New Concerns about Medicaid Expansion

You thought emergency rooms were crowded? Just wait.

You thought emergency rooms were crowded? Just wait.

The debate over Medicaid expansion in Virginia just got more complicated… again. A new study found that 10,000 new low-income Medicaid recipients in Oregon visited emergency rooms 40% more often than those without insurance, reports the Wall Street Journal. The finding undercuts claims that expanding the program would save money as low-income patients utilized primary care doctors instead of expensive ER services.

The new Medicaid recipients used ERs more often for all kinds of health issues, including problems that could have been treated in doctors’ offices during business hours, the WSJ writes. Using $435 as the average cost of an ER visit, researchers calculated that Medicaid increased annual ER spending by $120 per covered person.

Oregon extended the Medicaid program to 10,000 residents selected by lottery in 2008, providing, in effect, a controlled experiment showing the effects of Medicaid coverage. A separate study found that while new Medicaid patients spent less money out-of-pocket for care and reported improved health, they showed no improvement in such measures as blood pressure, blood sugar or cholesterol levels.

“It may be that some people did substitute the physician’s office for the ER, but there wasn’t enough of that to offset the increase in ER use,” said Katherine Baicker, an economist at the Harvard School of Public Health, a … principal investigator of the project. She said the data from all their research to date suggest that extending Medicaid to the uninsured increases health-care costs between 25% and 35% per person.

One still can argue that expanding Medicaid in Virginia  is fiscally prudent, even if total health care spending goes up, because the federal government will pay 100% of the added expense for four years and 90% after that. But it will be impossible to maintain, as some did, that overall costs will go down.

It was unclear from the WSJ reporting of the study what impact a statewide expansion of Medicaid in Virginia might have on the state’s health care system. However, based on the Oregon experience, it seems reasonable to conclude that adding an estimated 200,000 patients to Medicaid in Virginia would create a surge in demand for hospital ER services. On the positive side, hospitals would get reimbursed for those services; typically, they write off much of the cost of care for the near-poor targeted by Medicaid expansion. On the downside, ERs could become overloaded and the quality of service could deteriorate for all ER patients.

– JAB

15 Responses to New Concerns about Medicaid Expansion

  1. According to the NY Times, the Massachusetts’ numbers are significantly different than this Oregon Medicaid result. You may want to read that piece in addition to the WSJ before concluding that “decreased emergency room visits” is another Obamacare lie. It might be, yes, but the Times story, at least, implies that there is massive complexity in understanding the effect of health insurance on emergency room visits.

    • salz.. do you have a link for the Oregon deal?

      the other thing to think about here is what happens if you have regular employer-provided insurance and you visit an ER for something that does
      not require the ER?

      some plans ..will send you a summary of charges with a great big “not covered” on them.

      MedicAid needs to work the same way.

  2. this is a big problem. It totally undermines the premise behind reducing reimbursements to hospitals and using that money to provide primary care to MedicAid folks.

    and worse.. it shows that people will use the ER with insurance when before, without insurance, they would not.

    If we had the ability to make changes to the law – we’d need to do something like change EMTALA to turn away folks who have MedicAid and do not need ER care.

  3. we need to maintain a common-sense perspective here by recognizing that existing entitlements like Medicare and MedicAid also have had and continue to have flaws like this.

    Medicare is slowing going broke because we still provide non-deniable full coverage medical care to couples that make 170K in income for 100.00 a month.. AND we sell ALSO sell them subsidized Medicare GAP coverage to pay the 20% that MediCare Parts A and B do not cover.

    MedicAid is the second biggest budget item in Virginia’s budget in no small part because Virginia has chosen to provide an optional benefit – nursing home care for people who own their own homes – and doing that eats up about 1/3 of the MedicAid budget.

    ObamaCare suffers from some of the same issues and all 3 of these will need changes but none of them are going to be repealed anytime soon.

    it’s time to stop looking for excuses to kill it and work on all entitlements to make them less wasteful, more cost-effective – and stop giving away money to people who do not need it – for all 3.

