Agreed, We Can’t Risk Expanding Medicaid. But What’s the Alternative?

innovationby James A. Bacon

Republican leadership in the House of Delegates once again has slammed the door on Governor Terry McAuliffe’s proposal to expand Virginia’s Medicaid program. There are good reasons both for and against extending the entitlement but the decisive and most compelling argument is the likely inability of the federal government to honor its commitment to pay 90% of the cost of the expanded program far into the future.

If you need a sobering reminder of how dismal the long-term fiscal condition of the federal government is, just read this recent Senate Budget Committee testimony by Boston University economist Laurence Kotlikoff. As everyone knows, the national debt now exceeds $18 trillion. But that’s just the tip of the fiscal iceberg. The fiscal gap, the difference between revenues and obligations projected 75 years into the future, is $210 trillion — more than 10% of GDP. The gap between revenues and promises in the U.S. is worse than that of any other developed country, Kotlikoff said, worse even than Greece. (Hat tip: Tim Wise.)

If something can’t go on forever, eventually it won’t. At some point, whether ten years from now, twenty years, or thirty, the federal government will reach a crisis. There is a high likelihood that a future Congress will decide either to radically curtail Medicaid or to dump a significant share of the funding burden on the states. Either event would be traumatic for Virginians. This is not scare-mongering, it is arithmetic.

While rejection of Medicaid expansion may be fiscally justified, it leaves hundreds of thousands of poor and struggling Virginians without access to health care, except in emergency room settings. If Republicans and conservatives are going to reject the fiscally improvident expansion of Medicaid, they are obligated to present a different vision for Virginia’s healthcare future. We have seen bits and pieces of such a future — repeal the Certificate of Public Need (COPN) process that protects established companies from competition, and make patient-level data more widely accessible — but no one has articulated a coherent vision. Let me advance three propositions that may lead us to such a vision:

  • The main reason that medical insurance has become so unaffordable for so many Virginians is that the underlying cost of providing that care has increased relentlessly over the decades faster than inflation and faster than the increase in wages and salaries.
  • The primary thrust of public policy in the United States and Virginia has not been to stimulate productivity and innovation, making medical care more affordable for all, but to restrain cost increases by regulatory means and to redistribute wealth from the affluent to the poor in a zero-sum game. The resulting system, marked by rampant regulation, red tape, cross subsidies and an total lack of transparency, is a colossal failure.
  • To make health care affordable and accessible, Republicans and conservatives need to champion market-driven competition and innovation that drive down costs and improve medical outcomes.

That’s the vision, but a vision is nothing more than words and generalities. Where do we go from here? There are three things we can do in the short term that will move us in the right direction:

  • Eliminate COPN, which protects established hospitals from competition, not only from other hospitals and outpatient-care facilities but from entrepreneurs who might have novel ways to organize and deliver care. In so doing, we must recognize that COPN represents a back-door means of compensating hospitals for the significant sums they spend on indigent care, and acknowledge that some kind of political settlement will be necessary.
  • Eliminate mandated health benefits, which limit the ability of health insurance companies to create innovate products for niche markets.
  • Create market transparency. Patients have little consumer power in the medical marketplace because they cannot compare the price of different medical procedures or the quality of work performed by different hospitals and doctors. The methodological issues of comparing price and quality are formidable but not insurmountable. For market-driven health care to work, we must have price transparency.

That’s just the beginning. Thinking more long-term, we need to acknowledge that the concept of hospitals — centralized medical facilities that provide a bundle of unrelated medical procedures — may be outdated. The future belongs to the factory model in which specialized medical teams (doctors, nurses and others) work in specialized facilities with specialized equipment, and stay up to speed with the latest scientific knowledge about particular procedures or diseases. This specialization and knowledge allows them to treat patients at lower cost with better outcomes.

In parallel, insurance companies need to pioneer new reimbursement strategies that cover not just individual procedures but entire courses of treatment, rewarding medical “factories” described above for superior outcomes and lower costs.

Republicans and conservatives don’t have to come up with every answer. They’re politicians, not medical practitioners. But they do need to paint a picture of the future, eliminate legal and regulatory obstacles and push the health care industry in the right direction. If they fail to do so, the end result will be fiscal insolvency, hundreds of thousands of Virginians people dispossessed of health care, or a chronic health care crisis for all.

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81 responses to “Agreed, We Can’t Risk Expanding Medicaid. But What’s the Alternative?

