with the transition.

Elimination of prescription coverage was one of 10 areas of potential savings mentioned by Bentley and Azar today.

Various combinations of the cuts could be considered and would have to be approved by the Centers for Medicare and Medicaid Services.

Another savings option Azar listed would be for Medicaid to consider a pharmacy preferred provider. That would save an estimated $19 million to $30 million in state dollars.

But would eliminate money we use for matching, I suspect, thus multiplying the  reduction of services

Other programs mentioned, and the estimated savings in state dollars:

— Eliminate eyeglasses for adults: $300,000 – Probably will limit employment opportunities

— Eliminate outpatient dialysis: $3.7 million – 500 people dead or sitting in the ED waiting to get close enough to death they quality for emergency dialysis

— Eliminate prosthetics and orthotics; $500,000 – Hard to work without a leg

— Eliminate Program of All Inclusive Care for the Elderly (PACE): $2 million – putting 150 people into nursing homes, resulting in a net cost to Alabama

— Eliminate Health Home and Physician case management fee: $16.6 million – Adding even more people to the nursing home

— Eliminate primary care bump (pays doctors at Medicare levels): $14.7 million – Reducing the docs taking Medicaid

— Reduce administrative costs: $3.5 million – Reducing efforts to reduce waste,, fraud, and abuse I suspect

— Reduce reimbursement rates for ambulatory surgical centers, doctors, dentists, optometry, hearing and other programs: Zero to $50 million. – Reducing access for these programs and furthering the reputation of Alabama as home of the halt, lame, blind, and toothless.

Please call your state Senator or Rep if you live in Alabama and demand that they revisit the Medicaid budget. Please retweet this under #CanYouHearUsNowAl and #alpolitics

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“Unless there is a public outcry, I don’t see any changes.”

Alabama Senate President Pro Tem Del Marsh on passing a Medicaid budget that reduced payments to physicians, hospitals, and would end all “optional services” including home health programs, hospice, outpatient dialysis, adult eyeglasses and PACE, a program to help some elderly people avoid having to be admitted to nursing homes

How do you create a public outcry? That is the question for the 500 dialysis patients who rely on dialysis to continue living.

Dialysis is a funny thing. When Medicare and Medicaid were established in 1965, renal replacement therapy (known by lay folks as dialysis) was known to save lives. People who had lost kidney function from diabetes, polycystic disease, or some other malady, unless they were fortunate enough to be a part of an experimental protocol, would die from a build-up of toxins in their body. If they were enrolled in a protocol or had the good fortune of living near a place that was experimenting with renal replacement therapy, they would live.

In the late 1960’s, a report came out that identified renal replacement therapy as established as opposed to experimental. In addition, because of the “experiments” funded through Medicare, the number of people on dialysis increased by a factor of 10 (from 1,000 to 10,000) and the number of physicians performing dialysis increased dramatically. This set the stage for the hearings in the 1970 where this testimony was heard:

I am 43 years old, married for 20 years, with two children ages 14 and 10. I was a salesman until a couple of months ago until it became necessary for me to supplement my income to pay for the dialysis supplies. I tried to sell a non-competitive line, was found out,and was fired. Gentlemen, what should I do? End it all and die? Sell my house for which I worked so hard, and go on welfare? Should I go into the hospital under my hospitalization policy, then I cannot work? Please tell me. If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up? (U.S. Congress, House, Committee on Ways and Means, 1971b)

Following this, the house and the senate passed and President Nixon signed a bill creating a dialysis benefit for those eligible for Medicare.

Fast forward to today. In America we have 400,000 people on dialysis. They have to have their blood cleansed 3 times a week. If they do, they can live a relatively normal life. If they don’t, they can develop shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia) and when it gets bad enough that they’re deemed to be near death, they  are given dialysis via the emergency room.

Most people on routine dialysis have it paid for by Medicare. Who gets it on the federal nickel? To quote CMS, these folks are eligible:

  • You’ve worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee.
  • You’re already getting or are eligible for Social Security or Railroad Retirement benefits.
  • You’re the spouse or dependent child of a person who meets either of the requirements listed above.