  4. Larry’s comments raise an important issue – what is the proper balance between focusing entitlements on individuals with actual financial needs and ensuring broad political support for the programs. There is no easy answer. FDR designed Social Security to cover a broad swath of people, including those who probably didn’t need the coverage. Why? Because without broad coverage, we have a welfare program. Americans do not like welfare. They generally don’t like the idea of supporting someone who should be supporting him/herself. Social Security would not likely have passed or, if so, be a popular program had FDR limited it to those elderly with the lowest 25% of income. “Why should I work and pay SS tax for 30 years so support all those other people (the “undeserving poor”)? It’s little more than theft.”

    But once you expand the program and get the political support, it’s darn hard to reduce that support for anyone. The higher income elderly tend to vote and vote against people who are taking away what was promised to them. Therefore, as Larry notes correctly, we see federal and state tax dollars going to nursing homes and keeping Medicare Part B premiums low. If a politician proposes to take this away, I suspect he/she will be unemployed come the next election.

    I honestly don’t believe people would support Medicaid if it paid nursing home fees for the very low income, while forcing the middle class to sell their homes. “Why do we have to give up the money we worked hard for all those years to support people who didn’t work as hard, used drugs, fill in the blank?”

    As far as Medicaid enrollees continuing to use ERs, I suspect that such behavior will continue to happen to some significant degree, which is why I argue Obamacare will not reduce health care costs significantly. Expanding coverage will increase usage and the amount of money spent on health care, most of which will hit the middle class. This is yet another lie told by Obama and his crowd to get the ACA passed.

  5. social security is fairly well calibrated… you get out of it what you pay into it except at the lower tiers you get a minimum benefit if you paid into it and basically are working poor. But there are people who do not get Social Security at all…. I can assure you. Some never paid into it at all and do not get it – at all – even though they are dirt poor. They get welfare instead.

    and we are going to go to a chained CPI for inflation because the current method is too rich…

    we have a much bigger problem with Medicare where we charge people who earn 170,000 in annual income – $100.00 a month for guaranteed, no lifetime limit health insurance that covers 80% AND we then sell them heavily subsidized GAP insurance for the remainder 20%.

    AARP and United Healthcare make billions from these subsidies not to mention people who own 2 homes, several cars and have hundreds of thousands, millions in personal assets who pay 100.00 a month for health insurance.

    We have a similar problem in Va where 1/3 of our MedicAid budget goes to pay for nursing homes for people who own their own homes and could get reverse mortgages to pay for that care. Instead, taxpayers subsidize them.

    ” I honestly don’t believe people would support Medicaid if it paid nursing home fees for the very low income, while forcing the middle class to sell their homes. “Why do we have to give up the money we worked hard for all those years to support people who didn’t work as hard, used drugs, fill in the blank?”

    what about the folks who own homes and get nursing care from MedicAid?

    would you want THAT money to go to the poor instead?

    TMT – that’s really a despicable attitude. Virginia does not cover able-bodied people on MedicAid. It covers only children, pregnant women, the handicapped and the elderly and all of them are supposed to be poor…and not have assets but Virginia chooses to provide subsidies for those who have assets.. and it’s not required by MediAid.. it’s purely optional on a state basis.

    look at this slide presentation on Va. MedicAid:

    http://mirc.virginia.gov/documents/06-17-13/Medicaid%20Overview%20and%20Financing.pdf

    the money is not spent on people who don’t work as hard or use drugs unless you think moms, kids, handicapped or the elderly are drug users. I think that’s a despicable attitude TMT.. and it sounds terrible.

    It comes across as demonizing the people who receive MedicAid which is your basic right wing propaganda ….and not the truth.

    All 3 of these entitlements need changes.

    This is an opportunity for the GOP – to go to the Dems and agree to make changes to ObamaCare if the Dems agree to make changes to Medicare and MedicAid.

    somewhere in this conundrum.. the GOP has to recognize that people want Social Security, Medicare and some reasonable kind of health care for those who do not get employer-provided.

    Americans are not in favor of doing away with Social Security, Medicare nor EMTALA or MedicAid.. and the GOP needs to deal with that reality and stop screwing around playing games…

    Come November, Warner’s opponent is going to have to have more of a position than “repeal”.