  1. the thing to understand is that these are WORKING Virginians – working for wages too low for them to afford insurance .. working in the “gig” economy…

    and people who will use ERs and hospitals that will be paid for by other Virginians – on top of the taxes they are also paying for the MedicAid expansion.

    let me repeat that – Virginians are ALREADY paying taxes for the MedicAid Expansion… several billion dollars worth.

    these folks would be better off quitting, claiming disability …which then gets them coverage under SS and Medicare…. those who successfully get Social security disability – automatically get coverage under Medicare… – both of which are already broke and adding to the deficit.

    but you know – ideological ignorance knows no boundaries these days…stupid is as stupid does

    https://youtu.be/D_Komi7wnAw

    • Disability is actually quite difficult, and involved, to qualify for. You can’t just decide to put in for disability.

      Medicaid does go significantly beyond the medical care that we’re already paying for. Not arguing against it, just pointing out the math.

  2. Larry,

    I wonder if you might address what Jim has said re: some solutions. Obama and the left always say “Well, bring me your solution” and then when someone does, it’s never addressed or responded to. It fits my narrative of how the left never really engages; they just spout their talking points describing a problem but never offering a real solution. Obama Care has just been so peachy, after all.

    • what solutions Crazy? Do you call hair-brained “ideas” work no where in the world that way and that are never legislated here – “solutions”.

      “solutions” are things you pass in legislation and force a veto on.

      where are they?

      this is about ideology for you guys – not fiscal conservatism.

      fiscal conservatism recognizes the cost providing health care expensive and inefficient ways – to pretend you’re not providing it but people without health care – go to ERs and we pay for them. People without health care wait until diseases advances rather than treat it earlier – then taxpayers pick up the catastrophic downstream costs of not treating it

      we already pay taxes for the MedicAid expansion. that’s NOT a “talking point”. It’s a simple reality that Conservatives deny…

      this is like turning away Federal highway or education money or DOD money for ships in Hampton – because “some day” the deficit will bite. it’s a total and hypocritical double standard

      how about you do something that actually does save money UNTIL that you get your hairbrained ideas together in some form you can actually agree on and pass as legislation THEN say “we don’t have to take that nasty deficit money”.

      the “right” used to be pragmatic and deal with realities… now the right is full of ideological idiocy and gridlock…

      if you want an alternative solution – get it on the table – with wide/deep support from the right – and move it through the legislature.

      what Jim’s posts says essentially is that “we don’t have to address the health care issue anyhow and if we don’t like others ideas – we’ll block them also

      that’s in a nutshell the Conservative philosophy these days.

      • Expanding Medicaid doesn’t just cover what you’ve “already paid for.” It expands your expenses beyond what’s already required, and also expands your reimbursement for those additional expenses from the feds.

        The reimbursement is set to decrease over time.

  3. If we cut out the tax benefits, force out all those wasted admin people, that would help.

    • VN, have you looked into this? How much administrative overhead is there in Medicaid? All insurance policies have overhead. So does Medicare. It’s unavoidable. Is Medicaid’s worse than the others?

      • That’s called all admin. Medicare/Medicaid/Anthem/Inova/HCA, etc.

        • ? Admin, for insurance, covers minor things like accepting payments, paying claims, providing insurance cards, setting rates, checking for fraud – you know, the minor little things that actually let you take in money and pay claims.

          Admin costs have to be controlled, but you can’t have insurance – public or private – without administration.

          • Move to have the patient fill out forms online. Those who won’t learn how to, pay more.

            ? Admin, for insurance, covers minor things like accepting payments, paying claims, providing insurance cards, setting rates, checking for fraud – you know, the minor little things that actually let you take in money and pay claims.

            Admin costs have to be controlled, but you can’t have insurance – public or private – without administration.

  4. When a national benefit that cannot last is being handed out over our objections, nevertheless we have to ask, must ask ourselves, will Virginia’s abstinance, out of principle, which has the effect of prolonging the benefit, contribute to the greater good, or cause greater harm more than it will help.

    You and I can disparage Obamacare till we are blue in the face, but there are two essential facts which must be faced here: 1. we are a nation which does not let people die in the gutter, but carries them off to the hospital for emergency care regardless of their ability to pay, often ultimately at far greater expense than for preventive community-health treatment of the same medical conditions — in other words, we already have universal health care, it’s only a question of degree of need and the timing of intervention; and 2. within our nation, Virginia has many medically needy citizens, and while we cannot afford what Obamacare has said it will bring to the Nation, we cannot afford NOT to indulge as much as we can in its profligate distribution of wealth, as long as it lasts, or Virginia will find itself left far behind those who do partake of it, and who build a core of medical facilities and services which will serve those communities long after federal funding has shrunk, or even dried up.

    I do not argue for Obamacare’s impossible largess to continue, but I do argue for sucking on the federal teat as long as it’s offered! While at the same time, continuing to fight for amendments to our health care system, as well as other entitlements, to put them on a stable trajectory. These are NOT INCONSISTENT goals. The disadvantage to Virginia, and Virginians, of refusing to participate is too great to justify such a ‘principled’ stand.