If you don’t meet these criteria, and require renal replacement therapy, you pay cash (between $52,000 and $73,000 per year), obtain coverage from Medicaid, wait in a state of anticipation until you need emergent dialysis (costing about $300,000 a year as a strategy), or die.

Alabama would be the first state to take it away from ALL Medicaid recipients. Texas does not pay through Medicaid but instead pays through a separate fund.  They were able to take away dialysis from undocumented folks. Because of the pesky EMTALA laws passed by President Reagan, hospitals are required to provide EMERGENCY treatment. The consequence?  A bunch of folks who hang out at the hospital every day getting their blood drawn to see if they win the emergency dialysis lottery.

So, back to my original question. You see, Alabama is $100 million short on their Medicaid budget. On a budget of about $6 billion, that would seem like a small number.  Alabama legislators, though, are ready to make a stand. The 500 Alabama citizens on dialysis will either die or spend the rest of their days hanging out next to the emergency room so that we can prove the value of “low taxes”  unless there is a “public outcry.” How do you stop folks entrusted with the health and welfare of the citizens of Alabama if they are able to murder 500 people to prove a point? I can’t figure it out.

 

Person at a cocktail party to me: Do you think the Governor will expand Medicaid

Me to the person: If the past is prelude I think he will consider it for another two years then let the next governor decide, thus allowing many more people to be killed by lack of access to health care in Alabama then will ever be killed by terrorists in Alabama.

The Governor couldn’t decide what to do about Obamacare and poor people so he appointed a task force. His call made it pretty clear that, although Obamacare wasn’t the answer, there were indeed questions that needed to be answered. In the “Whereas” section, for example:

  • Shortages of healthcare professionals in 65 of 67 counties
  • 40th out of 50 states in primary care physicians
  • 594.000 working people between the ages of 50 and 64 wihtout health insurance
  • 10 hospitals closed in the past 3 years
  • etc, etc, etc

The task force met off and on for about 6 months and had one recommendation:

  • Find a way to close coverage gap that makes health insurance inaccessible to hundreds of thousands of Alabamians.

They didn’t specifically say “the medicaid expansion as written into the Affordable Care Act (Obamacare) will solve 90% of the “Whereas”s” but they, by recommending this one thing, got awfully close.

The Alabama TEA Party response was posted on-line last week. Consistent with the national talking points, it goes something like:

We Alabamians pay enough taxes and would rather keep people with mental illness in jails, have hospitals go under, and allow people to avoid health care and die of treatable illnesses because of fear of bankruptcy rather than pay an extra $10 a year per person in taxes because we are TAXED ENOUGH ALREADY.

Fittingly, on the TEA party editorial page was an advertisement for Farxiga. which made the list of Huff Po’s worst drugs of 2014:

But the more frightening news is that patients taking Farxiga in studies done for the FDA were more than five times more likely to contract bladder cancer than the patients who took an older diabetes drug.

Priced at only $10 a day and advertised as first line treatment, I am sure it’ll end up in many physician’s sample closets. Uninsured patients with diabetes, then, who are unable to afford insulin (which is surprisingly expensive) will get lots of Farxiga samples. With any luck, they will contract bladder cancer. Because they are lucky enough to get cancer, assuming the blood in their urine scares them enough to seek care AND assuming they can find a urologist who will scope them on credit, become Medicaid eligible in Alabama. Then they can get insulin for their diabetes and get their bladder cancer treated. Don’t know why the task force didn’t recommend this, instead.

david-sipress-are-we-there-yet-new-yorker-cartoon (1)

When I was growing up my sisters and I would play the “Are we there yet” game. For those of you who do not indulge, this game is played by getting in the car, allowing the adults to begin the journey, then about 5 minutes into the ride begin asking “are we there yet?” in a rapid fire fashion using the most annoying voice one can muster. The adult’s role is to sit and ignore the game as long as possible and, when the time is right (generally about 5 minutes in) turn to the back and say “WE ARE HALFWAY, NOW SHUT UP.” At that point, the game is over and, in my family car, generally transitioned to the pinching game (“Allen is pinching me”).

