Medicaid Expansion an Inefficient Way to Prop up Rural Hospitals

medicaid_expansionby James A. Bacon

One commonly cited argument in support of expanding Virginia’s Medicaid program in concert with the Affordable Care Act is that enrolling more poor Virginians would help prop up financially shaky rural hospitals. Rural hospitals tend to serve disproportionately poor populations, which means they tend to provide disproportionate amounts of uncompensated care. Expanding Medicaid coverage to poor and near-poor populations, the logic goes, would provide these hospitals with much-needed cash infusions. If Virginia doesn’t expand Medicaid, many struggling rural hospitals may close, making health care even more inaccessible for the poor.

Marc D. Joffe and Jason J. Fichtner have taken a look at that argument in a new paper, “Hospitals and the Proposed Virginia Medicaid Expansion,” and found it wanting. The study was published by the Thomas Jefferson Institute.

Overall, Virginia’s hospital industry is in sound financial condition, generating net income of more than $1.5 billion in 2013, the authors note. Profits were not distributed evenly, however. The large, multi-hospital health systems such as Sentara, Carilion, Inova and Bon Secours were highly profitable, while many rural hospitals lost money.

Expanding the Medicaid program would pump millions of dollars into Virginia’s health care system without consideration to a hospital’s fiscal profitability, Joffee and Fichtner argue. Most of Virginia’s hospitals remain solidly profitable despite the burden of providing uncompensated care. They don’t need extra Medicaid revenue to remain profitable. Moreover, not-for-profit hospitals already receive important benefits — the ability to receive tax-deductible contributions, exemption from property taxes and corporate income taxes, and access to tax-exempt bond funding.

If  legislators want to prop up Virginia’s struggling rural hospitals, the authors write, they should target failing hospitals directly rather than subsidizing rich and poor institutions alike.

Rural hospitals have bigger problems than uncompensated care; between 1990 and 2000, 208 rural hospitals shut closed nationally, mostly the result of consolidations or low utilization. That trend continues. Lee Regional Medical Center in Lee County, for instance, had  a 34% staffed-bed occupancy rate in 2012 before it closed — way lower than the median occupancy of 63%.

“In free, competitive markets, suppliers that attract fewer customers are more likely to fail,” the authors write. “Small low-utilization hospitals struggle and are sometimes obliged to shut down.”

Bacon’s bottom line: Joffe and Fichtner make sense: If Virginia legislators want to keep struggling rural hospitals open, they should target aid to struggling rural hospitals, not to hospitals generally. But I would go a step further. I would argue that the idea of supporting general hospitals, which provide a broad range of medical services, may be an outdated idea. Perhaps rural health care systems should restructure around providing good primary care, supported by free-standing out-patient centers that inexpensively provide non-acute services, while referring patients with more acute conditions to larger, regional hospitals. Large-volume tertiary care centers can provide those services more cost-efficiently and with better outcomes than low-volume rural hospitals can. In exchange for the inconvenience of traveling further, rural patients likely would wind up with better care.

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29 responses to “Medicaid Expansion an Inefficient Way to Prop up Rural Hospitals

  1. Good post. But I would say this…..if the “larger regional hospital” is the model of the future for acute care, what happens in SWVA? And I think that’s the rub. Let’s say Carillion on one end and the Tri-Cities on the other end are the “regional” players. If those rural hospitals in between went out of business, you’re still talking hours long drives to Roanoke or Kingsport. That’s really tough on families to make visits.

    I think this is just part of a greater nationwide issue that everyone at the fed and state level ignores…..the decline of rural America. While I appreciate your posts on Growth and urban development…IMO we need to also focus our best brains for innovative policies to serve rural areas and how they fit into the 21st century.

  2. My problems:

    (1) Consider the source. Of course you are going to get a pro-business, no-need for public care argument from this place.

    (2) The large compensation are at huge or very large places like HCA and Bon Secours that concentrate in large cities or suburban areas.

    (3) Closing hospitals in SOuthwest Virginia means injure dor sick people have to travel an extra hour or two to get help.

    (4) If Virginia’s rural hospitals are doing so well, then why does RAM give thousands of people free medical and dental care every year ion places like Wise County. I reported on a similar RAM event not far away in Pike COunty Ky. for my coal book. If things are so great, then why all the need and why no Medicaid?