    I also think, those who sit (and partake) at the table will have the greatest influence on the eventual solution.

    • Acbar, you have well stated the case in favor of extending Medicaid: Suck on the federal teat for the benefit of poor Virginians as long as we can. You shear away all the B.S. and get down to the nitty gritty. And it’s a fairly compelling proposition. In the final analysis, I don’t agree with you, but at least it is a defensible proposition.

      • It’s not only defensible – it’s the simple reality of how one intelligently goes forward. You take what you do have right now – as flawed as it is and you work to change and reform it – that’s the reasonable way to evolve.

        we do not let people die in the gutter – we don’t. But we do CHOOSE to spend in incredibly wasteful ways that cost us more than if we chose to adopt – imperfect but more cost-effective solutions.

        this is the way that Conservatives USED TO THINK! they had some common sense to keep their ideological devils under control and deal with realities.

        no more it seems. today – it’s all about their “ideas” that they want to implement and in the meantime – they’ll vandalize as much as they can the current approach – trying to blow it up – while they talk about “ideas” of which exist no where on the planet… except in 3rd world countries.

        They apparently PREFER to see people not get screened for cancer and diabetes and get treated for it – nope – we CHOOSE instead to deny the screenings and wait until massive cardiovascular and organ damage occur THEN we decide to provide taxpayer-funded “care”.

        and their “defense” ? “besides, we don’t have to propose alternatives anyhow”.

    • FYI, the cost of providing emergency only care is actually less than the cost of full medical care, in large part because so much medical care is actually not covered by the ER mandate. It’s not a cost savings to switch to full medical care. That’s why it hadn’t been done before.

      There is a good argument for it as a moral issue.

      As long as the Feds are paying for most of it, it’s not a huge cost. It is not going to pay for itself without subsidies, though, precisely because so much medical care is not covered by the previous mandates. It’s both the argument for and the argument against – the fact that ER requirements exclude things like chemo and planned surgery and so on show the need – but the need also means there’s additional, and fairly large, costs.

  5. you’re not “sucking” on the Federal teat with MedicAid – you’re getting the taxes we already pay into it – back.

    it’s NOT deficit money. It’s earmarked money collected specifically for that purpose. No matter what happens to the deficit – this money is not affected. It’s like the gasoline tax or the airport tax or other excise taxes.

    but don’t let the facts mess up perfectly good idiocy.

    no 1st world country on the planet does health care the way the right wing idiots are advocating – none. Every one of them does it with the govt and they do it for one half our costs – and they live longer than us.

    what the right is essentially advocating is 3rd world free market health care… because otherwise the deficit will kill us…

    this is what passes for conservative “thought” these days.

    it’s basically ” we choose to be stupid, it’s our right”.

    • “what the right is essentially advocating is 3rd world free market health care… because otherwise the deficit will kill us…”

      That’s a political spin on it, but the same point I was making. We agree! But it would be so much better if instead of making the most of this unsustainable mess our conversation could be about how to make health care delivery realistic and affordable and not a patchwork of “emergency room” services. Here’s the challenge, and the source of anyone intelligent’s frustration: if not Obamascare, WHAT? Because simple repeal and return to the status-quo-ante is not going to happen, because health is too important and matters too much to the electorate.

      Why don’t we, can’t we, discuss alternatives? LarryG is right, does anybody with a brain think they don’t exist?

      • That’s my frustration exactly.

        real fiscal conservatives want real cost effective solutions not mythological hairbrained theories that do not exist anywhere on the planet.

        and real fiscal conservatives don’t block alternatives they don’t like then claim they do not have to offer alternatives either.

        Singapore has a good approach in my view but it is govt sanctioned.

        they require everyone to save to an HSA – limited to a percent of their income and when spending exceeds the HSA -catastrophic coverage kicks in.

        Providers are required to post prices for services and drugs.

        the most inane thing here is that the govt already helps people with employer-provided, seniors with Medicare, the armed services with TRICARE and the truly indigent with MedicAid so we’re dealing with folks who work full time but can’t afford coverage

        and the so-called “Conservatives” are saying that the govt should not be providing care to these folks the free market should.

        how idiotic can that be?

        If they truly believe that – they should be ALSO opposing the other ways the govt is already providing health care as well as EMTALA which requires hospitals to treat charity cases.

        instead – they’ve targeted this segment – as a proxy for their general opposition to the current health care system.

        They’re not about reforming it – step-wise reform or anything like that.

