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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.

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.

Governor Bentlley and the state legislature agree that they do not like the open-ended nature of our state’s health care obligation to the poor. The state’s policy makers are debating (actually, posturing may be a better description) accepting the Medicaid expansion offered through the ACA that would open up Medicaid to those with household incomes up to 133 percent of the poverty level or about $31,000 for a family of four. The federal government would pay 100 percent of the cost of services for new enrollees for the first three years, but that eventually would drop to 90 percent.

Governor Bentley said “that he would not expand Medicaid “as it exists under the current structure.”

“It’s a broken system. It’s a totally broken system right now. It is not working well, not only in Alabama, it’s not working well anywhere,” Bentley said this week.

Predictably, the legislature is divided into the pro and anti expansion factions with the Democrats taking the pro as House Minority leader Craig Ford stated

“He should know better being a physician,” Ford said. “We’ve got a lot of people without insurance in the state of Alabama.”

and the Republicans the anti

Speaker of the House Mike Hubbard, R-Auburn, said this summer that the 90-10 match is not a bargain if ”you can’t afford the 10.”

Part of the problem is that the policy makers are looking at an unpredictable (and ever increasing) cost that they see as having little ability to control. Medicaid provides for care in a “fee-for-service” model in Alabama, meaning that when folks become eligible the state pays the bills. The state gets a Medicaid bill and pays it. Without coverage dictated by income and private insurance for those not on Medicaid, state has no control over who it might have to care for. Consequently, for the major categories of people it must now care for, the costs are unpredictable (Data from this paper and this website unless otherwise stated):

  • Nursing homes- Two-thirds of nursing home stays are paid for by Alabama Medicaid. Eligibility is determined by inability to provide a certain level of care for oneself and not having any resources. The state of Alabama has little contact with those who might be eligible and cannot at this time provide alternatives to nursing home care to those people. Thus, under the current structure, the system rewards allowing people to get so sick they need to be in a nursing home, and almost all nursing homes are dependent on Medicaid at some level. We spend 61% of our Medicaid long-term care dollars in nursing homes, compared to 41% on average in the rest of America. The elderly are currently 13% of the enrollment and 26% of the cost.
  • Maternity care – a little more than half of all maternity deliveries are already paid for by Medicaid before any expansion takes place. No woman who has not been pregnant and is not currently disabled is currently Medicaid eligible in Alabama, even those with $0 income. Many people with an income above $0 but below 138% of the poverty line are employed in jobs that have no health coverage. I have cared for many women who first get care for their diabetes, hypertension, or asthma as a consequence of finding out they are pregnant and Medicaid eligible. An unplanned (due to lack of access to safe and effective contraception) pregnancy complicated by one of these chronic conditions is much, much more expensive than even a “normal” unplanned (due to lack of access to safe and effective contraception) pregnancy. Adults are 16% of the enrollment and 8% of the cost.
  • Care of children – Alabama has historically taken advantage of opportunities to deliver health care to its children. As a consequence, only 6% of Alabama’s children do not have health care coverage.  Part of our success is that more than 40 percent of the state’s children are covered through Medicaid. Alabama offers coverage to 133% of the federal poverty level (FPL) through age 9 and offers CHIPS eligibility to 300% of the FPL. Health insurance isn’t everything. We rank 37th in children’s health measures but we are able to work to improve these as a result of our almost universal coverage. While these children are an “open-ended” obligation, they are very inexpensive to care for if done correctly. Children currently are 49% of the enrollment and 29% of the cost.
  • Adult chronic illness (disability) – 15.5% of Alabama’s population between the ages of 21 and 64 is disabled. This entitles them to Medicaid eligibility in addition to Medicare in most cases. Only 10% of all Americans in this age group are disabled. Alabamians report an average of 1 full day of limited activity per month above that of the average American. Having cared for a number of these people who on disability, it is clear that inattention to chronic conditions such as hypertension, diabetes, obesity, smoking, and others have led to the final illness that “qualified” them for disability. In addition, many of people have a coexisting mental condition that contributes to their disability but often escapes notice. Inattention to these also leads to decreased productivity and workplace disruption. The disabled are 22% of the enrollment and 37% of the cost.