    (5) The Belhaven, N.C. hospital is one I know very well. It has always been a small clinic kind of place. Why? Because the larger old Beaufort County Hospital (now owned by the same company that shut Belhaven down and renamed ) is only 20 minutes away. Much more advanced care is available at Pitt County Memorial associated with East Carolina University Med School 50 minutes away. Truly world class care is available at Duke about three hours away.

    But one problem with closing Belhaven is that east of town there are not any real hospitals for maybe 90 to 100 miles. It is a poor area.How do I know this? My late father was a doctor on staff at the Beaufort County Hospital for 17 years.

    The authors are comparing compensation and revenue at places like HCA, the country’s largest for-profit hospital firm, and then ignoring the real rural need as the RAM examples show.

    Jim, why do you keep pushing the Thomas Jefferson Institute?

  3. Agree with Peter. This is the “let-them-eat-cake” folks.. who don’t seem to care that WORKING Virginians – no matter WHERE they live have no means to get routine periodic preventive care that heads off problems downstream that advance undetected and untreated and when detected – cost taxpayers AND those with insurance -millions of dollars in costs to advanced disease that was detectable and treatable for a lot less costs to taxpayers and insured.

    worse than that – Virginians already pay the taxes that would fund the expansion.

    beyond that , 30,000 health care jobs that would boost the economy especially in rural areas which would not only provide needed health care but provide good paying jobs to rural folks.

  4. I find it interesting that most lawyers perform pro bono work for indigent/low income individuals and/or for non-profit organizations. We don’t expect the federal, state or local governments to reimburse us, even for out of pocket costs. But doctors and other health care professions expect taxpayers to step up and pay them for taking care of indigent/low income individuals.
    And rural areas are having trouble attracting lawyers as well as doctors. Sounds like another scam to me.

    • Not that legal assistance is not important, but health care is much more critical. Besides, a lawyer can provide sub-standard assistance; a doctor who does the same may actually kill someone.

      Most importantly, however, the lawyer raises his fees to the rest to cover the pro-bono work; and assumes it at choice. The doctor and hospital don’t have a choice in that they don’t first ask for proof of insurance, etc. before service is provided. Those details are raised after the fact.

      • NVS – I think it depends on the individual situation as to which is more important – legal or medical services. I’ve been fortunate in a couple cases to save a client’s business including a rural medical practice.

        Raising fees. That’s funny. It is very difficult to raise billing rates or in many cases, sustain existing ones. I’ve frozen rates for some clients for years. Lawyers who do pro bono or other public service work are leaving money on the table. If we (lawyers) do it, why doesn’t society expect the medical profession to do some pro bono work?

        • TMT – re: ” why doesn’t society expect the medical profession to do some pro bono work?”

          we do – see the link

          http://lloydfmossfreeclinic.org/

          these guys could have vastly expanded their help to people under the MedicAid Expansion… and at the same time – take a load off the ER at Mary Washington Hospital.

          You could duplicate this in SW Virginia – and team up with Community Colleges to graduate local kids to be medical technologists and physician and nurse assistants.

          we could solve these problems if we could get rid of the ideological zealots.

  5. I must agree with Peter above: when I had a heart incident, I did not choose to have one, nor when it happened, nor when it happened, nor where I was taken. So, all the crap I hear about the ‘market’ is precisely that: crap (actually I am thinking of a much stronger term). Likewise, when someone is in an accident, it is not planned; that is why it is an accident.

    One of the most disgraceful things that happen here in VA is Remote Access Medical: doctors who provide the only medical care many receive, and that is only once a year. Medicaid can help relieve such things. In other words hospitals (and miscellaneous health care providers) need to be where they are needed, even if it is not profitable!

    • Guys, guys, guys, you are totally missing the point. Even if you insist upon providing health care services bundled together in a central location called a hospital (as opposed to free-standing physicians offices, urgent care centers, outpatient centers, etc.), there are more efficient ways to support rural hospitals than expanding Medicaid. The authors argued that the state could provide direct aid to those hospitals.

      It sounds to me that you’re secretly in favor of a plan that unnecessarily lines the pockets of super-profitable HCA and the super-profitable non-profit health care systems! How can you live with yourselves?

