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A Reality Check On State Medicaid Expansion

By Dr. Christopher Hughes
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Colin McNickle, of the Pittsburgh Tribune-Review,  recently published a diatribe against expansion of Medicaid under the Affordable Care Act in this past Saturday’s edition. Mr. McNickle spends a great deal of the article worrying about “endlessly expanding government,”  and goes so far as to ridicule another newspaper for concern over the welfare of children. I am disappointed to see this kind of cynical and paranoid rhetoric about a government takeover of the economy via healthcare featured in the pages of the Tribune.

As a physician, I would like to respond to Mr. McNickle’s claims – both his long list of incorrect facts and his snarky dismissal of the medical needs of so many vulnerable Pennsylvanians. When you look at the facts, it’s clear that Medicaid should be expanded  in Pennsylvania.

He complains, counterfactually, that the 2009 stimulus was a failure. He argues that expansion of payments to health care providers in the commonwealth that will result from the expansion will not boost the economy. Mr. McNickles, the only way that bringing that much new money into the state would not create a major economic stimulus would be if we brought the money in on pallets and burned it as it crossed the border.

Others have gathered the actual data, along with rigorous analysis, and made the obvious case showing these benefits – more jobs, more good jobs, expansion of practices, a decrease in uncompensated care, higher reimbursement for primary care physicians and much more. The Rand Corporation, Pennsylvania’s Independent Fiscal Office, the Kaiser Foundation, the Center for Healthcare Research & Transformation, and more, all come to the obvious conclusion – money spent on health care in Pennsylvania will improve the economy and create jobs.

Mr. McNickle then quotes the far-right Commonwealth Foundation (not to be confused with the highly regarded Commonwealth Fund) about the failure of Medicaid to reduce poverty and difficulties with access to health care. He fails to mention that this is exactly the point of the current Medicaid expansion: Medicaid has been historically underfunded and ridiculously complex. Even back in in 1967, a Time article titled, “MEDICARE: Expensive, Successful MEDICAID: Chaotic, Irrevocable,” points to the problems that should be obvious: Medicare is a uniformly administered national program, and Medicaid is administered by individual states, some then, as now, with ideological and fiscal reasons to mismanage it. It is a “no-brainer,” if you will, that so many states manage to “screw the pooch” year in and year out, denying coverage to extremely needy people, providing embarrassingly low reimbursements to providers and all sorts of other fun tricks to make the program as undesirable to its clients as it is to the ideologues opposing it.

Mr McNickle goes on to note that many physicians won't see Medicaid patients due to low reimbursements. Again, ignoring what is actually in the ACA, and defaulting to some imagined awful piece of legislation in his head. Medicaid reimbursements for Primary Care and General Surgery are set to go to par with Medicare as the ACA kicks in. The Pennsylvania Academy of Family Practice has surveyed its members and found them ready and willing to accept new patients, including those on Medical Assistance.

I feel the need to quote the next  two paragraphs in total:

What's the real skinny on Medicaid? Higher taxes. Shrinking uncompensated care reimbursements for hospitals. Perversion, if not destruction, of private health insurance markets. Fewer doctors willing to put up with more and more (and more) government control and compliance nonsense. Less care, worse care and, quite possibly, no care for the neediest among us.

Who in their right mind would support expanding Medicaid in Pennsylvania?

1. Higher Taxes. The largest tax increase in the ACA is the increase in Medicare Tax on high earners of 0.9%. To quote health economist and Princeton professor Uwe Reinhardt regarding the cost of extending health care to all Americans, “Go tell God why you cannot do this. He will laugh at you.”

2. Shrinking uncompensated care reimbursements for hospitals.  A feature, not a bug. Since expanding Medicaid and mandating private insurance coverage, uncompensated care will decline dramatically and the hospitals will have increased compensated  care, a much more desirable situation. Ask the Hospital Association of Pennsylvania.

3. Fewer doctors willing to put up with more and more (and more) government control and compliance nonsense. Unfortunately, that ship has long sailed, but not as I imagine the author thinks. Our control over care has been, and continues to be eroded by private insurers whose byzantine rules and requirements cost the average practice about $86,000  per physician per year! Medicare is far more straightforward, and more and more physicians are coming to recognize that if no constraints are put on us, we will run the ship into the rocks.

4. Less care, worse care and, quite possibly, no care for the neediest among us.  Wrong, wrong and wrong. I can’t even imagine where in his fevered brain  he came up with this. Unless his fevered brain watches Fox News and listens to talk radio, where misinformation is king.

5. Who in their right mind would support expanding Medicaid in Pennsylvania?  As a health professional, I would be remiss in not making the moral case for Medicaid expansion, as I have done elsewhere, hereherehere, and here. The Affordable Care Act in general and Medicaid Expansion in particular, are our best hope for improving the health of all Americans, by virtue of the focus on quality and patient centeredness, and for those currently uninsured and underinsured, by improving their access to health care, once and for all, I hope. It is worth noting that some other “supposed Republicans”, the Governors of Ohio and Arizona most notably, who have come to realize that this is a moral imperative that cannot be kicked down the road nor swept under an ideological rug to soothe our consciences. As Governor Kasich put it so well, “Now, when you die and get to the meeting with St. Peter, he’s probably not going to ask you much about what you did about keeping government small. But he is going to ask you what you did for the poor. You better have a good answer.”

Thank you, Governor. I could not agree more.

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