Expand Free Clinics, Not Medicaid

Meadowview Health Clinic

Meadowview Health Clinic

by James A. Bacon

So, what’s the alternative to expanding Virginia’s Medicaid program? Let an estimated 400,000 Virginians continue without health insurance? That option was workable in the past because the federal government gave financial aid to hospitals to help offset some of the cost of providing health care to indigent patients. But the Affordable Care Act (Obamacare) is cutting that aid on the grounds that, between Medicaid expansion and the new health exchanges, most people will have health insurance now. Thus, a decision by the General Assembly to reject Medicaid expansion would force Virginia hospitals either to stop treating uninsured patients or to eat tens of millions of dollars in unpaid bills (some $100 million just for the University of Virginia and Virginia Commonwealth University health centers) every year. 

Del. Bob Marshall, R-Manassas, has proposed strengthening the non-governmental safety net instead. His idea is far from a complete solution — it can’t possibly make up the loss of hundreds of millions of dollars in federal Medicaid payments. But the proposal would put into place an important piece of a broader, market-based health system.

Marshall’s alternative to expanding Medicaid is to expand the network of free health clinics across Virginia by encouraging physicians and nurses to donate more of their time. His House Bill 39, co-patroned by Del. Patrick Hope, D-Arlington, would exempt voluntary health providers from civil damages for any injury or death resulting from volunteer treatment (excepting in cases of gross negligence or willful misconduct), and would have the Attorney General’s office represent volunteers if such immunity were challenged.

Marshall envisions churches, neighborhood groups and hospitals setting up neighborhood primary care centers staffed with volunteer labor. As it stands, Virginia already self-insures 3,400 physicians for care they provide in free clinics. No lawsuits are pending against free clinic care.

One could argue that free clinics staffed by volunteer labor cannot possibly provide the scope of coverage of an expanded Medicaid program. But, as Marshall observed in a recent Times-Dispatch op-ed, Medicaid has significant problems of its own. Medicaid pays less than Medicare or private insurance, and there are concerns that many Medicaid patients will have difficulty finding a doctor. Indeed, the reimbursement for Medicaid services is so low and the paperwork cost of complying with the program is so high that some doctors may conclude that it’s preferable to treat the indigent in free clinics.

Marshall’s idea would strengthen the primary care network for the indigent but it is not a comprehensive solution. There is no guarantee that doctors and nurses will volunteer in sufficient numbers to provide care to 400,000 patients — even assuming the free clinics had the capacity to handle such a number. And his bill would not cover the cost of providing tests, medication and procedures best performed in a surgical facility, much less a procedure requiring intensive care.

HB 39 is best seen as a small part of a larger package of state- and federal-level, market-based reforms that decouple health insurance from employment, create price and quality transparency, spur innovative treatment models and promote hospital competition and productivity.

32 Responses to Expand Free Clinics, Not Medicaid

  1. One could argue that free clinics staffed by volunteer labor cannot possibly provide the scope of coverage of an expanded Medicaid program. But, as Marshall observed in a recent Times-Dispatch op-ed, Medicaid has significant problems of its own.

    Oooh! I know! We’re pretending that these problems are equivalent! I can do this, too!

    One could argue that free aerospace clubs staffed by volunteer labor cannot possibly provide the scope of coverage of an actual space program. But, as Smith observed in a recent New York Times op-ed, NASA has significant problems of its own.

    One could argue that neighborhood militias staffed by volunteer labor armed with sticks cannot possibly provide the offensive power of the U.S. military. But, as Jones observed in a recent Washington Post op-ed, the military has significant problems of its own.

    One could argue that banks run out of cardboard boxes by gangs of homeless children cannot possibly provide the scope of coverage of an actual bank. But, as Menendez observed in a recent Times-Dispatch op-ed, banks have significant problems of their own.

    • And you are pretending there is a large enough supply of doctors that will accept new Medicaid patients for this plan to actually work. There is simply not a large enough supply of health care providers for Medicaid expansion to work as advertised. I don’t think that’s reason enough not to expand it, but its certainly a problem that must be addressed before we do. Delegate Marshall’s bill would would mitigate that problem, but it definitely isn’t a viable alternative by itself.

      • re: supply of doctors. If we have a large enough supply of doctors to treat the indigent in ERs then what is the problem?