    • ” …social security is fairly well calibrated… you get out of it what you pay into it …”.

      Untrue!

      The very people who paid the highest percentage of their incomes (and the most dollars) into Social (in)Security will receive 75% of the benefits currently being received by those who paid a lower percentage of income (and fewer dollars).

      The “Social (in)Security is fair” myth is just another big government talking point of the liberal left.

      Politicians are willfully paying out more in SS benefits than the system can sustain (given US demographics) because politicians are inherently dishonest weasels. To paraphrase Vince Lombardi – politicians believe that getting re-elected isn’t the most important thing, it is the only thing.

      Big government programs in America fail because our political process is broken. Until the process is fixed, the programs will continue to fail.

      Term limits are an essential component of fixing US government.

  6. Larry, I am discussing the politics of entitlement programs. I am not making statements about where I draw moral lines. But many people do think what I expressed in my comments.

    FDR was a political genius. He sold SS and established the ability to create Medicare by making the programs “semi-universal.” And dollars to donuts, if SS was not universal for senior citizens (did I really write that), the program would not have passed Congress and become a sacred cow. The GOP has tried to cut back on SS and lost seats. The reform ball is in the Democrats’ court and they won’t touch it.

    I don’t disagree that, in concept, people want to expand health care coverage, but they simply are not willing to pay for it. That’s why those on the far left wanted single payer. Hide the costs in taxes. But those with insurance are not willing to go to single payer because they will have Medicaid. I’m not arguing whether it is morally right or wrong to refuse to pay for universal health care. I am arguing that the average American – D, R, or I, is not willing to accept higher premiums, higher deductibles, a lesser choice of providers or a requirement to pay for services they won’t likely need in order to expand health care coverage. And it is because Obama lied to them and sent the message that they didn’t need to pay more to cover others, that the ACA passed. It barely made it through the House. Do you think it would have passed if the public would have been told the truth?

    And why isn’t it left wing propaganda that the ACA would make health care better, less expensive, etc.? People like the woman in Oregon believed the Great One when he made those statements.

    A pool of any kind must have winner and losers. Obama gave so much to the winners from what they had, that he need lots of losers and big ones to boot. I’m not making a moral statement. I’m just addressing the politics.

    Could the financial calculus be changed if Congress or the GA implemented some of the changes to Medicare and the IRC that you have proffered? Yes. But I don’t see those changes as politically doable. But Mark Warner and all other Ds running for office will propose or support raising the Medicaid B fees to cost. That creates a welfare program that, deep down in their hearts, the average person won’t accept. That may well raise moral issues, but it’s correct from a political perspective.

  7. “Larry, I am discussing the politics of entitlement programs. I am not making statements about where I draw moral lines. But many people do think what I expressed in my comments.

    ” I honestly don’t believe people would support Medicaid if it paid nursing home fees for the very low income, while forcing the middle class to sell their homes. “Why do we have to give up the money we worked hard for all those years to support people who didn’t work as hard, used drugs, fill in the blank?”

    did I read the above wrong? is that not what you intended ? that’s what I reacted to.

    “FDR was a political genius. He sold SS and established the ability to create Medicare by making the programs “semi-universal.” And dollars to donuts, if SS was not universal for senior citizens (did I really write that), the program would not have passed Congress and become a sacred cow. The GOP has tried to cut back on SS and lost seats. The reform ball is in the Democrats’ court and they won’t touch it.”

    you’re getting SS confused with Medicare. Medicare was done by Lyndon Johnson after Congress approved it.

    FDR was no genius. There was significant opposition and there remains opposition, witness George Bush trying to privatize SS. FDR was 70 years ago. In the interim if SS was thought to be a failure, there were a dozen or more Congresses to repeal it including Reagan – who did the opposite -he expanded it.

    trying to tie SS to a “gullible moment” under a snake-oil salesman POTUS is more right wing fairy tales… the program survived because it worked and people wanted it as they do today. If SS was a failure, people would want it repealed and it’s the exact opposite. Even Tea Party types say “keep your hands off my Social Security”.