        Instead – they just refuse to do anything and block anything else.

        and the thing is – we – taxpayers ARE paying for it anyhow and what they are accomplishing is not refusing to pay – but instead choosing to pay more… and indeed – we pay twice as much per capita than any other country on the planet.

        JimB goes on and on about ROI and bang for the buck for highways, settlement patterns and education… then when it comes to this – he herds up with the other “Conservatives” who have virtually nothing to say other than “leftist”.

        • Larry, Medicaid was not available to most truly indigent people prior to the ACA – mostly it was just kids, women who were pregnant or breastfeeding, and the disabled.

  6. Three times in the past ten years I have been hospitalized for serious conditions, two of which would have killed me quickly and one of which would have killed me slowly. With excellent employer-provided coverage the vast majority of my costs were covered but I had thousands of dollars in out of pocket copays and deductibles.

    Many people in the same situation would have seen those out of pocket costs and the lost work time destroy their savings or drive them into credit card debt, possibly bankruptcy. Those are people with coverage. With this recent plan I have to spend $2,800 out of pocket before coverage kicks in (the deductible) – do you know how many people do not have $2800 in a savings account?

    The people at the heart of this debate, working people with no coverage, might or might not have been given care. They might have been stabilized and discharged. If they got first rate care, the bills on the three situations would probably have run to $500,000. They don’t get the insurance negotiated discounts. Even if the real cost, the cost that the medical providers would have to eat, is the insurance discount rate those the total losses would probably have exceeded $150,000. I fully understand that the rest of us pay for that.

    We decided in this country, right or wrong, to create the Medicaid program and then we drew this arbitrary line about where to cut it off. Moving the line to another place will increase the caseload, increase the cost, and the costs are totally running away out of control. But that is also true of the costs if you are fully insured, or partially insured. Medical costs are insane. That issue needs to be addressed separate from this argument over where to draw the Medicaid line.

    I was clearly in the “reform and then expand” camp on the issue of Medicaid expansion at the beginning. And I still want to see radical reform. But the three conditions I had, in every situation I contemplated where I and my family would be with no coverage. And I can’t wish that on anybody, or celebrate their plight as good public policy.

    • the thing is Steve – you’d not have any coverage if not for the govt.

      You are protected by the govt even as you have formed an opinion that folks on MedicAid would be “too expensive”.

      HIPPA is what requires employer provided insurance companies to not dump folks that have expensive conditions. Without HIPPA, insurance companies could and would dump the ones who cost them money.

      Further you pay subsidized rates because HIPPA also will not let employer-provided insurance companies charge individuals per their health status – everyone gets the same rate – so the healthier ones end up subsidizing the sick ones – by law.

      ” HIPAA’s umbrella of protection:

      Limits the ability of a new employer plan to exclude coverage for preexisting conditions;

      Provides additional opportunities to enroll in a group health plan if you lose other coverage or experience certain life events;

      Prohibits discrimination against employees and their dependent family members based on any health factors they may have, including prior medical conditions, previous claims experience, and genetic information; and

      Guarantees that certain individuals will have access to, and can renew, individual health insurance policies.”

      http://www.dol.gov/ebsa/publications/yhphipaa.html

      basically we have a grossly disparate system where those with employer-provided are protected by the govt while those without it are not – and those who have employer-provided – don’t even realize they have that protection – and then form opinions about those that don’t have that protection – as to whether or not they deserve it or not.

      If the folks who opposed MedicAid expansion also opposed employer-provided law (HIPPA) – for the same consistent reason – i.e. that the govt should not be involved in it – then how many with employer-provided would be affected and put into the same boat as those without employer-provided?

  7. One thing that could be easily done is for a group of legislators to identify potentially monopolistic aspects of Virginia’s laws affecting health care and insurance and seek comment from the Federal Trade Commission. I’ve seen it done before. Armed with the results and public comment, the GA might then make some changes in the laws.

    • You can forget that. I have sent out emails regarding how at least one “monopoly” here acts, how the state medical board acts in terms of denying civil rights, due process of law to people, how the Va. Dept. of Health Professions (in addition to the Board) has conflicts of interest, doesn’t even have the resources (they claim) to perform their mission, can’t even prove they have ever done so by claims made by the Dept Head. Do I see action on it? No.

      The Governor knows that the US Supreme Court in May said to break up the MD monopoly on these boards and he has yet to do it. That includes his AG and of course the LT GOV, being a MD, isn’t going to toady along.

      The taxpayers are paying for $20 million to waste our money and give evidence to the MD’s lawyers without that being told to the people.

      • Another example of the Virginia Way!

        • I will keep on asking for patients’ rights over a businesses money and expose what the govt. does and does not do. Just because someone is not a billion dollar business doesn’t mean they aren’t entitled to be treated like a human being and get the shaft from our govt.