Our Governor’s journey through the changing healthcare landscape has been evolving. In 2010, while campaigning for Governor, he had some deeply held beliefs regarding the newly passed Obamacare:

I started laying the groundwork for Alabama’s rejection of Obamacare by pre-filing a Constitutional Amendment to prohibit any person, employer, or health care provider from being compelled to participate in any health care system. It also codifies Alabama’s 10th Amendment rights over this issue. I have real-world solutions that will result in affordable and accessible health care for all without bankrupting our nation or pushing us closer toward a government-controlled, single-payer system.

The Supreme Court decreed the Medicaid expansion part of ObamaCare to be coercive in 2013 (As an aside, for it not to have been coercive it would have had to meet the following criteria (1) related to the general welfare, (2) stated unambiguously, (3) clearly related to the program’s purpose, and (4) not otherwise unconstitutional.) 26 states elected not to take the expansion, preferring to stick with the (poorly funded, focused on wasteful inefficient care delivery) old program. Our Governor announced that we would be one of the states refusing the Medicaid expansion:

The Affordable Care Act–or ObamaCare–and Medicaid expansion is taking our nation deeper into the abyss of debt, and threatens to dismantle what I believe is one of the most trusted relationships, that of doctors and their patients. Essential to ObamaCare is Medicaid expansion–a federal government dependency program for the uninsured. …

Now they are telling us we’ll get free money to expand Medicaid. Those are your hard-earned tax dollars. Our great nation is $17.2 trillion in debt and it increases by $2 billion every single day. That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.

The good news is that his view continues to evolve. Over the objection of our state senators, he is now ready to accept Medicaid expansion IF there is a work requirement, along with a few other conditions:

“It would have to be in the private sector and there would have to be some requirements on it,” Bentley told reporters in December. One specific requirement he mentioned was that he’d like to see the system tied to employment. “(Recipients) need to be working on getting a job, or having a job.”

A couple of things, Governor, to consider before you start playing the pinching game with Senator Pittman. 72 percent of uninsured adults who are eligible for Medicaid coverage live in a family with at least one full-time or part-time worker. More than half (57 percent) of these adults are working full- or part-time themselves. The overwhelming majority of workers earning less than 138 percent of poverty—81 percent—don’t have coverage through their employer because their employer either doesn’t offer it or it is unaffordable to them.The Kaiser Family Foundation recently looked at the main reasons for not working among unemployed, uninsured adults likely to gain Medicaid coverage if their state adopted the Medicaid expansion. It found that 29 percent were taking care of a family member, 20 percent were looking for work, 18 percent were in school, 17 percent were ill or disabled, and 10 percent were retired.

Maybe we really are halfway there.

“…the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped. “ ~ Last Speech of Hubert H. Humphrey

When people think of Qbamacare, they think of the insurance aspect. A lot of the law, however, was  designed to deal with a health care system in crisis. No aspect of our healthcare system was more in crisis than the care of our seriously mentally ill. One reason is a lack of private insurance (many folks with serious mental illness can’t hold down steady jobs, which is how America distributes its private health care dollars). Secondly, if these folks had coverage it tended to be Medicaid, and Medicaid is known to be a poor payer, so poor that many general med-surg hospitals closed their in-patient psychiatric units in an effort to limit their “exposure.” Thirdly, through a quirk in the Medicaid enabling legislation, freestanding psychiatric hospitals were not allowed to bill Medicaid for services even if the folks were admitted to their hospital. (50 years ago, state and local hospitals provided such care, and Congress did not want to shift that expense to a federal program.)

The Obamacare act was designed to right many wrongs, and included was a effort to fix this problem. In a section called the Medicaid Emergence Funding Demonstration Act, it provided funding to freestanding psychiatric hospitals to:

provide $75 million to the new demonstration to determine whether it will improve access to psychiatric treatment, lower costs, and reduce crowding in general hospital emergency departments (EDs). At the end of the 3-year trial period, the CMS will make recommendations to the US Congress about the feasibility of offering the program nationwide.