    “I don’t disagree that, in concept, people want to expand health care coverage, but they simply are not willing to pay for it. ”

    this is like saying you don’t already pay for uninsured when you do though. It’s not a question of paying something you’re not paying now – it’s a question of whether we can take what we are paying now and make it more cost effective.

    your opposition should be with regard to what the reality and facts are not some misconception.

    “That’s why those on the far left wanted single payer. Hide the costs in taxes.”

    that’s what most OECD countries including Singapore have and it’s not “hidden”, it’s pretty open AND because it’s more cost-effective – they cover everyone and still pay 1/2 what we pay even though we have 30-50 million uninsured.

    Again.. you believe you’re not already paying and you are and yet you keep insisting you’re not.

    ” But those with insurance are not willing to go to single payer because they will have Medicaid. I’m not arguing whether it is morally right or wrong to refuse to pay for universal health care.”

    I do though. and I believe making it a class issue is morally wrong also but morality aside, you are paying right now and as a fiscal conservative you should acknowledge that…

    It’s not only ER TMT… it’s people admitted to hospitals who cannot pay.. downstream of the ER. It’s all uncompensated care that you are paying for right now.

    “I am arguing that the average American – D, R, or I, is not willing to accept higher premiums, higher deductibles, a lesser choice of providers or a requirement to pay for services they won’t likely need in order to expand health care coverage.”

    tell me you have not done all of the above over the last 10 years to the tune of DOUBLE your costs…

    “And it is because Obama lied to them and sent the message that they didn’t need to pay more to cover others, that the ACA passed. It barely made it through the House. Do you think it would have passed if the public would have been told the truth?”

    Do you think if we knew 5000 of our young people’s lives were going to be squandered , sacrificed over a NeoCon nation-building scheme and another 50,000 slice and diced for the rest of their lives – that we would have agreed?

    what is a lie more than “repeal and replace”? when there is no “replace” and 40+ repeal votes with no replace?

    Obama screwed up .. I do not deny that but you’re way overboard on it like the right is.. and you’re going to lose.. because you have no alternative.. and come October, you’re going to have millions of people who are insured and GOP candidates either promising to take away their insurance or “lying” that they won’t try.

    this time next year, ObamaCare is going to be like Benghazi with the far right still flailing away on it and the rest of the country moving on to what needs to be fixed.

    The right was opposed to health care from the get go and they were opposed to this POTUS from the get-go. They have only got as far as they have right now – because the POTUS basically told a lie and kept their opposition alive.

    but that’s done and over.. and the health care law is not going to get repealed just like the POTUS did not get unelected.

    the only people that I respect as legitimate in this – are those who voted for Obama and supported ObamaCare and have now changed their minds.

    The opposition – that was opposition from the get go – have no legitimacy in my mind. they never wanted a solution to start with – just like with immigration – they have a failure to govern. They just walk away from real problems that need solutions and that’s not leadership, and when the same folks all get together in a big tent with racists and evolution-deniers, creationists who believe the earth was created in 6,000 years, etc… it’s a tribe of neanderthals… that I do give credit ..they are good political fighters.. but beyond that they lack – not an ability – but a desire – to govern. they are unfit to govern the country.

    “And why isn’t it left wing propaganda that the ACA would make health care better, less expensive, etc.? People like the woman in Oregon believed the Great One when he made those statements.”

    no. the ACA was to cover more people and try to move money for uncompensated care to primary care… it was never designed to reform the cost structure.

    the cost structure was the next issue to be dealt with. Right now, we pay providers for as many diagnostic codes that they can put on a bill – whether it’s employer-provided or Medicare or MedicAid or Tricare. They can fill a sheet with diagnostic codes and it may not do a thing for someone is sick because the goal is to make money on those codes – not necessarily focus on the patient outcome.

    If the GOP had half a brain.. they would offer an alternative that included reform of our dysfunctional cost structure… but again, the GOP does not do well with tough issues any more. they’ve become masters of the sound-bite but as a group – they are split apart on the tough issues these days.. they’re anti-science, anti-teacher, anti-gay/lesbian, anti-same-sex marriage, anti-black, anti-Hispanic, etc..

    health care is totally beyond them.