          • Competition drives down prices and drives out waste. From what I’ve seen (and read on BR) medicine and education have largely been protected from competition and retain many monopoly attributes.

            I’ve watched the commercials for Doctor on Demand. For $40 most simple ailments seem to be addressable via telecom. If they cannot handle the patient’s problem and must make a referral, no charge is applied. I wonder how it is affecting Urgent Care practices that were created to challenge ERs. I expect that apps will be developed that can provide a lot more information to the remote physician.

            But all it would take is a couple legislators willing to buck the Elite to write to the FTC and ask for its views on various aspects of Virginia’s health care laws. With Dr. Northam as Lt. Governor, the D’s may be unwilling to rock the boat. And I suspect the Docs also contribute to the Rs.

          • I need to hunt up the letter I sent to the Lt. Gov. about since he was an MD, why he didn’t care about the issues I’ve brought up with the disaster we have now, and had no comment.

            Maybe I should just sent again and repost here.

  8. competition WILL drive down the cost of elective treatments but it will have no effect on someone who works at Walmart 40 hours a week and needs a bypass or has liver failure.

    If competition is so good why do we have insurance at all?

    Sometimes I think people fundamentally do not understand insurance any more.

    If you are a person who has employer-provided insurance – you would ot have that insurance for that price if it were not for the Govt and HIPPA.

    and yet the people who have employer-provided do not even realize that they have guaranteed insurance at the same time they advocate free market competition for those who do not have employer-provided.

    How many folks think they “earn” employer-provided?

    You don’t “earn” it. You get it because of the govt – which makes it tax free to both employer and employees and requires any insurance company to cover all employees regardless of their health. In the “free market” that is advocated -those folks do not get insurance or it costs far more than they can afford.

    with employer-provided -the govt forces the insurance company to see all employees insurance for the same price. In the “free market” you’d be charged per your health status, age, etc…

    so why do folks who have employer-provided advocate for the “free market” for others when they themselves are protected from that “free market”?

  9. What we all should want regardless of political views is two important things.

    1. – equal treatment of all citizens by whatever Govt health care policies we have. we should not be creating winners and losers with govt policies.

    2. – a cost-effective system that is competitive with other country’s costs either by our own unique policies that DO WORK and are not theories and/or by adopting other countries practices that DO WORK.

    what we cannot afford to have is a system that treats people differently according to their employment status and where some are protected from the free market while others totally exposed to it and the irony of those who are protected from it – advocate that others be exposed to it as a way to “cut costs”.

    Any political philosophy that supports govt policies that favors those with employer-provided insurance and penalizes those that work for employers who don’t offer it – is inherently dishonest and wrong.

    It’s hypocritical to defend govt-imposed protection rules and benefits for employer-provided health insurance – at the same time we are denying something equivalent to people who do work full time but whose employers and business models that do not allow paying for employer provided and especially so in the “gig” economy where more and more folks become independent contractors who have to provide their own insurance, and less and less folks have access to employer-provided.

    the truth is that few understand how the MedicAid Expansion is actually funded and believe the misinformation being promoted.

    so perhaps Mr. Bacon can get the facts out in a blog post
    and it would finally kill the misinformation being promoted that the MedicAid Expansion is funded from general revenues.

    how about it Jim?

    • I think the issue is also going to come down to favoring those who pay for others vs. those who don’t pay for themselves. If there is no “carrot” to those who work hard and those who don’t, there is no reason for any one to try to get ahead.

      Next is working on ways that people can improve their health on their own. I have listened to some documentaries and there are issues that need to be worked on (ie food cost) vs. personal responsibility needs to happen.

      • re: paying for others vs not paying for selves

        that’s a misguided view in my opinion unless I misunderstand your view.

        we have full-time workers whose employers do not offer govt-subsidized insurance because those business models cannot support such costs and especially so with smaller insurance pools where one person with an expensive illness can and does drive up the costs for everyone else in the same pool.

        but those folks on employer-provided are also net recipients of tax subsidies – ironically also paid for by those who do not have employer-provided insurance.

        330 billion dollars a year is the direct cost to taxpayers for employer-provided insurance but it’s far more than that in indirect costs – because the govt actually requires the insurance companies to cover people – they would not cover in a free market and charge more to others who were older and sicker.

        In other words – employer-provided insurance is required to cross-subsidize people in the employer plan and this in turn makes it difficult for smaller employers with small pools of people to offer insurance. one person with an expensive illness can and does drive up the premiums for other in the same small plan.

        and by “small” – I mean – even school systems with 3000 employees. Last year insurance premiums went up for 3000 teachers in Spotsylvania because of 5 individuals who got cancer.