Alabama applied for and received funding to do just this and the community mental health center in Mobile (Alta Pointe) took the money and opened many more beds to help relieve the congestion. The next thing that happened following the demonstration in Alabama? The slicing of the state mental health budget by 25% and the closing of acute crisis beds at several state hospitals. Thanks Obama!

The difference between Obamacare and other programs was the inclusion of evaluation and outcome measures in these pilots. This particular program is being looked at and so far has been found wanting.

So what’s the status? CMS reported on MEPD progress at the end of one year in a mandated report to Congress (see CMS Report To Congress On The Evaluation Of The Medicaid Emergency Psychiatric Demonstration). CMS’ endorsement was tepid – it stated it did not have enough data to recommend expanding the demonstration, but that it supported allowing the demonstration to continue through the end of its authorization in 2015.

At a year, though overall hospital costs were down, length of stay was the same, as was the rate of discharge to the home environment. In other words, the care by the measures agreed upon was the same. Anecdotally, though many benefited, in Alabama care delivery was not improved. In the words of a spokesperson from the Alabama Hospital Association:

“Most of the hospitals feel that the number of patients in departments continues to increase and the length of time it takes to get people into beds is increasing,” Blackmon said.

The national evaluators apparently felt that there were more comprehensive ways to provide care, so this program will likely not be reported favorably to congress and will end.

Which brings us to yesterday’s news story. Alta Pointe, which opened a hospital in response and is now the effective state facility of the seriously mental ill in Alabama (though with little state money), has been using this “demonstration” funding to provide services previously paid for by the state. Now that the demonstration is going away, they will likely close their 100 beds, leaving only 34 crisis beds for approximately 2,000,000 people. Congress has an opportunity to pass a stand alone to continue the program but, given the outcome and the mood in congress, this is unlikely. Alabama has the opportunity to replace the money with state dollars. Given that they are looking to cut half a billion from existing programs and didn’t budget for this expense, not likely either. Don’t think the citizens of lower Alabama are in the mood to pony up an extra $2,000,000 annually in donations, either.

In the words of one al.com commenter:

Let’s look for Al.com’s isolated sob stories to make our hearts heavy and give in to another tax hike. Nonsense. Cut the programs. Cut the departments. Cut the government in half.

So what will happen? Fortunately, space under the bridges is available and serves the dual purpose of allowing the non-afflicted to get to where they want to go. If it gets too cold, those with serious mental illness can commit crimes. Alabamians are always willing to pay for jail cells..

King

One of the advantages of living in Alabama (state motto: “We dare to defend our rights” which sounds much less like an angry, red faced person yelling when translated into Latin: Audemus jura nostra defendere) is that others are always more than happy to come here and help us defend our rights. The most recent came in the form of a “essay” from a rights defender in the Arkansas legislature (%uninsured before Obamacare 22%, % after 12%). Senator Bryan King (with help form the Alabama Policy Institute) examined Arkansas’ efforts and has issued a strong warning to us Alabamians. He dared us, at least as much as he could on al.com, to defend our rights. In his assessment, Arkansas did not do so with the following consequences:

1) Arkansas’ leadership was misled into thinking that they were being allowed through waivers to do something state-based, flexible, or innovative, which was, in Senator King’s eyes, untrue. He provides some examples of innovative things Arkansas was not allowed to do. They were not able to make healthcare access a privilege that came only through hard work, for example. They were unable to place burdensome restrictions on Medicaid recipients to force them to chose between medication and food. They were not allowed to arbitrarily identify certain segments of the population as unworthy of health care and deny it to them. This alone—not being able to deny the unworthy access to healthcare—is reason enough to defend our rights.