        If we cut the reimbursements to the hospitals for charity ER care – does it mean some ER doctors might become GPs if we need less ER docs and more GPs?

        besides that – what is wrong with the State of Virginia offering free medical schooling for those willing to sign on to 5 years of MedicAid doctoring?

        the question is – do we want to do something or do we want to make excuses?

        we have a wide variety of things we CAN DO – as Virginia.

        why is it we make excuses and blame the Feds for what we don’t like about the Fed approach but refuse to come up with our own?

        • I’m not making excuses, I’m just pointing out a fact. I’m not philosophically supportive or opposed to Medicaid expansion, I’m just looking at this mechanically. Before we do B, we have to do A. We should not expand Medicaid until we are sure there is an adequate supply of doctors that will be accepting all these new Medicaid patients at least 5-10 years into the future. The last thing we need is to have 400,000 people thinking they have health care when really they have just been signed up to an insurance program with an increasingly dwindling supply of doctors. It’s like the whole ACA website fiasco. Even thinking the entire ACA law would work as designed without first reforming most of the Federal IT procurement procedures and the legacy databases the system had to interact with was a boneheaded move. There are certain logistical steps we all have to admit must be taken to make certain reforms possible and opposing those reforms until those steps are made shouldn’t automatically mean you are opposed to the reforms themselves.

          • here’s the reality. we are cutting reimbursements to hospitals for ER care.

            does anyone think that because people without insurance go to ERs that we might have an excess supply of ER docs if we reduce the demand on the ERs?

            does anything – we cannot use para-professionals like RNs and Physician Assistants to cover the gap? One doctor with 5 physician assistants is better than 6 doctors… in terms of waiting to get the 6 but also in cost and availability.

            why can we not be innovative and insist on sticking with the status quo?

            the mistake here is thinking that people right now without insurance do not already receive medical care from doctors.

            we’re pretending that they don’t but they already do.

            And as I said before – why do we need to key our efforts to the ACA to start with? Why can Virginia not set up it’s own MedicAid clinic network with the MedicAid money and employ it’s para professionals that would essentially be a triage function for routine/periodic care and refer the legitimate tougher cases to doctors, even ERs?

            we have excuses.

            there is no question about it.

            we look for reasons why we “can’t” and that’s not acceptable.

            Let’s stop opposing and do something… rather than opposing and making excuses.

            we don’t like the Fed approach. Fine. Let’s do our own.

            what is keeping us from doing what Massachusetts and Vermont have done?

  2. I did wait, to give others the opportunity to respond, as I am aware of my frequent posting… especially on health care.

    but Waldo nailed it. Why do we think a physician of all occupations would have “free time” to “donate” and why in the world would we create a system where that is the fundamental backbone and no other planned way to provide enough resources to meet the need?

    what is the difference between the “cost of complying” and “volunteering”?

    that’s a red herring if i ever so one. The doctor does not pay for the cost of complying.. he has hired people that do that .. so that’s not his time – that’s not freed up to volunteer… with.

    don’t get me wrong – I BELIEVE in the clinic approach.. but the state has to have a real commitment of resourcing it not some cockamamie idea that some doctors might volunteer or some churches might help. there has to be an institution plan that is put in place by the state and/or the localities and doctors have to have real compensation of some kind to staff those clinics.

    You also need administrative help. Ever been to a doctors office lately? Count the number of employees besides the doctor. where do these folks come from and can you really run a medical office with volunteers giving a few hours a week instead of 40?

    Then how do you pay for supplies and operations, procedures, etc?

    this is not something you do by hand-waving ideas about churches and doctors with spare time.

    I think all Marshal did was demonstrate just how pitiful the conservatives are about the issue. It’s truly trickle-down, let them eat cake mentality. “Oh, lets get a few folks to volunteer and we’ll niggle out the rest of the details by talking about “ideas” for a few more years or decades”.

    this is not a ” oh give him a chance”.. to get all his ideas on the table. We already have a substantial pattern from the Conservatives on this issue. They are simply AWOL from meaningful and practical responses to the issue.

    they would rather turn down – MedicAid Expansion, take the hit on their budget and continue to watch their own citizens suffer from a lack of medical care – and blame the Fed and others for it rather than taking responsibility for it – like Massachusetts did.