        • Larry, how do lower income workers “pay” for the tax breaks received by higher income workers who receive employer-paid (usually in part) health care insurance? Most studies indicate 42-46% of Americans employed do not pay any federal income tax whatsoever. A person who lives in America, but does not pay federal income tax, is subsidized and not subsidizing others.

          I buy your argument that large pools spread the risk better than smaller ones. That is worthy of discussion and debate.

      • re: ” Next is working on ways that people can improve their health on their own.”

        totally agree. Now what do you do for the folks whose kid has a congenital heart defect or the 50 year old who has diabetes?

        you cannot “fix” the problems by solely having people be more “responsible” or by the “free market”.

        fudamentally the purpose of insurance is to explicitly address catastrophic losses…. that can occur no matter how “responsible” you are.

        this is like saying people should not need insurance for cars and homes because they’re not “careful” enough… and the problem is their own lack of responsibility.

        really bad things happen to the most responsible people. That’s why we DO have insurance.

        but health insurance is different because going “bare” just transfers costs to others.. and despite those who say they’d repeal EMTALA – the reality is – that there are far more people who would find that unacceptable.

        So our choices have to be in the realm of reality – not wishing for things that are not going to happen – and the reality is we’re all paying for the uninsured – and our choice is not to – but how to do that in the most cost-effective ways.

        until we accept that reality – we’re not doing anything that is going to solve anything.

  10. Wait here it is:

    Subject: Re: subscribe email list
    Date: Tue, 20 Oct 2015 22:26:02 -0400
    To: Nicholas, Ellen (LtGov)
    Hi,

    Is the Lt. Gov.’s office this far behind on emails or just doesn’t
    answer any emails? I know the previous ones I’ve sent have been ignored,
    but since he’s a physician, I wouldn’t expect to get support from him.

    • VN thanks for posting this.

      • VN, you’re digging into issues that no one else wants to touch. Licensure issues are huge. I should have mentioned them in my list of free market reforms that Virginia could enact. We’re facing a physician shortage in Virginia (and nationally), and yet the licensure laws forbid nurses from handling routine procedures that they’re perfectly equipped to deal with!

        • re: nurses – I do not know about you guys but when I go to the Doc these days – 9 times out of 10 I’m seeing Physician Assistants and Nurse Practitioners first and then the Doc sometimes.

          but this doesn’t address the fundamental issue of people who do not have insurance nor access to primary care.

          you say that VR is digging into issues that no one wants to deal with.

          really – how about the issues of the uninsured and how they get their care and who pays for that – and what to do about it?

          do you really think licensure issues will help the MedicAid Expansion issue?

          I’d say you guys want to talk about ANYTHING – EXCEPT the core issue.

          • Larry, the core issue is that our health care system is too expensive. It’s just like college education – costs are going up higher than inflation year after year. That creates affordability and access problems.

            VN has raised an important issue – licensing restrictions that may be designed more to protect the market position of the more expensive providers of service than to protect the public. Clearly there is a difference in knowledge and training between physicians and nurses, such that we don’t want the latter to replace the former in all instances. But nurses, nurse practioners & physicians assistants can provide many services at a lower cost as well as a physician can. Allowing them to do so threatens income for doctors. Hence, the importance of an honest investigation into, and debate over, current licensing restrictions.

            I’m not arguing (and I suspect VN isn’t either) that addressing the restrictions on competition issue will solve all health care issues in Virginia. But it would help. Removing costs or slowing cost increases contributes to better access to health care services.

  11. Buried in the torrent of words that make Larry’s posts so hard to even scan, let alone read, he makes a point. Those of us who enjoy employer-provided and government-subsidized and regulated insurance are not in a free market. And if the US really moved to a free market, we probably wouldn’t like it.

    He also makes the same point I made, which is that controlling the cost of medical care (no matter who pays) is a different issue than the question of where we draw the line for these government-sponsored programs for those with low incomes. Medicare, Medicaid, CHAMPUS, the Veteran’s Administration hospitals, COPN, FDA, HIPPA and now ACA – the left has won the basic battle that started under President Truman. The federal government runs health care. That fight is over. Maybe we can go back to a free market following a violent revolution but otherwise this battle is over.

    A point I’ve made about taxes is the same for health care. Only people pay. You can shift the cost from one person to another, but somebody pays with dollars out of their own paychecks or savings accounts. I’m much more interested in finding ways to control the costs and restore at least some market incentives than I am in fighting over how I pay (and I realize we all pay) for the uninsured person who ends up in the hospital. Fine with me if the state decides to expand Medicaid, but I also suspect that if it doesn’t, many of the people will continue to receive care – albeit with no coordination and certainly no oversight, and with the bill still coming to everybody else.