      • that’s total BS. the very same people would OPPOSE a tax-funded “direct” aid .. been there – done that – that’s why MedicAid is a FEDERAL program and not a state program.

        in terms of “central” “hospital” – what kind of world are you living in?

        MedicAid ALREADY supports different facilities and different providers as would the expansion..

        do you really believe that charity care ONLY occurs at “hospitals”?

        this is your answer ? “direct aid” to “decentralized facilities”?

        I cannot believe you really do think in such terms while totally missing the real issues…

        the reality is – that those options you suggest were ALWAYS options to the State .. and STILL ARE.. but where are they?

        why didn’t the GA adopt that brilliant strategy in place of the expansion?

        you guys kill me.. it’s all about evading the issues…”proposing” “ideas” that never happen , never did and never will.. but they are sure enough “ideas” that “could” be implemented – instead.

        this is loony. DO you REALLY think the GOP in the GA who would not take the Federal money – would actually appropriate Va taxpayer money for “direct aid”?

        what kind of planet do you live on?

        yes… this sounds exactly like the same argument against ObamaCare.

        I have one phrase for you – “where is the BEEF” ?

        you have empty buns Bacon.. that’s all.. but par for the “conservative” course these days.

        all talk – no action.. just excuses and obstruction.

  6. I’m amazed at folks who claim to be fiscal conservatives who apparently do not believe not getting regular periodic health care leads to advanced diseases that take 5, 10, 20, 100 times more to treat than if detected early.

    Diabetes is one of those diseases that when detected, can be treated and managed but when not detected and treated leads to kidney and liver disease, massive cardio-vascular disease that requires bypasses and hundreds of thousands of dollars of treatment – then amputations and dialysis, etc.

    these are costs that others pay – taxpayers and those with insurance.

    the people with these diseases are working people who are rendered disabled by the disease if not treated -more entitlements from taxpayers.

    In what alternate reality to these folks who promote themselves as fiscal conservatives live?

    It’s as if they just deny the realities.. as long as it satisfies their ideology.

    If any of these folks had the cajones – they’d oppose EMTALA – the law that requires – taxpayers and those with insurance – to pay for charity care.

    but they know that if they did that – they’d be exposed for who they really are so instead they play the nuanced games with words.. and “studies” – pretending, in essence, that uninsured and untreated people don’t cost too much or that we can simply deny them health care facilities.. i.e. close them up.

    used to be “conservatives” had principles.. they’d stand up and be unabashed about their beliefs even if it did make them look like pariahs.

    no more.. now they hide.. and play word games.

    In what alternate reality do these folks who pretend they are fiscal conservatives live?

  7. “The authors argued that the state could provide direct aid to those hospitals.”

    You really expect the General Assembly to do that. More naive than I thought.

    NoVaShenandoah is absolutely right, Jim. You cannot ever get over that medical care is an essential SERVICE, not some widget whose function and price can be decided by the free market and bean counters like these “analysts” the TJ INstitute ginned up.

    Emergency medical care is not free market based. Period. So when some mountaineer has a heart attack, you are suggesting that she or he must risk their lives by taking an extra hour or two to get help?

    I’ve been arguing with you on this point for years and it’s getting tiresome.If you are in a car wreck and your femurs are jutting through your skin and your lungs are collapsing, you do not have the time to screw around on the INternet doing some price reviews, efficiency ratings, etc..

    Can’t you connect the dots — emergency care is not market driven.

    • IF Virginia had done it’s own health care for citizens – I’d be the first to argue against the involvement of the Feds but the harsh reality is – with health care and education and roads – to name 3 – the Commonwealth simply is irresponsible about taking care of it’s own issues.

      that’s how Head Start and Title 1 and EMTALA and MedicAid came to exist in the first place.