    JimB finishes out his post with:

    ” HB 39 is best seen as a small part of a larger package of state- and federal-level, market-based reforms that decouple health insurance from employment, create price and quality transparency, spur innovative treatment models and promote hospital competition and productivity.”

    where in the DOODA ….. IS that “larger” “package”?

    and tell me what does providing adequate/sufficient medical care to the poor and indigent have to do with ” …. price and quality transparency, spur innovative treatment models and promote hospital competition and productivity”

    It’s one thing to fight the Feds and say that they have the wrong approach to MedicAid. It’s quite another to do essentially nothing but blather about “ideas” ….

    where is the substantiative proposal from the folks who oppose the Medicaid expansion?

    there’s a real irony here. Many of the folks who need, depend on MedicAid hail from rural Va – which is overrun with bible-thumping, GOD fearing conservatives who could care less about the loyal voting serfs health care other than “perhaps we can convince some doctor to volunteer”.

    grump!

    If you want to be a Conservative on the issue, please – learn to do the second part of talk-the-talk – … walk-the-walk. If you truly believe clinics are a better way ( something I AGREE with) – then take responsibility beyond gesticulating “ideas”. Put together a system. more “do” and less “talk”.

  3. and here’s the thing about Clinics.. and I don’t call them “free” because they are not. They cost money to operate and it has to be real money that is sustainable and not just ‘donations’.

    donations certainly should be PART of any budget but they should also be recognized for what percent they reliably pay for and not used as a catch all excuse for why there are not enough doctors or hours of operation or services not provided.

    Clinics could have enormous potential – for instance for community colleges training nurses and Physician Assistants, etc.

    Kids without resources for college could get free scholarships in return for working in the clinics. One full-qualified doctor could have 4 or 5 physician assistants on his/her team when they take care of the things that they are skilled in and leave only what they can’t do – to the doctor.

    MedicAid itself could be financial support for specialists and procedures the clinics cannot do… but regular, typical and periodic care would be rendered by the clinics – and each county would contribute to the clinics like they do for regional libraries and jails , etc.

    We keep saying that the Federal govt should not be doing this but where are we on doing this ourselves in Virginia?

    Our excuse for not doing it is what? that we opposed the Feds doing it but that relives us of the responsibility of doing it ourselves?

    and on this basis one of the few Conservatives to stick their head of our their “let them eat cake” foxholes.. is Marshall.. blathering on about volunteering “ideas”?

    If Conservatives in Va were actual SERIOUS about doing something real, they would accept the MedicAid expansion – on a limited basis – to buy them some time to put together a legitimate state-wide community clinic system, with a goal of flying on their own without Federal aid or strings.. downstream.

    ANY PLAN. Any REAL PLAN to actually address the issue rather than oppose what they don’l like would be a responsible position from the Conservatives.

    The problem we have here is not that the Feds have run amok or that the lefties are devoid of fiscal responsibility – it’s that the Conservatives are absent all together from the issue beyond sniping about what they don’t like and offering cockamamie “ideas” that they themselves as a group – cannot agree on as a legislative agenda.

    but the most remarkable thing here – is that people support the GOP position on this.. which is basically an irresponsible one.

    • Patrick Hope – D – Arlington. But just sweep it under the rug.

      I’m not opposed to Medicaid expansion conceptually. But the idea it’s free money is a accurate as a WaPo editorial on Virginia. As I understand the ACA, Congress stated that, one expansion occurs, it can never be reduced. That’s a smart thing to do. It’s like giving a teenager car keys unconditionally. But we could always raise taxes.

      Move money from what the Commonwealth spends on health care to fund Medicaid expansion. But then, cut what’s left. Either the ACA works or its doesn’t. Since Congress did not even phase out the EMLTA obligations, I’d say the Democrats don’t expect the ACA to provide the projected savings. But then, aren’t they the party that said, “If you like what you have, you can keep it”?

  4. I plan on filing my own post on Medicaid, but the Marshall plan is truly silly. Jim, with his usual caveats, inflates the silliness by elevating the Marshall idea, which Larry and Waldo, nail, into a form of “free clinics” which is Jim’s spin.
    First, the ideas of dealing with 400K people out on a limb and getting some doc to spend a couple of hours a week seeing the poor for free is not equivalent. Many doctors do this anyway, but it is a drop in the ocean. Many doctors don’t take Medicaid not because they hate the poor but because they don’t want to admin costs. One fix for Medicaid — fix the admin structure.
    Marshall in his op ed, says that his plan to provide docs with Atty. Gen. representation in malpractice, is ” tax free.” Nonsense. Taxpayers are paying for this in another form — namely the state lawyers are still getting paid and their time should be accountable. Marshall and Cuccinelli tried this stupid ruse when they claimed that Cuccinelli’s witch hunt against Michael Mann was “tax-free.”
    If I were a physician, I would have a hard time wanting some assistant atty. gen. to represent me in a serious malpractice case. I would want a malpractice specialist, not some thirty-something part-timer who spends most of his or her time doing highway right-of-ways or helping big energy companies screw property holders out of their natural gas rights. I am sure the office will change for the better with the new attorney general, but the point stands.
    It really is amazing just how staunch conservatives like Marshall stretch to deal with very real problems. They dip into their privatization pocket. Then they dip into their “faith-based” social service pocket. Churches and true free clinics certainly must do commendable work but to simply say that we can hand off this huge problem to an already highly stressed system and take it off our minds is simply ludicrous.