    • sorry Steve and others but health care costs are something that is killing us at the same time people are in denial about how.

      but thank you for seeing the point about employer-provided and the free market

      Mitt ROmney said the same thing – and that we cannot reform our system as long as we do not reform employer-provided – as opposed to MedicAid alone.

      The Federal govt DOES OWN health care in the US – AND it ALSO owns health care in every other 1st world country – on the planet.

      for the deniers – give me a short list of the best countries in the world for health care that do not have govt involved.

      where is that list that backs up folks claim that it is the govt that is the problem? the reality is that there are 200+ countries on earth – find me the ones that found the best way to do health care.

      VR, Bacon and TMT talk about licensure.

      how about this – you take the MedicAid money and you created a network of Community-based managed care clinics staffed heavily with Nurse Practitioners and Physician Assistants?

      Again – I differentiate these days between conservatives and fiscal conservatives because they are very different.

      One goes after costs – the other, now days, is all about ideology and blaming govt and people for those costs.

  12. re: sorry about the torrent of posts – I DO NEED to reduce it so my apologies – and thanks to those that actually read them and respond to the points.

    Re: ” Larry, the core issue is that our health care system is too expensive. It’s just like college education – costs are going up higher than inflation year after year. That creates affordability and access problems.

    VN has raised an important issue – licensing restrictions that may be designed more to protect the market position of the more expensive providers of service than to protect the public. ”

    @tmt – if you think that the answer is to deny the reality of where those increased costs are coming from – then you’re missing the issue.

    why are we so expensive? could it be that people without insurance don’t visit primary care that detects disease before it becomes advanced?

    and what good is the licensing issue if people STILL can’t get to Primary care – with nurse practitioners? how does that help reduce costs if you’re STILL paying for those without insurance?

    • I don’t believe that expanding Medicaid would be less expensive than the status quo. Yes, there are costs associated with ER and other charity treatment of those without insurance. Yes, some of those costs are paid by taxpayers and insurance premium payers. Some are eaten by the health care providers as they are pushing hard for Medicaid expansion. Why would they use political capital and spend money on lobbyists if all they were going to do was break even? The health care industry believes that they will get more money from Medicaid expansion than they will receive from taxpayer-funded indigent care or from higher insurance premiums.

      A couple years ago, I had a conversation with a Democratic state senator, whom I respect and who has considerable knowledge about state budget issues. The senator made the same basic argument you make. I asked whether assuming that, if there were savings for taxpayers and premium payers by expanding Medicaid, why not put in a mandate for those savings to be passed back to taxpayers (such as by shifting money from indigent health care to education) and ratepayers (in the form of decreases in premiums or decreases in premium increases). The senator danced around the issues. The senator, who generally pulls no punches, had no answer. This is very strong evidence that either: 1) there are no cost savings; or 2) the Democrats have made a sweetheart deal with big health care. What other possible conclusion is there?

      Second, I had a separate conversation with another Democratic senator (whom I don’t respect or trust). This senator had regularly argued that expanding Medicaid would reduce ER visits and produce cost savings. I asked the Senator that, given both Oregon and Washington experienced significant increases in ER use by those newly covered by Medicaid and higher costs, why should anyone expect different results in Virginia. The answer was Virginia would use managed care. Of course, this is not an honest answer since both Oregon and Washington had managed care plans in place for those covered by the Medicaid expansion. Given a false answer, why should anyone believe that the Democratic plan to expand Medicaid in Virginia would save taxpayers and premium payers money? I respectfully submit that there is strong evidence supporters of Medicaid expansion do not believe the argument that you make. They really believe there will be no cost savings from Medicaid expansion — at least not for taxpayers or those paying insurance premiums.

      It all boils down to Democrats trolling for votes. They want to give away “free” things to people to induce more people to vote the Democratic ticket.

      Some people want to do this expansion based on their moral opinions. But isn’t this trying to impose moral opinions on others? What is the difference between these people and those who want to outlaw abortion or prevent gay or plural marriages?

  13. re: Democrats trolling – how does that explain 11 GOP states that expanded?

    re: moral imposition

    the concept espoused here is that we CAN reduce costs if we deny access to health insurance and care –

    and we characterize it as a moral issue…

    yep

    in other words – ‘we got ours” and “we’ll deny you from getting what we have”.

    nice.

    re: costs –

    it’s a real dollar issue also for those who want to embrace reality – we DO pay twice a much for health care – in no small part because people who do not get cancer and diabetes screening and treatment – and later – after catastrophe strikes – they do go to the ERs where the hospitals and taxpayers get tagged with the costs of things like heart bypasses, organ replacements and amputations, kidney dialysis, etc

    so basically what our current policy does is deny the reality of what happens when people don’t get basic primary care… the very thing all other countries do – that keeps their costs at 1/2 of ours and they do live longer also – no surprise. Not rocket science.

