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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.
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.
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
“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.
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.
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?
Essential to Obamacare is Medicaid Expansion – a federal government dependency program for the uninsured, which is administered by states. Since 1980, Medicaid spending has increased nationally by over 1500 percent. Here in Alabama, Medicaid takes up 35% of our General Fund. And under Obamacare, Medicaid would grow even larger – bringing millions more people to a state of dependency on government, and saddling our state and our nation – the taxpayers – with the enormous expense.
Robert Bentley, Governor, State of Alabama “State of the state” 2014
- $4.2 billion is from THE FEDERAL GOVERNMENT. We put up matching money (approximately a 1:4 match) to draw it down. For this money the General Fund is essentially a holding account. If we didn’t ask the feds for it, someone else would get it. Alabamians will not get it back in the General Fund, no matter how many hospitals close.
- This leaves $1.5 billion of Alabamian’s hard earned cash…well, not really. Hospitals, nursing homes, and pharmacies put about $900,000 of the cash they get from patient care and other activities into an account, the Alabama Medicaid Fund, so that we can show it to the feds and they match it. The money in this “provider tax” then goes back to the providers. Alabamians will not see this money in the General Fund if Medicaid goes away. These providers would need to hang on to that money to care for poor people who are uninsured.
- In actuality, Alabamians put in $650 million dollars from the General Fund for Medicaid.
This is about 10% of the non-dedicated revenues, not 33%. It pays for the health care of 1,000,000 people and brings in 10 times that amount in dollars to pay for care that would otherwise have to be given away or not happen at all. The federal government has already increased our taxes to pay for the 300,000 people who would have been covered in the expansion. We have to at least maintain the current bare-bones Medicaid program, or else give it up completely.
The Governor awoke at midnight on January 1, the first full day of Obamacare and shivered. He knew that people who did not deserve healthcare would be getting it starting now. He could hear the clock chiming the quarter hour in the mansion and suddenly felt a cool chill. “Jefferson Davis, you leave me alone” he said.
“I am not Jefferson Davis, I am the ghost of healthcare past”
“No, YOUR healthcare past. Come”
They wonder into a Birmingham that no longer exists and saw the poor in the University Hospital. The Governor pointed to them and said to the ghost “see how well they are cared for. Most could not pay for their care and yet we cared for them as if they were our own family.”
The Ghost says “If they were fortunate enough to get here, you provided care, sure. In exchange they gave you their bodies for you to practice on. Is that a good trade off? Marion Simms, one of your fellow Alabamians practiced on slaves without anesthesia so he could repair white women with anesth…”
“Hold on a minute, I thought you said this was MY past”
The Governor was silent. He saw poor people in open wards with wounds that will never heal because of poor nutrition. He saw medical students doing operations with no supervision. He saw people dying of pneumonia because they were placed on the wrong antibiotics.
“Enough. I don’t like this. I went into dermatology for a reason.”
They then wondered over to Tuscaloosa.”Hey,” said the Governor,”there’s my old practice. Never needed to take insurance and sure had no call for them gummit programs. I’d see patients for free if they needed my care”
The ghost held up a web page “This says your practice takes Medicare, Medicaid, Humana Military, and Tricare. Aren’t those “gummit” programs?”
They go to the Druid City Emergency Rooom and see a person with an obvious skin cancer who is uninsured being told that he’ll need to bring $400 to have his dermatologic surgery in Tuscaloosa or else drive to the residency clinic in Birmingham. They can tell that he doesn’t have the transportation and likely won’t go.
“Remove me,” the Governor said, “I cannot bear it.”
The ghost says “I will, but because of budget cuts I have to be the ghost of health care present as well.”
“I ran across a copy of “Putting Alabama Back to Work” and we think you should be reminded of what you said you would accomplish in regards to health care as Governor in 2009 (before Obamacare was passed):
- Encourage health savings accounts – present in ObamaCare
- Reject ultraliberal single payer – again, ObamaCare
- Prohibit any person from being compelled to participate in any health care system – Obamacare
- Portability of insurance across state lines – could work with ObamaCare, understand Blue Cross of Alabama had a little something to say about that.