    “A pool of any kind must have winner and losers. Obama gave so much to the winners from what they had, that he need lots of losers and big ones to boot. I’m not making a moral statement. I’m just addressing the politics.”

    Have you considered the pool of senior citizens that get Medicare? 50 million of them. Do you know how much is paid to provide them with health care on a per person basis? Do you know the number – i.e. how much Medicare costs in the US budget? If you don’t know, you should find out – because it will tell you what the cost per person is for a “POOL” of 50 million who are heavy users of health care.
    if we can cover that group , why can’t we cover a younger group for less?

    “Could the financial calculus be changed if Congress or the GA implemented some of the changes to Medicare and the IRC that you have proffered? Yes. But I don’t see those changes as politically doable. But Mark Warner and all other Ds running for office will propose or support raising the Medicaid B fees to cost.”

    did you mean Medicare? not MedicAid?

    folks like you are the problem TMT. the people who now get MediCare for 100.00 a month are opposed to paying more… even though they know the program is going broke.

    The Dems are not going to propose cuts to Medicare as long as the GOP is focused on totally destroying Medicare – aka the Ryan voucher plan.

    there is a middle ground but it does involve keeping Medicare but reforming it rather than getting rid of it.

    No Dem with half a brain is going to look like they are siding with the GOP to get rid of Medicare.. both sides must say they want to reform it not repeal it and then go forward. As long as the GOP wants to kill it no Dem is going to even talk about reform.

    “That creates a welfare program that, deep down in their hearts, the average person won’t accept. That may well raise moral issues, but it’s correct from a political perspective.”

    wait.. are you calling MediCARE – for seniors , a “welfare” program?

    yes or no?

  8. Larry, you seem to be ignoring all the evidence that millions of people are seeing cancelations in their existing health care policies to force them to pay even higher premiums to subsidize the expansion of insurance. Why don’t those people count? They are equally important as the people getting access to insurance under the ACA. Or maybe they aren’t since some of them probably didn’t vote for Obama. Your guy – Obama told them over and over and over again they could keep what they had if they liked it. You know as well as I do that, had Obama told the truth, the ACA would not have passed the House. The Democrats lied and lied and lied for political gain. If they had any honor, they’d pass a bill in the Senate that grandfathers all insurance policies that don’t meet ACA standards. Let that part of the market function until we are all dead and buried. Let Obamacare grow on its own. But it won’t happen because the Democrats believe they are better positioned to make personal financial decisions. And the arrogant Obama is the worst.

    I think we are in agreement that there is great political risk in making the reforms you tout – increasing Medicare B premiums; forcing people to sell or reverse mortgage their house before qualifying for Medicaid for long-term care. You make some reasonable economic arguments for moving in that direction. But you want the GOP to take the lead to give the Ds cover. It’s Charlie Brown, Lucy and the football all over. The GOP candidate for Senate makes the proposal, and Mark Warner dumps all over him. Why would any thinking person do this?

    Where I think we agree is many people getting taxpayer money object to their being forced to give money to others. Where we disagree is: not a dime of the this taxpayer money is being paid by those to whom Obama wants to expand health care. They don’t pay taxes that go into the US general fund. And the Democrats have over the last 80 years told these people that they earned SS, and later, earned Medicare, etc. If you took a poll of reasonably educated, SS and Medicare recipients, it would overwhelmingly show they believe they are just receiving for what they paid earlier for others. So why shouldn’t Warner, Kaine and McAuliffe disabuse them of this fact? They have the bully pulpit. But they won’t use it because they want to take the other side of the issues to batter the GOP.

    I wonder whether any other two people in the Commonwealth have punched as many keys on the ACA as we have!