      Thomas Jefferson is essentially saying – let the folks in Rural Virginia not only have inferior access to health care -but let them die – if they get sick or injured because they’ll be two hours away from a hospital..

      serves them right for living in rural Va.

      right?

      we’re dealing with willful ignorance and rank hypocrisy here.. the hallmark of the right these days.. they no more look for cost effective, fiscally-conservative solutions – nope.. they totally bail out from dealing with the issues.. blame the Feds and run away at the state level …

      I bet if Va and TJ had their way – Va would not only opt out of the MedicAid Expansion but they’d opt out of Medicaid and Medicare also.

      remember – the folks who would be served by the expansion is – working Virginians – people who work for a living.. people who pay State and Federal taxes…

  8. this whole blog post – is insulting to anyone with a minimal modicum of intelligence and awareness of how Conservatives these days deal with health care.

    they cannot, as Peter has stated, get it through their thick heads that health care does not work in a free market.

    when people get a brain aneurysm or a stroke or heart attack – they do not go looking for the best price and best value – because they are DYING and need help right now. A women giving birth – does not drive two hours because the hospital is “better”.

    a person who needs dialysis is not going to drive 5 hrs to get to a “cheaper” place…

    what kind of world do you guys live in? ya’ll live in LA LA LAND apparently.

  9. Conservatives are simply looking for alternative approaches to delivering rural health care that does not entail an open-ended raid on taxpayer pocketbooks. Of course, that’s an alien concept to Peter and Larry, who have no trouble spending other peoples’ money for causes they personally believe are important.

    • bull hockey – what they are looking for is a way to abandon the poor all together and then blame it on someone else like the Feds.

      they have had the option from day 1 – long before MedicAid to take care of their own citizens who live in rural areas who are entitled to equitable treatment and access to health care as others in Va are.

      they’d do the same thing to education and roads if they got half a chance.

      you INVEST in the kids who grow up in rural areas to grow them into adults taxpayers and not continue the cycle of poverty.

      people who do not receive medical care often cannot work – which means even more entitlements.

      the premise of conservatives is that we can save money by not providing services to the poor, vulnerable , and elderly. let them eat cake.

      you’re NOT providing alternatives – you’re PRETENDING that you MIGHT.

      if you were serious – you’d not be writing studies – you’d be writing legislation and passing it.

      all talk – no go – obstruct others is the game plan.

      Other states like Vermont, Massachusetts, Tennessee have all taken responsibility for health care for their citizens. In Va – we make excuses and blame the Feds.

  10. It’s unconscionable that all Virginians are now paying taxes and our idiot legislators are refusing to take back what we are paying.

    They don’t do this with highway money, or education money, or even basic MedicAid money… we pay gas taxes, Federal income taxes, and other Federal taxes on phones and internet and we take the money back and spend it.

    I’d like to see those fools in the GA refuse to take highway money because they disagree with Federal transportation policies.

    this is the dumbest thing since Massive Resistance.

    If the opponents had one serious iota of “alternative” and actually processed it legislatively – they might have a leg to stand on.

    we are refusing to take the money that would employ 30,000 health professionals – that would provide jobs to kids growing to be adults in our rural areas – that, in turn, would help their communities economically as they spent their paychecks locally.

    again – if you really had a serious alternative – you’d implement it – and you’d do it no matter what the Feds did and you would have done it long ago because MedicAid even became a program.

    They had that chance with the Tobacco settlement and what did they do? Did they set up rural clinics or help rural hospitals?

    nope.

    Over and over – Virginia Conservatives goes out of their way to do really dumbass things and it has no shortage of truly ignorant apologists… who are apparently proud of Virginia’s backward “ways”.

    It is irresponsible and unconscionable to not educate and not provide basic medical care to Virginia’s young, vulnerable and elderly.

    and then cite “studies” by these right-wing wacko-birds… as if it legitimizes our ignorant politics…

    barf!

  11. What is distressing is that so many facts are being left out of this argument.

    let’s follow this:

    (1) This report claims that it is better to address the problems of rural hospitals and health care by not expanding Medicaid and benefiting all health care outlets, be they rich or poor.

    (2) It is better to concentrate some kind of public fundings — presumably from the state — with struggling rural hospitals because expanding Medicaid would benefit all hospitals including rich ones where execs make a ton of money.

    That’s the argument. But:

    (3) It is extremely unlikely that the General Assembly would do anything to help improve rural health care. It took the suicide of Creigh Deeds son for the state to even considering improving mental health facilities in a modest way.

    (4) Virginians have already paid for much of the expanded Medicaid funding through their federal income taxes.SO, the conservatives are saying Virginians should not benefit from a federal program that they’ve already paid for, at least in the next few years.

    Jim Bacon and his cabal never address points (3) and (4). Their goal is to raise some irrelevant issues to suggest that expanding Medicaid is a waste of funds because too much of it would go to rich suburban hospitals operated by HCA, Bon Secours, etc.