- Tort Reform – with the entire legislature Republican you should be able to do that. What’s the hold up?
- Change Medicaid awards so that those states with more poor people get more Medicaid – Didn’t Obama try to do that for you?
- Establish state run exchanges – uh, this is getting kind of redundant
- Tax relief for individuals who own their own insurance plan – ok, now this is getting scary
- Electronic medical record support
- More primary care physicians”
“What can I say, I was a very forward thinking candidate”
The Governor goes back into his room and waits. Another cold chill hit him. An apparition enters.”Now, YOU’RE Jefferson Davis’ ghost”
“No. I am the ghost of healthcare future. I could show you a bleak world where people who make over $3000 but less than $30,000 a year are denied healthcare and left in counties devoid of health professionals to sicken and die, but I won’t. I am going to assume you meant it when you said you were a forward thinking individual and made those promises and you just let things get away these last three years. Let’s see what the future can hold…”
They fly over to the Department of Public Health and Medicaid Transformation and things are hopping. The director is excited at the new world of data. They overhear him say
“We measure the right thing over time, reassess and trend what we are measuring, and bring the measurements to the attention of the governor and the legislature every chance we get. If it is easy to measure, we measure it a lot. We have counties in Alabama where infant mortality rivals Zimbabwe. These numbers used to be hidden in a report on page 133. We are making them a part of the policy conversation. We have the opportunity to decide if we want to be better or not.”
They then go into another office in the same building where they see folks looking to other states and even other countries for solutions. Why? They hear
“Don Berwick said we “Yanks” have ignored lessons from other countries. Paul Grundy of the Patient Centered Primary Care Collaborative has been going about singing the praises of Denmark (and it is a compelling story) but we’ve discovered that even in countries with universal access, disparities exist. In England, for example, income predicts poor health outcomes nearly as well as it does in Alabama. We need to look for answers outside the box.”
They then move down the cramped hall to the newly established Office of Patient Engagement (thought to be important in reducing peoples “risk factors” such as obesity and lack of exercise.” The director is already letting her staff know that the Office is obsolete
“We need to move beyond patient engagement. This is a term that implies a lone patient overcoming adversity to move singlehandedly into better health. Let’s acknowledge that “It takes a village.” The lesson of Portland and other communities is that healthy people lead to more healthy people. The lessons of McAllen TX and Grand Junction CO is that the right doctors can keep patients from iotrogenic harm and the wrong doctors, well, the opposite is true as well. The community needs to be healthy together…”
The Governor awakens and looks out the window. The camellias are in bloom. He looks over towards the hospital. The doors seem to be still open. He calls out to his aide “What year is this?”
“2014” the aide yells back.
“Still the law”
He calls the Health Officer:
“Don, the good news about being way behind is you don’t have to repeat the last 20 years. Did you know that a healthy woman, let’s call her Ms Cratchit, with a car who lives in rural Alabama has a less than 1/100,000 chance of dying in childbirth in 2014 and her baby Tim has a chance of dying of much less than 1/1000. Did you know that Ms Cratchit with diabetes and no car, has a personal risk of death about twice that of her non-diabetic self. Tim has about a 1/100 chance of death. This needs to be changed.
“But Governor,” Don says, “about 50% of Alabama counties offer no provision for care delivery for pregnant women. What can we do?”
Don, what we KNOW is that access to contraception and pregnancy delay until the medical problems are controlled improves outcomes dramatically. What we suspect is that effective transportation is much more important that a poorly prepared health care provider with no ability to provide pregnancy care. What we need to find out is how to leverage technology, realign incentives, or utilize non-licensed providers to improve outcomes further. We need to focus our improvement methods ON A COMMUNITY SCALE to improve measurable outcomes.”
…and it was always said of him, that he knew how to use ObamaCare well, if any governor alive possessed the knowledge. May that be truly said of us, and all of us! And so, as Tiny Tim observed, God Bless Us, Every One!