2) Arkansans are now dis-incented to work. Senator King points out that many Arkansans are sitting around sucking up free health care because if they make over 133 of poverty they will have to pay “thousands” for healthcare (Senator King must not have read the guidelines for premium assistance and cost sharing under ACA, which provides health care very inexpensively to the working poor). Better to spend time in the doctor’s office, I suppose. Keeping those deadbeats out of my office and into a low-paying job with no health coverage is something we should certainly want to continue as a state.

3) We are threatening Arkansas’ safety net for the truly needy. This argument goes something like the way lifeboats are filled on a sinking ship: the Medicaid net is mighty frail, and if more childless adults are added, it will break and all the women and children will fall into the ocean, um, that is, the uninsured void. As Arkansas now manages to get only half of her children vaccinated, the safety net their may actually already be a little frayed. But, none the less, we should aspire to be better (worse?) than Arkansas and decline the expansion. No sense in keeping folks HPV-negative for free, is there?

4) Arkansas opted to not go with the traditional expansion, which cost them more money. This is, per Senator King, is a reason not to expand at all. If we can’t go in a Cadillac, let’s not go at all.

5) Provision of healthcare to the poor already costs states a lot of money (the Senator points out that it is 35% of Alabama’s general fund, not pointing out that the bulk of that money is a provider’s tax that would not be collected if not for Medicaid). Per the Senator, this is a deal breaker.

Governor Bentley has recently appointed a “task force” to identify ways “real ways to make health care accessible and affordable to everyone while also combating the shortage of primary care physicians in 65 or the state’s 67 counties.” I suspect this article was targeted at the members of the task force. Expanding Medicaid would be an important tool to accomplish the governor’s charge. In addition, it would bring 30,700 jobs into the state, shore up the rural (and urban) hospitals, and provide currently uninsured citizens citizens access via the same provider network current Medicaid recipients receive care. Our 15% uninsurance rate post-Obamacare would be reduced to about 7% if we were to accept the expansion. Yeah, but you say, where does that money come from? Obamacare, as expertly explained by Dr David Bronner, takes the money states were already getting to take care of their poor (disproportionate share funds) and moves it into the Medicaid expansion program. If you don’t take the expansion, you no longer get those funds. In our case, the $14 million/year that used to come to us is going somewhere else.

Fittingly, the state motto was taken from  the poem “What constitutes a State?” written about the Gordon Riots in England. Adopted by Alabama in 1939, the rest of the line is as follows:

Men, who their duties know,

But know their rights, and, knowing, dare maintain,

Prevent the long-aimed blow,

And crush the tyrant while they rend the chain:

Wonder in this case, if our elected officials choose to deny Alabamians access to healthcare, who the tyrant is?

 

 

2645472-moon1“To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications.”

—Louis Pasteur

Henry “Moon” Mullins was the founding chair of the department of which I am now the Chairman. He trained at Tulane (as did I) and was in private practice for about 20 years in Fairhope Alabama when he got a call from Fred Whiddon, the founding President of the University of South Alabama. Dr Whiddon wanted to see if he would consider leaving his practice to create a Department of Family Medicine in Mobile, which he did. When I met him, in 1991, he was in 64 and had just completed a sabbatical studying medical infomatics at the National Library of Medicine. As a resident and later as junior faculty, I would have long discussions with Moon about how to get  “docs” to practice based on best practices rather than using techniques and information obtained during training (regardless of how many years ago) or for better or worse, from pharmaceutical reps.

In that discussion, we would often mention the problem of diffusion. From an article in 2006:

Studies of dissemination of evidence-based guidelines (aka, consensus statements) suggest that awareness varies widely across medical subspecialty, with awareness ranging from as low as 20% among cardiac surgeons to 90% to 95% among obstetricians.17 The dissemination gap for clinical research also has a time component. A review suggested that it took an average of 17 years for 14% of original (i.e., discovery) research to be integrated into physician practice.

17 years seemed to me like a very long time. Why so long? Many people my age have stained teeth from tetracycline, a miracle antibiotic that was introduced in the 1960s. For that antibiotic, it wasn’t 17 years but 17 months before 90% of physicians were using it. The combination of its remarkable effectiveness and peer pressure from early adopter colleagues was enough to overcome physician inertia. Many discoveries though, such as the life saving effect of beta-blockers for a year following a heart attack, are not given to all eligible patients even today, more than 20 years after the data was definitive.