    They do not address that VCU and UVA which do handle a lot of urban poverty cases say they are going starving because of the lack of expanded Medicaid.

    The biggest issue is they do not suggest where the alternative funding would come from. They just want to keep the debate going to skimp onopublic funding for health.

    Meanwhile, as Larry points, let poor people in rural areas be damned.

    • one thing is not correct in Peter’s otherwise dead-on words.

      ” Virginians have already paid for much of the expanded Medicaid funding through their federal income taxes”

      that’s not true. The taxes are earmarked taxes separate from the income tax.
      The expansion does not come from the general fund nor does it contribute to the deficit for the most part.

      they’re more like the excise tax on gasoline or taxes on your phone or internet.

      they include explicit taxes but also include rolled-back limitations on tax breaks for health care purposes.

      And example is changing the limit on itemized health care deductions from 7.5% to 10%.

      • 2.3% Tax on Medical Device Manufacturers 2014

      • 10% Tax on Indoor Tanning Services 2014

      • Blue Cross/Blue Shield Tax Hike

      • Excise Tax on Charitable Hospitals which fail to comply with the requirements of ObamaCare

      • Tax on Brand Name Drugs

      • Tax on Health Insurers

      • $500,000 Annual Executive Compensation Limit for Health Insurance Executives

      • Elimination of tax deduction for employer-provided retirement Rx drug coverage in coordination with Medicare Part D

      • Employer Mandate on business with over 50 full-time equivalent employees to provide health insurance to full-time employees. $2,000 per employee – $3,000 if employee uses tax credits to buy insurance on the exchange (AKA the marketplace). (pushed back to 2015)

      • Medicare Tax on Investment Income. 3.8% over $200k/$250k

      • Medicare Part A Tax increase of .9% over $200k/$250k

      • Employer Reporting of Insurance on W-2 (not a tax)

      • Corporate 1099-MISC Information Reporting (repealed)

      • Codification of the “economic substance doctrine” (not a tax)

      • 40% Excise Tax “Cadillac” on high-end Premium Health Insurance Plans 2018

      • An annual $63 fee levied by ObamaCare on all plans (decreased each year until 2017 when pre-existing conditions are eliminated) to help pay for insurance companies covering the costs of high-risk pools.

      • Medicine Cabinet Tax
      Over the counter medicines no longer qualified as medical expenses for flexible spending accounts (FSAs), health reimbursement arrangements (HRAs), health savings accounts (HSAs), and Archer Medical Saving accounts (MSAs).

      • Additional Tax on HSA/MSA Distributions
      Health savings account or an Archer medical savings account, penalties for spending money on non-qualified medical expenses. 10% to 20% in the case of a HSA and from 15% to 20% in the case of a MSA.

      • Flexible Spending Account Cap 2013
      Contributions to FSAs are reduced to $2,500 from $5,000.

    • Thanks for engaging in a substantive conversation here instead of simply dissing the report because the Thomas Jefferson Institute is ideologically suspect. And thanks for refraining from the same level of insults and ad hominen attacks that characterize Larry’s approach to the issue, which leave me with no desire to interact with him in any way on this particular subject (although I do note your use of the phrase “Jim Bacon and his cabal,” an effort to delegitimize your foes by applying negative labels).

      Now, onto substantive conversation.

      Regarding Point 3 above, in which you say that it’s “extremely likely that the General Assembly would do anything to improve rural health care”…

      First, you are confusing should should be done, as in, the General Assembly should provide targeted incentives to keep rural hospitals afloat, with what is politically practical to do. The blog post addressed what should be done. That is a necessary step before deciding what can be done.

      Second, I take exception to your argument that it is extremely unlikely that the General Assembly will do anything. Rural areas are disproportionately represented by Republican legislators. I think that Republican legislators, just like Democratic legislators, are intensely interested in making sure their constituents maintain access to health care. If given an alternative to expanding Medicaid, they would welcome it. You have no basis, other than your partisan biases, to suggest otherwise.

      Regarding Point 4 above, in which you say that Virginians have already paid for expanding Medicaid funding, so they might as well get the benefits from it. Yes, that is a strong argument (though hardly conclusive) argument in factor of expanding Medicaid. But it is also irrelevant to the study and blog post. That argument explicitly addresses an entirely different argument for expanding Medicaid — that it would bail out rural hospitals — and only that argument.

