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From the Montgomery Advertiser:

MONTGOMERY — Gov. Robert Bentley said Thursday after a speech at a legal conference that his administration is considering expansion of Alabama’s Medicaid program, but has not made a final decision.

Bentley said he was concerned about the health care access for the state’s working poor and rural health care infrastructure.

However, Bentley said a stumbling block is figuring out a way to fund the state’s share of costs.

Thirty states have expanded Medicaid under President Obama’s health care law.

The governor has previously said he might support a state-designed program with work and premium requirements on recipients.

Remind the governor that the state needs this and that states that have expanded have seen increased tax revenue and lower costs of care for their citizens.

From Kaiser Family Foundation

If all states accepted the expansion:

  • The number of nonelderly people enrolled in Medicaid would increase by nearly 7 million, or 40 percent.
  • 4.3 million fewer people would be uninsured.
  • There would be $472 billion more federal Medicaid spending from 2015 to 2024.
  • States would spend $38 billion more on Medicaid from 2015 to 2024.
  • Savings on reduced uncompensated care would offset between 13 and 25 percent of that additional state spending.
  • States would be able to realize other types of budgetary savings if they expanded Medicaid that are not included in this report.

Remind the governor that a major cause of bankruptcy is unpaid medical bills from catastrophic illnesses and Medicaid protects people from this and in general people with Medicaid get better quicker.

From Urban Institute

Why insurance is important for folks:

Uninsured people receive less medical care and less timely care, they have worse health outcomes, and lack of insurance is a fiscal burden for them and their families. Moreover, the benefits of expanding coverage outweigh the costs for added services. Safety-net care from hospitals and clinics improves access to care but does not fully substitute for health insurance.

And let the governor know that despite the beliefs of our delegation, “repeal and replace” is not an option in Congress so let’s work with what we can get:

From The Hill

Repealing the Medicaid expansion is a dicey proposition for endangered Senate incumbents running in four states: Illinois, Ohio, New Hampshire and Pennsylvania, all of which broadened Medicaid.

Another Senate Republican, speaking on condition of anonymity, expressed concern that states that expanded Medicaid would be penalized by billions of dollars if Congress repealed the federal assistance.

“Repealing the Medicaid expansion is not going to be in there because it’s too problematic for many Republicans,” said the lawmaker, adding, “I don’t want to stick the state with the bill.”

Here is the governor’s contact information. Let him know what you think.


Me (while in the military): Well, why can’t we do it this way. This person is malingering and really needs to be “not in the Marines.”

My superior: You really don’t want to. This person might be a screw-up but he is well connected and you really don’t want to start a “congressional.”

In Hawaii, where I was stationed, we lived in fear of “congressionals.” Some enlisted person or another would get what he or she perceived as bad care and before you new it, a letter from a congressperson’s staffer would appear on the commanding officer’s desk.

Dear Captain (blank),

This is to inform you that one of our constituents feels that the care they received  was substandard. Please provide in writing the circumstances surrounding this incident. 


Congressman Foghorn Leghorn

This letter would initiate a chain of events that resulted in all productive activity stopping until all of the minute details could be compiled into a mountain of paperwork and sent “up the chain.” The reality was that the Congresspeople probably could care less about what actually happened but, being the representative of the people, wanted to respond (or be seen as responding) to their constituent. The actual effect was to keep us from doing what we were being paid to do, provide quality care to the troops, and instead focus on the distraction.

This past week our Congressman, Bradley Byrne, responded to what he perceived his constituents wanted. He voted aye on a blank check for congress to “investigate” Planned Parenthood’s role in, I don’t know, having a disturbing lunch conversation regarding embryonic tissue donation. (If you want an in-depth discussion on the ethics of the use of cells in scientific discovery, a good source is this book.)