  5. I plan on filing my own post on Medicaid, but the Marshall plan is truly silly. Jim, with his usual caveats, inflates the silliness by elevating the Marshall idea, which Larry and Waldo, nail, into a form of “free clinics” which is Jim’s spin.
    First, the ideas of dealing with 400K people out on a limb and getting some doc to spend a couple of hours a week seeing the poor for free is not equivalent. Many doctors do this anyway, but it is a drop in the ocean. Many doctors don’t take Medicaid not because they hate the poor but because they don’t want to admin costs. One fix for Medicaid — fix the admin structure.
    Marshall in his op ed, says that his plan to provide docs with Atty. Gen. representation in malpractice, is ” tax free.” Nonsense. Taxpayers are paying for this in another form — namely the state lawyers are still getting paid and their time should be accountable. Marshall and Cuccinelli tried this stupid ruse when they claimed that Cuccinelli’s witch hunt against Michael Mann was “tax-free.”
    If I were a physician, I would have a hard time wanting some assistant atty. gen. to represent me in a serious malpractice case. I would want a malpractice specialist, not some thirty-something part-timer who spends most of his or her time doing highway right-of-ways or helping big energy companies screw property holders out of their natural gas rights. I am sure the office will change for the better with the new attorney general, but the point stands.
    It really is amazing just how staunch conservatives like Marshall stretch to deal with very real problems. They dip into their privatization pocket. Then they dip into their “faith-based” social service pocket. Churches and true free clinics certainly must do commendable work but to simply say that we can hand off this huge problem to an already highly stressed system and take it off our minds is simply ludicrous.

  6. Those who are ideologically and philosophically committed to the idea of government-run health care — whether Obamacare, single-payer or some other permutation — will not be satisfied with Marshall’s idea. It doesn’t come close to meeting their standards of perfection. I don’t write for them.

    For those who would like to explore the idea of a market-driven health system with a safety net, Marshall’s idea has much to recommend it.

    HB 39 is not a comprehensive solution, nor does it pretend to be. It is best seen, to quote myself above, “as a small part of a larger package of state- and federal-level, market-based reforms that decouple health insurance from employment, create price and quality transparency, spur innovative treatment models and promote hospital competition and productivity.”

    Larry asks, where is that “larger package”? Virginia did pass legislation a year or two ago to build more price and quality transparency into the system. I’m not sure where that stands right now…. probably working its way through the bureaucratic netherworld. Hopefully, we’ll see tangible results in the not-too-distant future.

    As for competition, productivity and innovation, Obamacare has sucked all the oxygen out of the room, displacing any other ideas for reform. Indeed, we’re getting the opposite, thanks to Obamacare. In innumerable measures that have gotten zero attention from the media, Obamacare limits competition between providers and hampers productivity. On this blog, I have written how hospitals are protected from competition by upstart physicians with the gall to launch their own specialty surgical facilities. That provision only reinforces state laws that thwart competition by means of Certificates of Public Need.

  7. “Marshall envisions churches, neighborhood groups and hospitals setting up neighborhood primary care centers staffed with volunteer labor.”

    We have one where I live. What Marshall describes is possible. Here is a link to the Annual Report. Maybe this will help others understand them a little better.

    http://www.fmcwinchester.org/about-us/annual-report/

    Some form of charity will be part of any medical system we come up with. Some people simply don’t have the means to pay. If the number of people who don’t have the means to pay for services is out of control, that’s not the medical system’s fault. There are other things we need to focus on to lower that number.

    • oh we have one also: http://lloydfmossfreeclinic.org/

      but with respect to the number of people who need service.

