The Doctor Is In. And He Wants to Expand Medicaid.

Ralph Northam as physician

With a near 50/50 balance of power between Republicans and Democrats in the General Assembly, Governor-elect Ralph Northam will be in a much better position than his predecessor Terry McAuliffe to enact Democratic priorities. And what are those priorities? As he told NBC 4, Medicaid expansion tops the list.

Said Northam: “No family in Virginia should be one medical illness away from financial demise so, Medicaid expansion is very important and I will do everything I can to make that happen.”

We can all agree on the desirability of making health care affordable and accessible for all Virginians. It’s not so clear that expanding Medicaid is the best way to accomplish that goal. I have blogged in the past about the inadequacies of the Medicaid model, which has not demonstrated an ability to substantially improve medical outcomes. Among the more obvious problems: While Medicaid expansion provides coverage to the uninsured, it does not increase the supply of primary care physicians willing to take on Medicaid patients for whom they are paid 30% to 60% less than privately insured patients.

Despite below-market reimbursement rates, the cost of Medicaid expansion is considerably higher per patient than anticipated when the Affordable Care Act was enacted several years ago. The table below, taken from an article in the “Handbook on Healthcare Reform” published by the Thomas Jefferson Institute for Public Policy (TJI) last month, shows how Medicaid actuaries have consistently revised upward their cost projections since FY 2013.

The 2013 report projected that newly eligible adult Medicaid patients would cost $3,625 on average. By 2016, the figure had risen to $5,926 — a 63% jump. If Medicaid expansion was unaffordable four years ago, it’s even more unaffordable now. Despite their political setbacks, Republicans are highly unlikely to roll over on this issue.

It’s not as if states have no other options to improve affordability and access. The TJI report discusses several. They include eliminating mandated benefits so insurance companies can offer bare bones policies; removing barriers to healthcare technology innovation; rolling back onerous Maintenance of Certification requirements that encourage physicians to retire early; reforming the medical liability system that prompts physicians to practice defensive medicine; encouraging transparency in pricing so consumers can push back against expensive providers; abolishing the Certificate of Public Need process so physicians can provide high-quality, lower-cost outpatient surgery; promoting telemedicine; enabling Direct Primary Care that strips out third-party-payer middlemen and administrative costs; and repairing the broken Medicaid delivery model.

Most of the TJI essays were generic, not specific to the Old Dominion. As it happens, Virginia has taken limited steps toward implementing some of the ideas in the report, but much remains to be done.

The health care sector is a dense jungle of special interests, however. Hospitals, insurers, pharmaceutical companies, employers, physicians, and a welter of allied health professionals work doggedly to shape legislation to their benefit. Sadly, ordinary patients have no organized group representing their interests.

As a physician, Northam has a keener understanding of the issues confronting the health care sector than most lawmakers. He enjoys a unique opportunity to reshape Virginia’s health care sector in a way that lowers costs and improves outcomes for all Virginians. It would be a shame if he expends all his political capital to capture the dubious benefit of Medicaid expansion when so many alternatives lie fallow.

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22 responses to “The Doctor Is In. And He Wants to Expand Medicaid.

  1. On WTOP a few weeks ago, Gov McAuliffe said it was already a slam dunk to pass Medicaid expansion this session, because enough repubs are known to support it. But he could well have been posturing I suppose .

    Of course I believe McAuliffe stresses that Va. would get millions from the Feds to subsidize, and we’d just be crazy not to grab those dollars in his view.

  2. Well – you do have 50 states…

    so how about ranking them on what TJI says , if implemented , would reduce costs:

    1. – eliminating mandated benefits so insurance companies can offer bare bones policies;

    2. – removing barriers to healthcare technology innovation;

    3. rolling back onerous Maintenance of Certification requirements that encourage physicians to retire early;

    4. – reforming the medical liability system that prompts physicians to practice defensive medicine;

    5. – encouraging transparency in pricing so consumers can push back against expensive providers;

    6. – abolishing the Certificate of Public Need process so physicians can provide high-quality, lower-cost outpatient surgery;

    7. promoting telemedicine; enabling Direct Primary Care that strips out third-party-payer middlemen and administrative costs; and

    8. – repairing the broken Medicaid delivery model.

    so here’s a map of the Red states… how about ranking them on the TJI suggestions .. and health care costs ?