The investigation, though, seems not to be investigating the use of embryonic tissue in medical advances (think rubella and varicella vaccine) but, very specifically:

Requires the Panel to investigate and report on:

  • medical procedures and business practices used by entities involved in fetal tissue procurement;
  • any other relevant matters with respect to such procurement;
  • federal funding and support for abortion providers;
  • the practices of providers of second and third trimester abortions, including partial birth abortion and procedures that may lead to a child born alive as a result of an attempted abortion;
  • medical procedures for the care of a child born alive as a result of an attempted abortion; and
  • any changes in law or regulation necessary resulting from such findings

Congressman Byrne, please don’t let them turn this into an expensive distraction. Let’s investigate how to make it REALLY difficult for these entities to procure fetal tissue by making pregnancy termination rare. I would ask that Congress use the  “any other relevant matter” clause to investigate the real causes of our abortion crisis and these should include:

  1. In states that have not expanded Medicaid, working parents are only eligible for Medicaid if their incomes are below 61 percent of the poverty line (about $11,900 for a family of three), and jobless parents must have incomes below 37 percent of the poverty line (about $7,200 a year for a family of three). In most states, Medicaid coverage is not available at all to adults without children. This large group of people does not have easy access to long-term effective contraception and thus is more likely to have an unwanted pregnancy and seek out pregnancy termination. How are these states responding to the challenge?
  2. Health coverage during the period before pregnancy allows women to receive preventive care like regular doctor visits, birth control, information about making healthy food choices, tobacco cessation programs, and substance abuse services that decreases their own health risks and makes it more likely that their babies will be born healthy if and when they become pregnant. For example, research shows that prenatal care for high-risk pregnant women reduces the incidence of costly premature births. In states that have not expanded coverage. these people only seek care after they become aware of their pregnancy and make a conscious decision to go to the doctor’s office. They are more likely to have a fetus with a problem and seek out termination. What are we doing to provide access to women prior to conception in the states that have not accepted expansion?
  3. By accepting the Medicaid expansion and eliminating gaps in coverage, the state administrative costs are reduced because the states  no longer have to process enrollment and disenrollment for women who move on and off Medicaid coverage based on pregnancy, thus reducing the size of government and saving the state needed tax revenue that could be returned to the taxpayers. In those states not accepting the expansion, how are they justifying this needless expansion of bureaucracy?

I expect my response soon.

Signed, your constituent and a taxpayer.

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.


Is it society’s duty to ensure equitable access in healthcare?

Question posed to my students in a health policy course

In his book “The Healing of America,” T.R. Reid identifies four distinct methods of (paying people who are) providing healthcare to the citizens of a country. Some countries follow the model of England and collect money form all citizens, mostly via taxes, and use that money to pay for needed care. It is also referred to as  the Beveridge model, after Lord Beveridge, who wrote a report in the war years identifying disease as one of the five “Giant Evils” and recommended state action to combat this and other evils. In this model everyone is entitled. The second was the German model which mandates participation in private insurance. This is also referred to as the Bismark model, after Otto von Bismark, the Prussian chancellor who determined that universal healthcare could be a force in the fight for a unified Germany.  In this model, everyone is mandated to participate. The third is the Canadian model, which taxes citizens to pay for care but allows health care entities to be private contractors. In this model, budgets are set at a regional level and as a consequence some artificial shortages are created. In this model, everyone is treated equitably within the system.  Lastly is the “out-of-pocket” model. In this model, prevalent in developing countries, care is rationed based on ability to pay. In this model, no money=no access.

As T.R. Reid explained in his book and my class identified as America’s unifying model, we use an “all of the above” approach. For those over 65, active duty military, eligible veterans, and native Americans we apply the Beveridge model. Once Americans are in one of these groups, it IS society’s responsibility to provide equitable access in healthcare (well, sort of. Physicians can “opt-out” but for the most part, this is true). For those who work at jobs in larger businesses, we tend to apply the Bismark model (and Obamacare reinforces this). The employers are given a significant subsidy to provide health insurance and most Americans (before 2010, 66%) pay through healthcare via this mechanism. For some of the poor (mostly children and pregnant women but some with chronic illness) and military dependents we apply the Canadian model (how Medicaid and Tricare work, for the most part). For everyone else, we apply the pay- out-of-pocket-or-die-or-go-to-jail model. Obamacare attempted to move the last three groups into an amalgam of Beveridge (poor) and Bismark (everyone else) model.