      • TMT – I give you credit – you actually did put forth a much more credible idea than TJI or Jim but the basic premise of “rural” is fundamentally incorrect and you can see this clearly if you look at the Colorado report and our own urban cores in Va where in this very blog we talk about the poverty and education crisis in places like Richmond. Is there any real honest view that we don’t have charity care issues in urban hospitals and other health care facilities – like cancer centers or dialysis centers or rehab facilities?

        that’s the basic problem with many of TJI and Jim Bacon’s premises which are often based on stereotypes and ..sorry to say – just plain ignorance of the facts.

        It’s not that the fact do not exist – they do – look at the Colorado report but use your own intellect to understand that there are also urban core hospitals with large populations of charity care.

        Then we have TJI and Bacon both claiming that subsidies are the answer to the problem – when both vociferously argue against subsidies in general and specifically with regard to ObmaCare.

        The health care issues are not things that suddenly “popped up” .. they’ve been with us a long time and Virginia and TJI have stood by and said and done nothing … not promoted real alternatives but engage ideology like blaming torts on the cost of health care – as if the folks who don’t have insurance and go to the hospitals to get charity care – are not the real issue and ignoring the fact that Va already has capped medical torts.

        but what spun me up – is the espoused idea that rural hospitals are inefficient and too costly to keep open – via MedicAid expansion – but instead we can subsidize them directly from Virginia taxpayers.

        None of their thinking passes the smell test.

        Virginia has had decades of “opportunity” to do something to help rural Va health needs and what have they done?

        What they have done is refuse to take back the taxes that Virginians already pay while doing a song and dance about what they “might” could do…

        My basic premise is this:

        I do not advocate subsidies for subsidy sake.

        what I do advocate is to recognize the reality that people in rural Va (and it’s urban cores) are real people who we have decided (via EMTALA) that we will not turn away when they are sick or injured.

        No amount of speculating about what we “might” do will change that reality.

        the question is not what we might do – it’s what we WILL do to MINIMIZE the subsidies that are needed.

        that’s a responsible fiscally-conservative approach.

        One that accepts the realities that we are not going to refuse to treat people who cannot pay. that idea is off the table except for two groups of people:

        1. – the group that is honest enough to admit that if they had their way they WOULD deny treatment to those who can’t pay. Hate their morality but admire their honest and let the voters decide if that’s what they want.

        2.- the second group is much more sneaky about how they go about essentially promoting “ideas” that are DOA … and they know it.

        things that will effectively accomplish number 1 but in a way that it masks their intentions – which at the end of the day – will result in a lack of facilities for the folks who would need access ..

        and in this particular case – it’s even more onerous because the same folks who say they oppose subsidies and want the free market – put forth a proposal for subsidies that they KNOW would never be accepted by the Va GA.

        Finally – if I actually do engage in an (or more than one) AD Hominem – point it out – and I will apologize – no excuses. We all have our faults and I do too but in this case I believe Jim is using that as an excuse

      • re: ” insults and ad hominen attacks”

        I’m looking back over the dialogue and I’m having a hard time finding where I attacked you personally…

        can you please point out where I did?

        if you cannot , would you consider revising your statement?

  12. The basic premise of the blog post is also wrong when Bacon says it’s all about rural hospitals. It’s not. there are many urban core hospitals that serve those without health insurance..

    here’s some real facts about the Expansion – something you’ll never see
    Bacon highlight in one of his less than forthright posts on health care:

    Impact of Medicaid Expansion on Hospital Volumes

    Table 1. First quarter comparisons between 2013 and 2014 for Colorado hospital peer groups – page 4

    the whole report is only 6 pages – and I hope Jim takes a few minutes to read THAT study which I realize will do the opposite of confirming his biases…

    http://goo.gl/sl9sDO

    • Larry, name me the urban hospitals that are losing money.

      Oh, you can’t name any?

      I guess that means it’s a rural problem.

      • Oh – you’re talking to me again?

        😉

        Jim – where do you think the urban hospitals are getting money to pay for charity care?

        do you think it matters where they get it?

        did you read the Colorado Report?