And the one it doesn’t have to care for:

  • Adult and sub-acute illness – In Alabama, unless you are in a nursing home, pregnant or a single parent in a family with young children, or on disability, you are not a “cost” to Medicaid. However, Alabama has an access crisis for all of her citizens. We have 8 counties with no hospitals, 35 counties that provide no obstetrical care, and there is only 1 county that does not include a medically underserved area. Alabamians are more likely to die of influenza, pneumonia, heart disease, strokes, notor vehicle collisions, and have a shorter life span than the average (or indeed most) Americans. This is because not only are we spending a lot of money in the wrong places, we are not spending enough money in a manner that would allow a better care delivery system to grow and flourish. The hospital is not the optimum place to go for a flu vaccine. If there is no one delivering care in a county because the care delivery system is broken beyond repair, there is nowhere to go for a flu vaccine or to receive life saving care for severe influenza, either.
  • Coordination of care – In Alabama, doctors get paid a lot of money for doing stuff to people. Coordinating care would mean elimination of duplicate tests, reduction of unnecessary re-admissions to the hospital, elimination of unnecessary physicians visits, and moving care into the most appropriate setting. Alabama has started doing some of this (a description is found here) but we are not doing enough nor are we doing it as well as we could.

If you have not heard of the story of the community by the river and the babies floating downstream, I refer you to this version. The question for the villagers is always how to best deploy their assets. Do they stay and catch babies or do they go upstream and find the baby source, perhaps risking some babies floating down in the interim. Medicaid was created as a sick people catcher, a way to partially reimburse doctors for caring for the sick poor who showed up in their offices and hospitals. In the interim, it has become the primary source of payment for pregnancy care and childhood illness care. It only catches sick adults after the harm of chronic illness cannot be undone. It doesn’t catch poor sick adults who, while working, are too poor to purchase health coverage.

While catching babies is inefficient and ineffective, we still need to pay some folks to stay here and catch them. Meanwhile, let’s use the expansion and other programs made available through the Affordable Care Act to go upstream. Let’s keep people from becoming disabled, keep babies from accidentally being born to women who cannot carry them to term, keep people out of the nursing home, and work to improve our child health standings. The answer to my question, therefor, is we spend both too much and not enough. Let’s spend Medicaid money more wisely to make Alabama’s health system work better.

Here in the south, we often seem to be bristling up and posturing on the outside while quietly doing the right thing. That is happening in Alabama as it relates to care delivery, much to my delight. Per an op-ed by Jim Carnes in today’s Press Register:

If [ObamaCare] survives the multistate challenge it will face this spring in the U.S. Supreme Court, Alabama will be well on its way to securing an expanded and fairer health insurance market for everyone, and a stronger safety net for low-income workers and their families.

That outcome will be thanks to the work of a commission Gov. Robert Bentley appointed to study the ins and outs of implementing a key aspect of the reform, despite his strong opposition to the law.

Mr Carnes points out that the combination of expanded Medicaid and these exchanges  will be a boon to the 15% of Alabamians who currently lack access to anything but emergency care and care provided by the charity of others. Once the law is fully enacted, people will qualify for subsidies to purchase insurance:

One crucial step for expanding coverage in Alabama will be the creation of what the law calls a state health insurance “exchange.” This will be a user-friendly marketplace where people who need insurance can compare and choose plans and get assistance for paying their premiums, on a sliding scale determined by income.

The full report of the Commission is found here. In addition,

The Affordable Care Act requires all states to offer Medicaid coverage to people earning up to 133 percent of the poverty line, or just under $30,000 for a family of four. That’s more than 12 times Alabama’s current Medicaid income limit. Alabama Medicaid estimates the change will bring coverage to around 500,000 more Alabamians.

Thank you, Governor Bentley, for setting aside your personal feelings and putting the groundwork for implementing the Affordable Care Act in Alabama into place.

Since the election, Congressman Boehner has made no secret of his desire to replace the Affordable Care Act with a “common sense” approach as has our newly elected Governor, whose intentions I spoke of here. Just what that means is a matter of speculation. What the Congressman has said repeatedly is that he wants the people to be heard. In order to facilitate that, I am posting the responses from a poll posted by Kaiser Family Foundation regarding the components of the law (Click on the picture to view responses)

Interestingly, people seem to want to keep the benefits but not pay the taxes. Going to be an interesting couple of years.