Turns out the sticking point is the question I asked my students. Unlike my students, who had about a 70-30 split that it was a society and thus government problem, the American public thinks differently. Only 42% of Americans feel a responsibility for their fellow American’s access to healthcare. This increases as people get older peaking with of those who are 65 and older. 53% of these  believe that government should not be providing their health care. The majority of folks opposing the law, in all fairness, despite this believe it is the responsibility of our elected officials to make the existing law (be it via Bismark, Beveridge, Canada, or other) work.

The New England Journal of Medicine has published two essays on this topic this week. The first, out of Kentucky, discusses the benefits to patients living in a poor state that has elected to avail itself of the improvements in access offered by the Affordable Care Act. The author, who had previously written of access problems, says it this way:

But during the past year, many of my lowest-income patients have, for the first time as adults, been able to seek nonurgent medical attention. I recently evaluated a 54-year-old man with hyperlipidemia and a systolic blood pressure of 190 mm Hg whose last physician visit had been with a pediatrician. Before he enrolled in Medicaid, he would have been unable to pay for his appointment and laboratory work, and I wouldn’t have considered offering him a screening colonoscopy since he would surely have been billed for it. Newly insured, however, he was able to afford the tests and medications that most Americans would expect to receive, and he told me he felt proud to have witnessed a sea change in health care delivery in Kentucky and that recent reforms seemed “just.”

On the other side of the discussion is South Carolina, an equally poor state that has elected not to avail itself of the benefits afforded via implementation of  Obama-care. The author speaks of the many attempts to influence policy makers into accepting access for South Carolina’s poorest citizens. This culminated in a series of arrests following peaceful protests on the capitol steps. In his words, he had to act because

When I graduated from medical school in 1979, we did not take an oath, but I have since striven to adopt the words of Moses Maimonides as my guiding philosophy: “The eternal providence has appointed me to watch over the life and health of Thy creatures” and “Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend.” My interpretation of this prayer is that I need not only be a good clinician in the hospital or clinic but also attend to the effects on my patients’ lives of the wider world, whether my own hospital or the state government. [W]e must pay attention to the whole patient. Similarly, I now believe that our concern for our patients should encompass the effects of public policies that result in direct harm.

I do believe it is society’s responsibility to provide equitable access and believe Obamacare is the mechanism through which to accomplish this. Living in Alabama, a state that has not accepted the Medicaid expansion, how do we as educators look those we teach in the eye and say “We did all we could” to ensure access for those who are poor, who have mental illness, who are unable to speak for themselves? Anyone else ready to march on Montgomery?

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.”

GhostScrooge was better than his word.  He did it all, and infinitely more; and to Tiny Tim, who did not die, he was a second father.

Charles Dickens, A Christmas Carol

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”

“Point taken…”

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?”

“Point taken”

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.”

“Say what?”

“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.

“And ObamaCare?”

“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!

From Kaiser Family Foundation, information found here

President Obama announced and defended his budget yesterday. Having studied the federal budgeting process in graduate school I know that the proposed budget by the executive branch is hardly ever what ends up on the President’s desk so I tend not to pay a lot of attention to it. The budget did get some press in Alabama, however. It seems that a program to train pediatric generalists and specialists has been listed for extinction in the President’s budget and that would cost the state of Alabama approximately $7,000,000 annually. Turns out the President wants to use the money differently

The money for training pediatricians is one of about 200 federal programs targeted by Obama to trim $33 billion starting in 2012. The White House wants to cut the program in favor of competitive grants “that create incentives for improved performance,” according to the president’s budget.

Who isn’t in favor of improving performance?  Maybe the feds see their role as a more global, pointing out to the states how they can deliver care better. Unfortunately, the $7,000,000 of federal money  coming into Alabama every year is not only used for training residents but it pays for a lot of care that gets delivered as a by-product of this training. The current thinking in Washington is that the health of Alabamians shouldn’t be  a federal problem as is the current thinking in Alabama. Maybe we need to find another source for the federal money we now use for care delivery.