      UNTIL we figure out how to get that under “control”…

      is the answer to just not provide the services that people need and let these
      clinics turn away people?

      my complaint is that we talk and don’t act.

      we keep saying we ‘need to figure this out’ .. but we never do and then that
      becomes the excuse de-jure for not only not acting.. worse that that – opposing other approaches.

      In other words – we don’t want to do anything and we don’t want anyone else to do anything either.

      we need to recognize what we are doing …. more important.. what we are not doing and spending years, decades pretending we are “working it out”.

      every one of us that buys auto insurance – go look at your policy – ….we pay money for people who are uninsured. we ourselves have to buy extra insurance in case we have an accident with an uninsured.

      Now tell me why – we find paying this extra money for autos – acceptable

      but not something similar for those without access to health care?

      the very people who claim they know how to do this with the free market – provide ZERO solutions.. just more delay and obstruction.

      It’s time to stop blaming those nasty “progressives” and hold those who obstruct – accountable for their own failures.

  8. blather. pure 100% unadulterated BLATHER!

    there is NO PLAN. the PLAN is to do nothing but talk some more.

    Our health care system was an unmitigated disaster before the words “ACA” were every uttered!

    re: ” Those who are ideologically and philosophically committed to the idea of government-run health care — whether Obamacare, single-payer or some other permutation — will not be satisfied with Marshall’s idea.”

    where does that leave us with regard to Virginia’s own citizens who do not have insurance and cannot afford health care?

    tell me how you are going to help those folks without government?

    tell me BEFORE you do away with MedicAid. What IS …YOUR PLAN?

    you don’t like the govt or MedicAid but you have no plan other than to imply that we should repeal EMTALA and let those without access to medical care – just do without …

    OR.. if I am being too rough here.. then tell me what your PLAN is that does not rely on Government?

    this is THE … PROBLEM with Conservatives on this issue. They just flat out refuse to deal with the realities and to cover it up – they blame “progressives” for their approach.

    give me a real plan.. not just some “ideas”….

    while you’re chewing on that .. I have a plan… unlike the Conservatives..

    Create a law that allows non-profit Private, non-govt health clinics to operate. excuse all taxes on all services an equipment that they buy.

    fund the clinics with:

    1. – an uninsured health insurance tax similar to what we all now pay on
    our auto insurance for uninsured drivers.

    2. – put a sales tax on medical devices, therapies and procedures that are elective.

    3. – put an occupancy tax on hospital bed like we do for hotels – except unlike the money for hotel taxes – the money goes to operate the clinics.

    4. -Any company that sells MRI and other kinds of medical equipment in Va – has to sell it to the non-profit clinics at cost.

    5. – the non-profit clinics are allowed to advertise and sell medical services at a discount for those who want to pay cash or whose insurance will allow them to use the clinics lower priced services.

    we do really weird stuff like putting a tax on property recordations to pay for all manner of unrelated things – like transportation – why not health care?

    once again.

    Lets put a BAN or BLATHER and a tax on blaming progressives while offering nothing of your own.

    I blame progressives also – by the way… but when you have little more than feckless cowards masquerading as conservatives, what do you expect?

    If people who claim to be conservatives are really serious about the issue – they will get in the game.

    If what Marshall did is an example of conservatives getting into the game , all I can say is.. “so what else is new”?

    this is like a forever game of how many different excuses an entire political party/philosophy can make us as to why they won’t act.

  9. The lack of competition driven by large private hospital corporations is a serious problem and so are certificates of public need, but it does not address the actual problems at hand with Medicaid.
    Handing the poor over the charity sounds good but is neither realistic nor sustainable.

  10. Free clinics are great and already providing much needed care to the uninsured, and they will continue to do so. But clinics are not hospitals, and most of the expense of these hospitals is for hospital care – cancer, strokes, vasulcar disease, end of life. Del. Marshall’s proposal does nothing for the hospitals who will have huge bills that neither the federal government nor Virginia will pay.

    Who will pay? Alternatives: Those who can’t afford to pay will not get the care, unless they can convince a charity to pay for them. Or, the hospitals will pass the cost on to their paying customers – those with health insurance.

  11. I appreciate the discussion that this entry invited, but thanks go to Peter and larryg, inter alia, for their good sense.

    It may take another painful, wasted five years before we cease this debate and as a nation finally recognize that basic health care ought to be a government-guaranteed service — certainly with all the appropriate fiscal monitoring, and yes, possibly increased revenue, that we can muster. Reliance on churches and public charities is, as a practical matter, absurd; chancy and unreliable. Time for the U.S. to join other OECD countries in providing health care.