    • That would be an interesting ranking, if it were possible. You’d have to adjust the baseline for the different demographics and different medical challenges of the States to get closer to comparables, but it would still be very interesting even unadjusted. Did TJI attempt such a thing?

  3. I’m sounding like a stuck record — but, public health is everyone’s concern.

    Even Libertarians must care about what affects them directly. Public disease and lost productivity and social unrest affects people directly. If Obamacare collapses, as the Republicans seem determined to make happen, what will replace it? Because it will be replaced. The status quo ante was so unacceptably inefficient and inadequate, an attempt to return there could lead to serious disturbances.

    And Obamacare is largely an insurance, or payment, mechanism, NOT a health care mechanism. Are Republicans so unable to provide leadership on addressing the real problems of U.S. health care delivery — the ones that cause it to be so much more expensive than the comparable systems elsewhere — that they will wreck what we have, guaranteeing the need for remedial action by someone, and then simply wait for the Democrats to impose their single payer alternative vision by default? Because the Democrats will. They will be elected in sufficient numbers to assure that they will.

  4. As a follower or health care and a harmed patient, I see both sides.

    Putting salary caps on administrative/BS/suit positions for insurance, pharma and hospitals/health care would do more than anything named for the rising costs. Anthem paid the CEO millions and just gave him a $3 million parachute. They booted one of my docs’ out of network. Anthem said they were asking for too much money. They’ve more than heard from me.

    Going after any pharm company rising rates on generic drugs like dataprim, instead of BS’ing about it would fix a lot of problems. Don’t pay for drugs that are just reformulations of stuff for rare drugs. They’re going for rare diseases when they need to focus on the every day stuff.

    Pay for bariatric surgeries – 2 per lifetime. That would cut out a lot of obesity related diseases like hypertension, diabetes and cancer rates.

    Offering bare bones policies makes sense for the younger and healthy.

    Getting rid of MOC because it does squat to help docs or us is a good thing.

    They already have way too many laws slanted to malpractice reform. If they spent less money trying to hide and defend their mistakes, and admitted it and fixed it, that would be cheaper. They’d get some of the respect back they’ve lost for the gaslighting and other illegal/unethical/immoral things they do. If you want references I have 3 and almost 4 of 150 page documents tracking all sorts of screw ups in the health profession. Those are links, not full articles. That should tell you how much crap we are paying for in terms of mistakes, because WE pay for them, NOT the doctor or hospital.

    If we had transparency, the American public would have mobs. We’re wasting that much money on bureaucratic BS.

    I see that O’Bannon fooled you on that COPN stuff, Jim.

    Those items alone would take a tremendous chunk out of the costs.

  5. This is not chiefly about health care. It’s standard Democratic buying votes with other people’s money. Name a single government program that hit its budget estimates. It won’t be too many years before a Virginia Governor says he/she needs a tax increase to keep funding Medicaid, especially when all the new Democrats vote to cover illegal immigrants.

    Northam would be in a perfect position to expose the layering, over-payment and waste, fraud and abuse in the health care system. But he won’t since its all about vote buying. He won’t touch the supply side. We won’t see funds diverted from care for indigents even though many Democrats have said over and over again, expanding Medicaid would save the Commonwealth money. We won’t see a reduction in health insurance premiums even though many Democrats have said Medicaid would save money for premium payers. Soon it will be Katie bar the door.

    • re: What we won’t see from Northam …

      will be a LOT MORE than we’d ever see from the GOP.

      There are reforms in Medicaid already underway started under McAuliffe that will continue. One of the most significant is to put Medicaid recipients on Managed Car where their medical records are electronic and shared by doctors treating them so that each doctor , even new ones that replace others – will easily see their entire medical history.

      This is a “bullet” that Bacon did not post and the GOP has not said will reduce costs and so has not pursued it.

      This, by the way, is what the VA – and many other industrialized countries do to improve care and reduce mistakes – and save money as well as detect disease and other conditions faster than with regular fee-for-service care.

      You don’t get to any of this with the GOP because fundamentally the GOP is opposed to the govt doing this to start with and so what they do is set up a narrative that the Dems “could” do “this” and “that” but won’t to deflect attention from their own non-efforts – as said earlier – even in the states they have total control of healthcare – they’re not doing it.

      The hypocrisy just REEKs! TMT , you should be ashamed of supporting the GOP on this… at least admit the fact that all they do is oppose and block and obfuscate. Show me the legislative agenda for the GOP in Virginia.. where is it? It must be that they are so worried about being perceived as trying to “Buy votes” with their health care proposals that they do none, eh?