Perhaps the state is responsible? Unfortunately, former Governor Riley spent his time avoiding increases in taxes and hence did not leave Alabama much wiggle room to pay for health care this year. In his recent testimony to the Alabama House, the new Medicaid Director points out that there is a projected $700,000,000 shortfall and I guess he’ll have to add the $7 million to that. Dr Mullins was fairly straightforward with the legislators

Mullins said he is reviewing the program looking for places to cut. “I have to be honest with you, even those trim backs are not going to make a difference in $700 million,” Mullins said.

Mullins urged lawmakers to remember that Medicaid is critical to the state’s health care systems. Medicaid pays for about half of all Alabama births and provides medical care to 40 percent of Alabama’s children,

“Without Medicaid, the rural hospital system would probably collapse,” Mullins said.

Seems like a problem that has a potential solution. Unfortunately, that solution (more money into the system in the short term and ultimately transforming the system to be more efficient)  is not politically viable at this time.

Rep. John Rogers, D-Birmingham, said the $700 million request will be difficult to meet.

“We’re in real trouble,” Rogers said.

Perhaps the answer is local. Maybe the health care providers in a local area should all get together and provide the services to those most in need, especially those that are vulnerable and can’t care for themselves. In 2001, the local newspaper looked at our community (Mobile Alabama) and here is what they found

[From 1995 – 2000], the levels of charity care at all three private hospitals have dropped significantly, according to hospital reports filed with the state. Providence, a 349-bed, tax-exempt, Roman Catholic-affiliated hospital in west Mobile, proclaims a mission to pay special attention to the poor. In the last five years, though, 10 percent of its patients were uninsured or on Medicaid, records show. The hospital showed a positive net income of almost $14 million in fiscal 2000 — an 8.5 percent profit margin — although a sister company lost $4 million. At Springhill, about 7 percent of the patients in the last five years did not pay their bills or were covered by Medicaid. Springhill’s profit level topped $2 million last year, financial records show. But 252-bed Springhill, some community leaders say, may have less of an obligation to provide charity care than other private hospitals: It is a private, for-profit company that pays taxes.

My employer, the University of South Alabama is the other care provider in Mobile and it has 40% of its adult beds taken up by medically indigent people at any given time. How do we do this?

The medical college’s faculty salaries are among the lowest in the country and it has fewer teachers per student than any public medical school in the Southeast.

In addition, we rely heavily on Medicaid money which, I’m afraid, is likely to go away.

My experience tells me that it is important to pool our money to provide access to health care for our neighbors. On what scale that happens, whether national state, local, or family, is currently up for debate. I know that here in Mobile it is me, my colleagues, and the USAMC who are not being paid like our peers in order to allow poor Mobilians to receive what care we can provide. I’m not sure that it should be our problem, but it is…

I’m giving a talk tomorrow to the first year medical students about financing health care. This is a talk I give every year, takes about an hour and a half, and it will be all of the information they get on this topic from our medical school for the next 3 1/2 years. The talk tracks health care financing from no insurance to the development of private “insurance,” public payment,and proceeds to the system as it is evolving as a consequence of the Affordable Care Act.

If you’re interested in why things are as crazy as they are, I refer you to The Social Transformation of American Medicine. This book, written in the 1980’s, is still the best resource for this subject matter. Written with attention to context, Paul Starr discusses the transition from a cottage industry which relied on patients paying cash (or other medium of exchange) into, well,  a cottage industry where large swaths of the population did not have access to care. For those who were not independently wealthy, it became clear early on that they would need to pool their money so that when the odd really bad thing happened, there was sufficient money from those to whom bad things had not happened to cover the costs. This was how private insurance came about. For some reason, major population groups were given access to alternative types of care (veterans, railroad employees).

The elderly were a special case. It was clear that every elderly person would need the service (at the time of Medicare’s passage 1 in 6 elderly went into the hospital on an annual basis) and they voted. Congress reported more mail on the subject of elderly access to health care than any other subject. The AMA, according to Mr Starr, was loath to give up the cottage industry aspect for this population. As a consequence, the law accommodated the needs of the elderly (access) and the desires of organized medicine (maintenance of the status quo) for this group. I refer you to the CMS website if you want to see the convoluted consequences of these compromises.