Today, appropriate beta blocker use varies regionally from 68% to 92%. What is surprising is the factor that predicts the best who will get the appropriate medication: Tractor use in 1940.

The introduction of hybrid corn in the 1930s and the introduction of tractors in farming was not via a disruptive innovation model. The first states to have over 10% of farmers planting high yield corn and using tractors? Illinois and Iowa in 1935. The last states (1948)? Alabama and Georgia. Being a “late adopter” state for these technologies correlates strongly with being a late adopter for the use of beta-blockers after a heart attack. For example, Alabama was last to adopt tractors and to adopt beta blockers.

What set apart the early adopters? One of the factors is having folks (farmers and doctors) talk to each other in informal settings. We late adopters need to pay more attention to having quality information exchange among health professionals. Another is that, educationally, a rising tide floats all boats. A better educated populace demands better care. Lastly, innovation likely didn’t occur because it was more profitable to wait. Second-mover advantage, risk aversion, and uncertainty are powerful de-motivators. We need to change the incentives such that physician are paid to do the right thing.

Moon is now 86 and calls the department every now and again to check on us. As a department, we continue to work on ways to encourage physicians in Alabama to “do the right thing”  and overcome our historic tractor disadvantage.

Thanks, Moon, for starting us on this journey.

1_123125_123050_2279896_2300573_2302170_3_lineup.jpg.CROP.original-originalDoes the money to pay for this come from taxpayers held at gunpoint?

Comment on a forum about an upcoming meeting on the need for Medicaid expansion

Long answer: I am serving on a panel in Fairhope, Alabama to discuss the need for Alabama to accept the Medicaid expansion. Fairhope is a Victorian resort town on the bluff overlooking the Eastern Shore of Mobile Bay, about 30 miles from where I live. The town itself was first known as Alabama City but a group pf 28 folks from Des Moines, Iowa, purchased land in the area in 1894 and created a single tax colony:

The people who established Fairhope wanted to create a community that would, as best they could, implement the theories of economist and social activist Henry George. George wanted government to tax the full rental value of land, the value of which is created by community improvements and not by labor or invested capital. He felt that if the full rental value of land were taxed (including minerals under the land) that all other taxes could be abolished, thus becoming the single tax. Others termed his theories the Single Tax, and the name stuck.

The single tax corporation collects all taxes associated with property due to state and local governments and distributes them as well as administration and demonstration fees. These fees go to things that raise the value of the property for all. These projects include bayfront parks, a pier that goes a quarter mile out into the bay, the library, and many others. The Fairhopeans do indeed get value for their housing dollar. They also get waterfront parks.

The state share of Medicaid in Alabama is not paid for by a tax on property. In fact, very little of the tax dollars the state actually collects are used to pay for healthcare for the poor, as I have previously outlined. Though the people of Fairhope may want further the common good, averages Alabamian seems much more concerned about keeping their hard-earned in their own pocket. As such, they are seemingly willing to forgo 30,000 jobs and hundreds of millions of dollars of federal money to keep their own, personal, income taxes from going to someone who is undeserving. In the words of one commenter “Why should I work anymore if the government will give me everything I need?”

So, I will go and spread the word to the gentle socialists of Fairhope of the reality that corporations look for good community health when they relocate, along with the concern that, since the mechanism to fund poor people who become sick has changed, we are getting LESS federal dollars as a consequence. I feel certain that those in the room who are true Fairhopeans will see the need for them to look after their brother and, given that the federal dollars going into Medicaid ARE OURS ANYWAY, will nod their heads in agreement. I despair of convincing the people of the rest of Alabama that poor people are folks who get sick anyway, need care to prevent illness, and Medicaid is the only mechanism to provide that care. I can only hope they remember the wisdom of the Fram oil filter man, “You can pay me now, or, you can pay me later.”

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