      So.. the long and short of it is that if you try to do something – you’re buying votes.. and so the GOP simply does not “buy votes” … uh huh…

      • More empty ranting. More set up a program with promises of savings and then when questions about the savings are raised, change the subject and call the other side immoral and heartless. And how come a legislative agenda is always about spending more and more and more taxpayer dollars?

  6. Republicans are in charge of more than 26 states and have had YEARS to do all those things that Bacon keeps posting over and over that supposedly if implemented would reduce costs.

    Why haven’t they done it – and in the process – win over all those votes that TMT says the Dems are getting?

    Nevermind that the idea of lower health care costs – for everyone is a different thing that how you pay for health care for people who cannot afford – period.

    The GOP complains a lot… spins up all kind of “ideas” but not even in the States they control has much, if anything actually been done to reign in costs and reform Medicaid.

    All they do is attack the Dem proposals.. and like the proverbial dog chasing the car – they like the chasing much more than the catching.

    Oh.. and caught this little tidbit:

    Medicaid Expansion Leads To Increase In Early Cancer Detection

    “The rate of early cancer diagnosis was higher in some states that expanded Medicaid compared to other that did not.”

    [ The States that did not expand are the GOP-controlled states or stares where the GOP blocked – like Virginia]

    A new study from University of Pittsburgh and Indiana University, published online last month by the American Journal of Public Health, found that states that expanded Medicaid increased cancer diagnoses by 6.4 percent more than ones that did not. Researchers compared data from 2014, the first year of Medicaid expansion under the Affordable Care Act, to previous years to see if there was a significant increase in the diagnosis rate in states that extended the program in contrast to those that did not.

    Because earlier diagnosis of cancer means patients are more likely to survive and have lower treatment costs, Sabik said her research should be considered as the country debates the future of the Medicaid and ACA.

    “I think our findings show that these expansions of Medicaid have important implications for individuals’ health and diagnosis of serious and costly diseases,” she said. “These expansions of Medicaid coverage may, in the long-term, save lives.”

    http://wesa.fm/post/medicaid-expansion-leads-increase-early-cancer-detection#stream/0

  7. Larry The G:

    Buying votes depends on who’s money you are using. Taking my money to people who don’t earn it and won’t work for it? No one calls that a good investment. For a couple of years, I wrote to the Dems, trying to get them interested in enacting legislation that would help minority health care issues. No interest. Except for the documented phone calls, all in writing, in case you need proof.

    EHR’s can be faked. Docs are wrong in cases. If someone thought you were a piece of garbage, and they use the EHR to transmit that, you think that’s right?

    https://www.aafp.org/news/government-medicine/20150319werginsenate.html gives good and bad.

    I hope you have proof of the money save. The millions of dollars it takes to implement Epic, where are the studies showing the cost savings? I’ve not seen it. Please give me proof that EHR’s save money, make a dent in the errors, and detect disease and other conditions faster than with regular fee-for-service care. Please also show how EHR’s get rid of gaslighting and the white wall of silence.

    Thank you. PS Please use fairly reputable resources.

    https://www.medpagetoday.com/practicemanagement/practicemanagement/47716
    http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html

  8. The number one thing that will reduce health care costs is making people’s complete medical history including all doctors they have seen – available to every doctor they see in the future.

    That then allows the person to “shop” for both price and quality. If they want to see a doc-in-the-box.. one day- it’s not a problem… the next time they see a doctor – a different one – that encounter at the doc-in-the-box is recorded in their medical history. The availability of the complete medical history reduces both duplicative tests as well as mistakes made by not knowing prior tests and treatments.

    These complete medical histories should be MANDATORY for ANYONE who is receiving entitlements from the Govt – they ought to be a requirement in order to get the entitlement so that ANY Medical Provider will have access to your complete history that will reduce redundant tests and treatments as well as mistakes.

    I’ve not seen that recommendation from the GOP as part of their suggestions.

  9. The difficulty of health care discussions is the lack of agreement on the starting point – does everyone need health care coverage.

    If we don’t think everyone needs health care coverage, we can simply let corporations, insurance companies, health care systems, pharmaceutical companies work out their differences. If you can afford the end result, assuming the insurance companies will cover you at all, then you will get the coverage you pay for. If you can’t afford it, or if you are denied coverage, well, too bad.