    • “Larry, you seem to be ignoring all the evidence that millions of people are seeing cancelations in their existing health care policies to force them to pay even higher premiums to subsidize the expansion of insurance.”

      not true TMT. the reason they have to pay higher premiums is to meet the minimum standard covered services like colonoscopies, they are no longer allowed to cap lifetime benefits, cannot deny insurance over pre-existing conditions.

      so it will cost more to provide these – that’s true but it also protects people from future loss of insurance… due to pre-existing conditions, etc. It’s not to pay for others. You need to read about where the funding for the newly insured is coming from. You’re basically repeating right wing talking points here – that are not the truth. Get the truth TMT.. I can disagree with you on facts but not propaganda that you cite.

      ” Why don’t those people count? They are equally important as the people getting access to insurance under the ACA. Or maybe they aren’t since some of them probably didn’t vote for Obama. Your guy – Obama told them over and over and over again they could keep what they had if they liked it. You know as well as I do that, had Obama told the truth, the ACA would not have passed the House. The Democrats lied and lied and lied for political gain. If they had any honor, they’d pass a bill in the Senate that grandfathers all insurance policies that don’t meet ACA standards. Let that part of the market function until we are all dead and buried. Let Obamacare grow on its own. But it won’t happen because the Democrats believe they are better positioned to make personal financial decisions. And the arrogant Obama is the worst.”

      they do count. and right now kids can stay on policies until 26. Women cannot be discriminated against – they have to get the same rates (like Federal FEHB insurance does). They cannot be denied for pre-existing conditions no matter their circumstance or whether it is employer-provided or not. They will not have lifetime limits. All of this will cost more but it also protects people into the future where some people would have developed conditions that were not covered.. or would hit lifetime limits, etc.

      I note to you that these new standards are exactly like what we current offer to seniors with Medicare AND we cover all 50 million Medicare subscribers for one cost.. and I’ve asked you to tell me how much.

      in fact I’ve asked you to acknowledge several numbers which you have not and you do that while you continue to spot right wing talking points instead.

      “I think we are in agreement that there is great political risk in making the reforms you tout – increasing Medicare B premiums; forcing people to sell or reverse mortgage their house before qualifying for Medicaid for long-term care. You make some reasonable economic arguments for moving in that direction. But you want the GOP to take the lead to give the Ds cover. It’s Charlie Brown, Lucy and the football all over. The GOP candidate for Senate makes the proposal, and Mark Warner dumps all over him. Why would any thinking person do this?”

      the basic problem is this ( and it’s the same problem for Social Security, Medicare, auto insurance, homeowners insurance, flood insurance – and …
      health insurance and that is – who pays if people do not get insurance?

      who pays?

      if someone does not save for their retirement and there is no social security – who pays?

      the mandate is a CONSERVATIVE idea to require people to be responsible for the costs that they will inevitably incur – instead of pushing those costs onto others.

      “Where I think we agree is many people getting taxpayer money object to their being forced to give money to others. ”

      and I once again point out to you that you already pay…

      “Where we disagree is: not a dime of the this taxpayer money is being paid by those to whom Obama wants to expand health care.”

      again, we need to distinguish between the exchanges and Medicaid expansion as they are not funded the same way.

      They don’t pay taxes that go into the US general fund.

      you need to show me what taxpayer money is going to ObamaCare. Please list the sources of the money.

      “And the Democrats have over the last 80 years told these people that they earned SS, and later, earned Medicare, etc. If you took a poll of reasonably educated, SS and Medicare recipients, it would overwhelmingly show they believe they are just receiving for what they paid earlier for others. So why shouldn’t Warner, Kaine and McAuliffe disabuse them of this fact? They have the bully pulpit. But they won’t use it because they want to take the other side of the issues to batter the GOP.”

      because people did not pay for Medicare Part B, TMT. I’ve told you this many times and you are free to verify it if you doubt it.

      people did not pay into Medicare Part B. taxpayers pay for 3/4 of it and the 1/4 is a 100.00 a month fee for guaranteed health care with no lifetime limits.

      you pay for this right now. people who get Medicare pay 1/4 of what it costs.
      Please go find out how much Medicare costs taxpayers and come back and tell me what it is.

      How can you talk about these issues if you do not know and won’t deal with the facts?