    • we went through this with Medicare. Right now, we insure 50 million people older than 65 for about 500 million a year… about $500 a month which is subsidized to the tune of 400.00 a month but it’s guaranteed insurance with no life-time limits.

      I totally support cutting that subsidy to the richer folks .. No one who is making 85K in retirement income should be paying just 100.00 a month for unlimited health care.

      I totally support Community Clinics as an integral part of MedicAid.

      I’d like to see people who get MedicAid give back in labor what they do not have in money for some of them to be trained to get jobs as medical care providers… etc..

      but we have a shameful group of others who are bereft of basic morality and fiscal responsibility. They pretend that the system we have is not broke and that Obama broke it. They’d rather do that than admit the reality.

  12. Let’s see, we just cannot seem to grasp the Delegate Patrick Hope is a co-patron. Must be his party designation.

    Now the ACA is coming back because somewhere between 1 and 2 M people have signed up. But what about the 4 M whose policies have been canceled? http://www.memphisdailynews.com/news/2013/dec/30/that-health-care-law-by-the-numbers/ Hopefully, some have been reinstated. But this is the GOP’s fault, because they didn’t amend Obama’s bill when the D’s had control over both houses of Congress. But how did these policies get canceled when Obama and others promised they could keep what they had if they liked it?

    The ACA was built on this lie. And the evidence strongly suggests that, even with the new pools and an expansion of Medicaid, taxpayers will still be paying for health care.

    Obamacare is about giving away money on the backs of the middle class. What a fine Democratic Party plan.

    Let’s go further, free health care, free college educations, caps on rent at $500 per month.

    • re: ” But this is the GOP’s fault, because they didn’t amend Obama’s bill when the D’s had control over both houses of Congress. But how did these policies get canceled when Obama and others promised they could keep what they had if they liked it?”

      they’ve refused to amend. It’s repeal or nothing.. right?

      “The ACA was built on this lie. And the evidence strongly suggests that, even with the new pools and an expansion of Medicaid, taxpayers will still be paying for health care.”

      they will. but paying for periodic routine care is cheaper than paying ER rates for care.

      “Obamacare is about giving away money on the backs of the middle class. What a fine Democratic Party plan.”

      ObamaCare is what happens when the GOP flees the healthcare scene and refuses to do anything.

      “Let’s go further, free health care, free college educations, caps on rent at $500 per month.”

      Let’s see how many Va GOP Congressmen put their money where their mouth is and repeal EMTALA and tell the poor to eat cake?

      The GOP and it’s supporters seem quite happy with watching those who need care – just be sick or die… and if they could secretly kill EMTALA and MedicAid and not have to face voters at election – they’d do it.

      opposition without an alternative is cowardly and feckless. Those who sign on to that approach .. bear responsibility also.

      • Larry, you keep arguing that expansion of health care coverage will save money. I agree uncompensated ER care costs are passed along to insurers and patients, at least to some degree. In theory, “putting those users” into the insurance or Medicaid system will allow such costs and pass-throughs to be reduced. But no one has offered to do that. No one has said, we’ll spend XX billion on Medicaid expansion and subsidizing premiums to people with somewhat larger incomes; and we will pass along YY billions to the middle class in premium cuts.

        I can see some caution in the first couple years, as transitions aren’t always smooth. But no Democrat from Obama on down has said we will pass along YY billions or reduce premiums by 15% (at least in real terms). Why? Because health care reform is not about saving money or helping the middle class. It’s about the Great Man of Hope and Change giving money to those who voted for him. And the facts are coming out to show that, to give away all this money, the middle class gets screwed. Policies canceled. Premiums increased. Deductibles increased. Choice of hospitals and doctors limited. Tell me why this is moral? I guess it’s because the 1 to 2 million who now get insurance or Medicaid trump the 4 million plus who have lost insurance coverage.

        Americans voted for Obama and got a truck load of crap – the ACA. It’s all the Democrats fault. They didn’t need to vote for it. They caved.

        mbaldwin What federal program has “appropriate fiscal monitoring”? Let’s just raise taxes. That will get businesses hiring. That will help the forthcoming retirement crisis.

        • TMT – this is the same dialogue we heard when Medicare was passed.

          but to have an informed discussion – we need to differentiate between the health care exchanges and expansion of MedicAid.

          the “great man of hope” is not informed comment but partisan blather.