    On the other hand, if we think everyone needs health insurance, then we can start talking about what that means: what’s the budget, how do we allocate the budget among competing needs, how do we allocate the costs?

    Some of the proposals for cost reduction mentioned in the article are worthy of investigation. Some will eventually be included in how health care is provided in the US. But they do not, by themselves, ensure everyone has health care coverage.

    Medicaid might be a flawed means of providing health care, but for most of its recipients, it is the only health care they are going to get. Of course, this only matters if you believe everyone needs health care coverage.

    By the way, here’s a related thought – prohibit employers from providing health care insurance and have everyone look for coverage in the private market. Most Americans have no say about their health care coverage – their employers force the choice on them. Let’s see what the health care insurance market looks like when everyone is in it as individuals.

  10. Well .. rather than talking about who ‘needs’ insurance.. perhaps it’s who pays for those that don’t get it – when they find out they need medical care?

    Young folks especially think that ERs are public services..

    Others who don’t have it – KNOW that they WILL be treated….

    re: ” By the way, here’s a related thought – prohibit employers from providing health care insurance and have everyone look for coverage in the private market. ”

    Yep.. that would do it… especially when they realize they have no protections for pre-existing, annual/lifetime caps, and community rated premiums like they had under Employer sponsored.

    That’s the big hypocrisy with those that do have employer provided – believing that those on Obamacare should not have subsidies and protections – like they have.

    Put all those people in the same boat as those who want ObamaCare and you’ll see an overnight sea change.. in their views that the govt should not be doing health insurance.

    The average American who has employer-provided thinks that the tax-free insurance is a “benefit” from the employer rather than govt tax Law.

    And they take for granted that they all pay the same premium regardless of age or health status – they think that’s provided by the employer also – not Govt law that requires it.

    With MedicAid – we’re talking about people who cannot afford insurance..more than a few of them are actually full time employed… not on entitlements.. or welfare.. they work … That’s who the MedicAid Expansion was supposed to cover… The number one cause of bankruptcies in this country is health care debt.

    https://www.fool.com/retirement/2017/05/01/this-is-the-no-1-reason-americans-file-for-bankrup.aspx

  11. The issue comes in because you do have chronic, long term, costly medical problems that people made choices that steered them in that direction.

    There is a difference between a married couple where a person gets a cancer that has no propensity to cancer in the family. There is a difference when someone gets cancer who works full time.
    There is a big difference in what people want to pay for cost for hypertension, diabetes, etc. when the issue is not enough exercise and eating a diet predisposing to those conditions.
    There’s a big difference when out of wedlock kids are had by teens when the dad is not around to support or be in the family.

    People are living much longer with issues that were quite different when Medicare/Medicaid was first started. What was life expectancy? In the 70’s. Not a whole lot of MRI’s, CT’s, or administration that drags on the cost of health care.

    • People need to take personal responsibility for their own health.

      Neither my wife nor I smoke, and we have always preached to our children to never take up the disgusting habit. But our college-age son has started smoking. We’ve given him all the lectures about how bad it is for his health (and how girls don’t like to kiss boys who smoke), but he doesn’t give a hoot. He’s young, he’s healthy, and the prospect of getting cancer is so remote he doesn’t care. Some people just refuse to take responsibility for their actions. There is no question in my mind that he should pay a higher rate for health insurance than non-smokers!

      The situation is more complex with obesity because some people have genetic proclivities to accumulate fat more than other people, and viruses have been implicated in some cases of obesity. So, some unlucky people have a harder struggle maintaining their weight than the rest of us. But they still have control over how much they exercise and what they eat, and there needs to be some way to hold them accountable for their behavior.

      By subsidizing all forms of careless and slovenly practices, we are driving our country to fiscal insolvency.

      • The problem is pretty much all of those said people prefer all others pay for the consequences of their choices, rather than do things with their own funds and time to make choices that don’t require others to pay for it.

  12. The premise of America is that you work hard for something to get it. Why should those who don’t work hard for it get it? There are those in your list that that happens for. From what I’ve seen there are solutions being tried out for those small businesses.

  13. re: ” The issue comes in because you do have chronic, long term, costly medical problems that people made choices that steered them in that direction.”

    then why doesn’t that ALSO apply to people who have access to employer-provided insurance?