      I wonder whether any other two people in the Commonwealth have punched as many keys on the ACA as we have!

      yes they have. I think there are some HONEST issues worthy of debate but I get frustrated in listening to right wing talking points and no acknowledgement of the actual facts including where the money is coming from for the ACA, Medicare and MedicAid.

      you need to know the facts … on the money before you so readily accept the propaganda which is a mixture of facts and misinformation and disinformation.

      get the facts … argue the facts.. not the propaganda… please.

  9. As usual, the author takes one study that can be used to make a point he likes and then he goes far beyond its intrinsic research value.

    Giving more poor people access to medical coverage is not likely to swamp emergency rooms. Bacon uses the 200,000 figure as those possibly beating down the doors. That is roughly 2.5 percent of the state’s total population.

    It also might depend where the emergency rooms are. In Richmond, downtown MCV might see an increase, but the plusher hospitals liker St. Francis Bon Secours not likely. Why? You’d need a car to drive the 15 miles to get there from the inner city. Buses not available.

    Lastly, if there’s such a threat of the great unwashed overtaxing ER resources then why do hospitals advertise their ER wait times on fancy billboards to drum up business? I could never figure that out. If you were in a car wreck with a couple of compound fractures and a collapsed lung, it isn’t likely you are going to drive around doing comparison shopping by viewing billboards.

    Maybe that is Jim Bacon’s idea of bringing the magic of the market to health care.

    • I think JIm got valid info… the preliminary data does suggest that newly covered are going to ERs… and it’s not that surprising because that was often how they got care before .. but at the same time – they realized that the hospital would send the bill collectors after them so they did not use it as readily as they might if they had “insurance”.

      the solution to this is pretty simple. Don’t cover ER visits unless they are legitimate. The word will get out pretty quick. Don’t go to the ER or you’re going to pay the bill not MedicAid if it’s not an emergency.

      If we don’t have enough primary care docs, then we need to create community clinics and staff them with nurses in training, physician assistants, etc.

      basically – we have to take responsibility for making it work.

      it’s no more going to work on auto-pilot than Medicare does.

      we keep talking about the ER as shorthand for uncompensated care but it’s much more than the ER.

      when someone goes to the ER and they are sick – they get admitted to the hospital and they get services, doctors, tests, procedures, etc and these things cost money… and prior to Obama Care.. the hospitals would bill the patient, then send bill collectors after them but they still lost money so the govt would reimburse them – AND the govt allowed them to cost-shift .. essentially to charge those that were insured higher costs for services than the services cost.

      that’s why an MRI in this country costs 3 times what it costs in OECD countries. Somebody has to pay for the MRI and when 1/2 the folks getting and MRI don’t pay for it – you and I get to pay for it with our insurance, then our insurance, come every January, will increase their premiums to cover that cost shifting.

      We have a badly messed up system ….. and we have people who don’t want it to change because they are not currently in harms way… and they are afraid that is changes are made that they will get hurt.

      so the whole system is a disaster but people defend it as long as they THINK are not directly penalized .. even though over the last 10 years, on average, most policies have doubled in premiums.

      It’s hard to defend such a system but people do. It’s even harder to reform it without disruptions that affect many and so the GOP wants no part of reforms. The Dems.. had they had their druthers and not have Obama pushing them would likely have had no more ardor to reform than the GOP.

      but our health care system is failing.. it’s a bad model. Employer-provided healthcare is just as bad as employer-provided pensions – in the 21st century.

      People no longer have “careers” at one company unless it’s the govt.

      more and more people change jobs multiple times over their “career” and they need BOTH portable pensions and portable health insurance.

      that’s what the rest of the OECD countries have.

      A guy in Canada can change jobs anytime he wants or needs to – because his medical care has nothing to do with his job.

  10. The bigger problem is that more and more doctors are refusing to accept Medicare patients. The reimbursements are too low. The paperwork and bureaucracy is too high.

    In a recent Virginia House of Delegates race the Democratic Party candidate suggested forcing doctors to accept Medicaid.

    http://masonconservative.typepad.com/the_mason_conservative/2013/11/virginia-democrat-calls-for-forcing-doctors-to-accept-medicare-and-medicaid-patients.html

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