          If you were serious about your objections -you’d have a preferred alternative solution and you don’t seem to have it so your opposition is mostly ideological and partisan not substantiative.

          you cannot prevail in the argument that way TMT.

          you lose in the long run and reality overtakes the propaganda …

          do you know what “open season” is for ObamaCare?

          life events…

          do you know what one kind of life event is?

          it’s when you lose your employer-provided insurance.

          do you know what people are going to do when they lose their employer-provided insurance?

          do you know how many people are going to do that in the coming months and years?

          what is your alternative?

  13. I’d also have people that get care –

    1. – pay something or provide volunteer hours, etc that might well include getting training to do things.

    people feel good about giving something for what they get instead of having it feel like they are on the dole.

    volunteers, in training, could provide much of the labor resources required in clinics but it would have to be organized and institutionalized.. not some Ad Hoc.. approach.

    but as communities – if we can organize and support libraries, parks and rec, etc.. why in the world do we ignore health care?

    and if we are going to re-direct ER reimbursements to MedicAid why in the world can we not use that money to provide for Physicians Assistants and training and convince some ER doctors about to be unemployed to become Clinic GPs?

    I still ask – why do we direct our fury at the ACA and the Feds instead of taking on this issues ourselves ?

    • Probably because the ACA has largely preempted the field. I don’t suppose Obama will propose allowing any state to design and implement its own plan.

      Also, we have the Washington lobbyists, making sure their clients are taken care of.

      • each state CAN design their own plan TMT.

        you’re spending too much time reading propaganda and too little time fact-checking on your own guy.

        the people who oppose the ACA are not telling the truth because they feel that enough people are gullible that they can get away with it and guess what.. they are right!

        but the reality is that states have flexibility not only in their Exchanges but in their Medicare Expansions…

        http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_96.pdf

        and again – the opponents have no suggestions about how to improve it just opposition and promises to kill it totally.

        this time next year – the opponents are going to look like this years Benghazi critics..

        • States could establish exchanges, not decide not to participate in the ACA by developing their own plans. My goodness, 4 million plus people have had their insurance canceled because the policies didn’t meet federal standards. How can that be state flexibility? No state could say, “Feds cannot cancel any policy that meets State standards.” The ACA tossed out state standards.” How can that not be federal preemption?

          Designing a state exchange is not designing state health insurance law. Similarly, once a state joins the Medicaid expansion, it cannot change its mind? How is that flexibility? Sorry, Larry this argument doesn’t cut it. The ACA cut out state law on health insurance. And every Democrat who voted for it is responsible for the loss of insurance policies by 4 million plus – the middle class sacrifice for Obama’s giveaway.

          Watch Mark Warner spend most of 2014 backpedaling. Again, there aren’t enough rich people to pay for the ACA expansion. So the Democrats pushed the middle class into paying much of the subsidies by canceling their policies that wouldn’t provide the needed subsidies into pools that overcharge them. Obamacare is based on fraud – fraud by the federal government.

          • “States could establish exchanges, not decide not to participate in the ACA by developing their own plans. My goodness, 4 million plus people have had their insurance canceled because the policies didn’t meet federal standards. How can that be state flexibility? No state could say, “Feds cannot cancel any policy that meets State standards.” The ACA tossed out state standards.” How can that not be federal preemption”

            in the same way that the ACA said that you could stay on your parents policy until age 26 or than the Feds tell you how to design interstate highways or put nutrition labels on food, etc or have to meet storm water rules or for that matter what you must cover in Medicare.

            are you into a state’s rights mindset on everything now or just the ACA?

            “Designing a state exchange is not designing state health insurance law. Similarly, once a state joins the Medicaid expansion, it cannot change its mind? ”

            they can change their mind but they lose the money just like right now.

            “How is that flexibility? Sorry, Larry this argument doesn’t cut it. The ACA cut out state law on health insurance. And every Democrat who voted for it is responsible for the loss of insurance policies by 4 million plus – the middle class sacrifice for Obama’s giveaway.”

            TMT – I think, if you want, you can go to a lot of Federal laws and make your claim about flexibility. What’s your point? Are you opposed to all Federal laws because they are not flexible enough for your tastes?

            our pre-existing health care system was and is a rabbit warren of dysfunctionality multiplied by 50 times. Doing anything was and is going to cause disruption to it. If you supported a better alternative plan, you’d have a better argument especially if it had less disruption but the truth is you’ve joined the opposition crowd with no one whit of an alternative – even your own … you can win that way. you lose in the long run and that’s the fundamental problem with the GOP these days. They have no solutions and really do not want to govern….