The poor were also a special case. Under the cottage industry model, the poor were the responsibility of the community. Care was delivered in public hospitals, by religious orders, by physicians delivering charity care, or more likely not delivered at all. Congress felt that the care was needed but was unwilling to take total control away from the states. As a consequence, Medicaid developed with a minimum level of services but allowed states to provide more services. Payment was a state-federal partnership. Medicaid thus has no long-term constituency (no one sees themselves as poor forever although many see themselves as old forever) and tends to be targeted for cuts by every governor, regardless of political affiliation.

All of these programs were tweaked over the intervening half century. Medicaid began to focus more on children and mothers-to-be in most states. As more illness moved outside of the hospital and the elderly couldn’t afford the medications, prescription drug coverage was added to Medicare. Cost containment has been a problem from the start, both in government programs as well as the private programs.

The New Republic has an amazing series about how the sausage was made to put together the Affordable Care Act, found here (subscription required). It turns out it was no different from the passage of Medicare or Medicaid—with one notable exception. When Medicare was being considered, the elderly were mobilized to assure its passage. The Affordable Care Act, by contrast, is focused on those who currently have no coverage and are unlikely to vote. It is disliked by seniors, possibly due to deliberate mis-information, and they vote. Interestingly, despite a rough start 45 years later Medicare is very popular and performs very well (although somewhat more expensively than it needs to). It may be that once the smell and taste of sausage is in the air the Affordable Care Act will be popular as well.

When I give the talk to the students, they politely listen. Although I am not old enough to have cared for sick elderly folks that were hidden in the attic for fear of exposing the family to medical bankruptcy, I am old enough to have cared for elderly  folks who were hospitalized because they could not afford life-saving medication. I still care for folks who have no insurance, and I have to game the system to get them needed care. I don’t know that the students appreciate how much easier Robert Kennedy and Lyndon Johnson (Medicare, Medicaid), George W. Bush (Medicare prescription coverage, expansion of the Community Health Centers) and Barack Obama (Affordable Care Act) have made their lives.

I was sent a bit of information regarding Blue Cross of North Carolina. It seems that they don’t want to pay a management fee for chronic illness care. Instead, they will increase reimbursement for office visits because

…patients who generate the most physician orders for medical services also generate the most office visits, so doctors are getting paid extra to see the patients most in need – rather than getting a capitated rate for both the healthy and sick, Komives says.  “When you’re actually spending time with the patient in the office, that’s the value,” she adds.

Is that really the value? Interestingly, Community Care of North Carolina (the Medicaid managed care product) has found differently. By paying for the following:

Local non-profit community networks that are comprised of physicians, hospitals, social service agencies, and county health departments provide and manage care.

•Within each network, each enrollee is linked to a primary care provider to serve as a medical home that provides acute and preventive care, manages chronic illnesses, coordinates specialty care, and provides 24/7 on-call assistance.

Case managers are integral members of each network who work in concert with physicians to identify and manage care for high-cost, high-risk patients.

•The networks work with primary care providers and case managers to implement a wide array of disease and care management initiatives that include providing targeted education and care coordination, implementing best practice guidelines, and monitoring results.

•The program has built-in data monitoring and reporting to facilitate continuous quality improvement on a physician, network, and program-wide basis. 

 They have found significant cost savings and

…asthma patients experienced improved care as evidenced by greater reductions in inpatient hospital admissions and emergency room visits. Diabetes patients had fewer hospitalizations and achieved high rates of performance measures, such as primary care visits, blood pressure readings, foot exams, and lipid and A1C tests.

Some say that what BC/BS of North Carolina is actually doing is benefiting from the changes initiated by North Carolina Medicaid. While thay may not have done the heavy lifting at least they seem willing to pay for improved care. I hope that patients and the doctors realize the value is in the care coordination which can occur when given extra time but doesn’t have to.