        Do you believe that there are certain hospitals in urban areas that primary serve the poor that are not “rich” and are heavily subsidized? Do you know of any like that in DC, New York, Richmond?

        I think you and the TJI folks are stereotyping a bit here.

        You yourself have talked about the poor in Richmond. Who do you think is paying for their charity care at Richmond Area Hospitals?

        let me know when I hurl another ad hominem at you.

        I very much desire a substantiative debate on the merits – all of them – on this issue and if I say things in ways that insult you or attack you as a person – then I’ve gone too far and I regret it – but please don’t mistake that for hard-nosed talk.. especially when it comes to how Conservatives approach these issues these days.

        My premise is simple. 1. we’re not going to deny treatment to people – that’s not going to happen. and 2. – if 1. is the truth – then our job is to find the most cost-effective way to get the job done – not play word games on how to avoid paying to provide care.

        someone has to pay.

        Are you implying that “rich” people who go to “rich” hospitals pay for the poor in urban areas? or who do you think is paying in the urban hospitals?

  13. Let’s treat rural hospitals and clinics the same way the FCC treats rural telephone companies. The Agency has frozen prices charged to other carriers; provided Universal Service Funds to support the ability to keep rates for local service comparable to those in urban areas and placed limits on expenses that can be considered for USF support, including administrative costs.

    Provide the taxpayer dollars, but limit prices that can be charged patients and limit reimbursable expenses including administrators’ compensation. Docs and nurses too. Ten to one the medical community wants nothing to do with this plan.

  14. Larry,
    I stand correcte don the source of Medicaid funding.

    Jim, you don’t like”cabal,” How about THESE!!!

    “posse”

    “wild gang”

    “cadre”

    “collective”

    “fellow travelers”

    !!!!

    PG

    • I think he likes “cabal” better than “willful ignorance”, eh?

      all I can say – is when TJI and Bacon offer half-baked and half-assed “ideas” – they deserve to be called out on it.

      We have too many so-called “conservatives” running around these days – opposing proposals from others but shucking and jivving in legitimate alternatives.
      You can turn down the MedicAid expansion – as dumb as that is – but to offer no real alternative other than to propose subsidies – which TJI and Bacon vociferously oppose in other discussions.. just seems… not right.

      I’m all for legitimate innovative alternatives – but these are totally bogus.

    • You know – one of the ironies of the ObamaCare taxes are how they got money to fund ObamaCare – and a good part of it came from reducing tax breaks and using the money saved to fund ObamaCare.

      like changes to tax breaks for IRA-like health care set aside plans that allow those of ample means to set aside money before it is taxed … the caps got reduced.

      • Elimination of tax deduction for employer-provided retirement Rx drug coverage in coordination with Medicare Part D

      • Medicare Tax on Investment Income. 3.8% over $200k/$250k

      • Medicare Part A Tax increase of .9% over $200k/$250k

      • 40% Excise Tax “Cadillac” on high-end Premium Health Insurance Plans 2018

      • An annual $63 fee levied by ObamaCare on all plans (decreased each year until 2017 when pre-existing conditions are eliminated) to help pay for insurance companies covering the costs of high-risk pools.

      • Medicine Cabinet Tax
      Over the counter medicines no longer qualified as medical expenses for flexible spending accounts (FSAs), health reimbursement arrangements (HRAs), health savings accounts (HSAs), and Archer Medical Saving accounts (MSAs).

      • Additional Tax on HSA/MSA Distributions
      Health savings account or an Archer medical savings account, penalties for spending money on non-qualified medical expenses. 10% to 20% in the case of a HSA and from 15% to 20% in the case of a MSA.

      • Flexible Spending Account Cap 2013
      Contributions to FSAs are reduced to $2,500 from $5,000.

      Now.. I’ve never read or heard a legitimate debate as to whether this method of funding something is acceptable.

      it actually goes one step further – in that the money re-directed is actually earmarked for a specific purpose – like FICA works for Social Security or the fuel tax works for Transportation.

      Some of the aforementioned tax expenditures are not only not taxed at the Federal and State income tax level – but they are not taxed for FICA either (and that’s 15.3% by itself).

      so these tax breaks – tax expenditures – not only are exempt from State and Federal income taxes but also FICA taxes – at a time when folks are yammering about unfunded liabilities for Social Security and Medicare.

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