    I bet both Jim and his wife ARE paying higher premiums because others on their insurance do smoke… and are obese and have other bad habits.

    Do we have one policy about this or do people who get employer-provided get it regardless of their lifestyle habits and people who don’t have employer-provided cannot get it because they do have bad habits?

    How do we justify money to help people with Opioid habits?

    re: ”
    The premise of America is that you work hard for something to get it. Why should those who don’t work hard for it get it? ”

    So if you have employer-provided what ENTITLES you to not have it taxes not Fed, State or even FICA and others who have to get their own insurance have to pay tax on it?

    Or how about Community rating when Jim and his wife pay the SAME premium as others older and sicker than they are .. or folks younger than them on the same employer-plan – pay the same premium as people older and sicker than them?

    How about pre-existing conditions and annual and lifetime caps?

    Are people who have employer-provided ENTITLED to those protections and people who don’t have employer-provided NOT ? Why?

    It’s NOT that employers set these rules – these rules are Federal Law that applies to employer-provided insurance but not to other insurance people have to buy on their own.

    But again – according to V N and Jim.. we should NOT be providing taxpayer money to help Opiod addicts.

    Is that correct?

  14. re: ” The issue comes in because you do have chronic, long term, costly medical problems that people made choices that steered them in that direction.”

    what about folks who have those conditions but did not have habits that caused them?

    How would you determine this? If someone at age 60 ..a few pounds overweight but not grossly obese – gets diabetes or heart disease?

    See the problem here is that you seem more than willing to do this to people who need insurance.. and who will STILL be going to the hospital and getting care – even if they go bankrupt.. the health care system will continue to treat them at taxpayer expense.

    How can you justify this? If you kick people off of insurance or in the case of Medicaid or Obamacare – refuse to cover them if they have a chronic condition – you’re not saving money. The bankrupt guys who needs kidney dialysis.. you’re STILL going to pay the costs of his treatment.

    The only places on earth that do what you advocate are 3rd world countries.

    When you and V N take this view – you essentially are saying this country should revert to a 3rd world policy where whether or not you can get insurance is totally up to the insurance company and if it costs too much, then you are just out of luck and will die because you didn’t exercise enough personal responsibility.

    It’s more than convenient that you guys can take this position if you yourself have guaranteed insurance from an employer insurance plan that is required by the govt to insure you regardless of your bad habits.

    If you took that away and did what you advocate – we’d have a 3rd world insurance environment – correct?

    Only those that are young and/or in good health could buy insurance. Everyone else except the rich who can afford it would effectively be denied access to affordable insurance.

    Isn’t that the position you guys are advocating?

  15. Its called paying for your insurance. Once I have to pay for someone elses’ care, I get the say in it. Don’t like it? Go pay for your own insurance.

    I saw an article that indicated putting work requirements, etc. on the welfare rolls was getting people off welfare and back to work. Of any kind. If you start making requirements that you do get that education, you do go for jobs, you can work, then you’ll see people get to work.

    Otherwise the weakening of requirements only makes it so that people game the system and don’t work to improve themselves. This country was built on people taking the gumption to go out and work, not living off others.

    As I have seen in my own family, those who are coddled and allowed to whine make the worst decisions (especially financially) and stay in a hole. Those who don’t are able to stand on their own 2 feet a lot better, work harder for what they have and are more careful with resources.

    Stop rewarding negative and reward the positive. At some point you have to draw the line and say this is it, you’ve had enough chances, no more. Fly right or play the price. That works in America. We’ve seen well too often the other response does NOT do anything for that person or society.

  16. re: ” Its called paying for your insurance. Once I have to pay for someone elses’ care, I get the say in it. Don’t like it? Go pay for your own insurance”

    Yep – so you are advocating that if the insurance companies want to charge you more for you age – they can so as you get older.. you no longer can afford insurance?

    Do you also advocate taxing health insurance no matter where you get it? It will cost you about 40% more for employer-provided if they tax it. You in favor of that? Why should the govt allow you tax-free money to buy health insurance but not others who have to pay 40% more?

    I want to also point out that Obamacare – unlike most employer health plans – you actually DO PAY MORE if you are a smoker:

    would you advocate this for ALL insurance , employer-provided included? How about a similar penalty if your BMI exceeds healthy standards?

    What would you do with people who ended up not getting insurance because it was too costly for them – at the hospitals?

    Would you repeal EMTALA?

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