            “Watch Mark Warner spend most of 2014 backpedaling. Again, there aren’t enough rich people to pay for the ACA expansion. ”

            that’s not how the expansion is paid for. you KNOW that as even Jim Bacon has showed you how it’s paid for – transferring ER reimbursements to MedicAid and taking some of the Medicare Advantage subsidies.

            Mark Warner is only in trouble with the opposition crowd. The more people who get health care, the more support he will have. Everytime a guy changes jobs and loses insurance and gets it back from the Exchanges is going to be one more vote for Warner.

            “So the Democrats pushed the middle class into paying much of the subsidies by canceling their policies that wouldn’t provide the needed subsidies into pools that overcharge them. Obamacare is based on fraud – fraud by the federal government.”

            for the opponents who have no alternatives – yes…

            for many more.. they will see and understand that the opponents have no alternative plan and come election time are going to promise to take insurance away from people as their campaign promise?

            think about what the GOP is going to run on TMT>

            they’re going to promise to take away health care from millions….because they have no alternative…

            how will they win like that? The only way they’d win is in people who have insurance never fear having to change jobs and lose their insurance. Anyone else who knows that their insurance is tied to their job and their job is not secure (as many are no longer) will thank God for the ability to get a another job and not worry about getting insurance for their family.

            the opponents are going to lose. It’s not going to be a slam dunk… it’s going to be a slow process but as more and more people get insurance that could not – those folks are not going to be opponents.

            If the opponents had moral and fiscal integrity – they would want to ether reform or they would have a real “Replace” but the do not. They just want to destroy, to vandalize…they have no positive agenda for addressing our health care system… failures…

            wrong side of history guy.

          • You know.. NOTHING keeps Virginia from doing it’s own plan like Massachusetts and Vermont have.

            We did reject the Federal Exchanges but nothing keep us from developing our own Virginia-based exchanges.

            Virginia has one of the tightest MedicAid programs in the 50 states, 48 I believe.

            Able-bodied people who are not parents get no coverage what-so-ever.

            Virginia has the ability to reduce benefits for nursing homes for people who own significant assets but it will not.

            it chooses to subsidize those who own homes rather than cover more people who have no assets and no health care at all.

            We have the ability.. we have always had the ability to do what Massachusetts and Vermont – and some other states are doing – which is take responsibility for Virginia citizens needs.

            and instead we shirked that responsibility … allow our own citizens to go without access to health care – and oppose any Federal efforts to help them.

            Compare this with how we deal with at risk kids and the Federal government providing Title 1 funds for specialized teachers to help them.

            what would people think if we refused the Title 1 funds and at the same time refused to do anything ourselves to help at-risk kids either.

            If one leans towards state’s rights – then fine.. but leaning towards State’s rights at the same time you evade any responsibility for dealing with the problem is just plain feckless… not leadership.

            We took responsibility for uninsured drivers in Va. why not uninsured healthcare?

            We could build a network of clinics across Va – perhaps partnered with Community Colleges to train people in Medical occupational careers.. with real clinical experience….

            we could “grow” not only jobs but more medical professionals including Physician Assistants to give care to MedicAid folks under the guidance of one doctor – a paid doctor rather than a “volunteer”.

            there is a wide array of things that Va could do regardless of what the Feds do … and yet we do essentially nothing ..except of course ..opposed the Feds.

            that’s not leadership.

  14. errata:

    “but the truth is you’ve joined the opposition crowd with NOT one whit of an alternative – even your own … you CANNOT win that way. you lose in the long run and that’s the fundamental problem with the GOP these days. They have no solutions and really do not want to govern….”

  15. People should look at this slide presentation about Virginia MedicAid.

    Pay special attention to the percentage of seniors vs other populations (7%) and the percentage of expenditures for seniors (35%) for long term care and pay attention to the fact that spending MedicAid money for that purpose is OPTIONAL.

    Virginia does not have to spend that money, it’s optional.

    In other words 1/3 of the Virginia budget for MedicAid goes to pay for long term care of many who own their own homes and get the state to pay the costs instead of getting a reverse mortgage on their homes and leaving the balance to their kids.

    this is the reality.

    this is how Virginia chooses to help it’s citizens. It turns it back on those who don’t even own a home and pays for care for those that do own homes.

    go through the slide presentation.. it has lots of other informative info in it that might help provide a better perspective of how Va deals with health care.

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