    • My questions remain unanswered. If expanding Medicaid will save costs (which means reducing the amount paid to the health care industry), why is the health care industry lobbying for expansion of Medicaid? Does business normally lobby for changes in the law that will reduce business revenues?

      If taxpayers will spend less under the expansion of Medicaid than we do for reimbursing uncompensated care (term of art), why doesn’t McAuliffe propose shifting health care appropriation to education or some other public purpose?

      If expansion of Medicaid will reduce the amount of money paid by insurance companies and, thus, ratepayers, than they do for reimbursing uncompensated care, why won’t supporters of expansion add a requirement for the VSCC to force insurance companies to lower their premiums or premium increase to reflect the cost savings?

      If expansion of Medicaid under a managed care plan (as proposed by many of Virginia’s Democratic legislators), what language in their proposed legislation will prevent replication of the results experienced by Oregon and Washington when they expanded access to Medicaid under managed care plans?

      I respectfully submit not a single supporter of Medicaid expansion would even attempt to answer these basic questions. And if a bill supporter cannot answer the other side’s questions, why should they expect the opposition to change its mind?

      Salz, I strongly disagree that human nature would lead individuals or society to do what is best for society (assuming we could agree on such definition). Human nature, by definition, is selfish. We reflexively look for solutions that benefit ourselves and then those close to us. Absent other factors, we look out for ourselves first even as we behave fairly in life.

      Look at Warren Buffett. He calls for higher taxes, but pays only what he has to and has used the effect of the estate tax on heirs to purchase businesses at lower prices. Look at Bill Gates. Instead of giving away his money, he retains control through a non-taxable foundation. Look at labor unions. Despite strongly supporting enactment of the ACA, they are fighting the so-called “Cadillac tax” on expensive health insurance plans. This does not make any of these people bad in any way. But we are all selfish.

      • Sorry, Too, I guess I wasn’t clear. I was referring to the numerical precision of mathematics, (“rocket science”) and saying what I believe you are saying. Every human — because of our humanity — sees and reacts to situations/stimuli/ideas in slightly (or hugely) different ways. If our selfishness (to use your example) was part of rocket science, it would be in an equation backed by a theorem and proof and we would ALL react exactly the same every single time. Instead, Buffett reacts slightly differently than Gates and greatly differently than Zuckerman (is that the Facebook guy?). Elizabeth Warren reacts differently than Hillary Clinton who reacts differently than Bernie Sanders who reacts differently than…

        If human behavior was rocket science (instead of human behavior), we’d all do the same thing every time was the (not very funny) point. Instead, we have and maybe need government.

        I’ve enjoyed reading the give-n-take between you and Larry (and others). There is never an easy answer, I submit, and your discussion illustrates nicely.

  14. Thanks for all the insight above. To reply solely to Larry’s last line: “Not rocket science.”

    Human behavior is not rocket science, it (as someone long before me once said) much, much harder than that.

    And what we talking about whenever we’re talking about government, governmental policy, politics, is the attempt to manage human behavior. If human behavior was entirely rational (which in itself is a difficult concept to define), there would be no need for government because ALL would immediately, without being convinced, do what is best for all society.

    Rocket science, I submit, is easier than trying to run a good democratic system producing good policy for the benefit of all. Two plus two always equals four, or the U.S. and Russia couldn’t be running a joint space program, but “good” “democratic” “system” “benefit” and even the word “all,” have multiple definitions in multiple minds with multiple backgrounds and philosophies.

  15. If Mr. Bacon would allow me a series of posts, I can tell you how we can knock out a boatload of $$$$ out of the system:

    1) diagnostic errors
    2) under and over testing
    3) inefficient use of resources
    4) top heavy/too many administrative people
    5) hospital/insurance lobbyists/corporations need to be publically accountable w/mandated limits (in many areas) and no more tax breaks
    6) EMTALA reform (will include certain doctor office practices reform)
    7) public knowledge of where the $$$ are going to: admin/new offices/doctors
    8) reform of all state medical boards (starting w/the US Supreme Court ruling they’re not following)
    9) licensing changes along with MOC changes
    10) legally not allowing gag orders except the patients’ information may be modified so that it is not identifiable
    11) opening up the NDPD to everyone
    12) incorporation of EBM in practices & medical education reform

    Those are for starters. Notice I mention nothing else. By reforming the above, from my examples and others, you’d be able to see where costs are really going in the system. After this, I would say you have to hit up patient responsibility in terms of food choices & “intimate practices” (not sure about the censorship here), where the education should start in kindergarten.

  16. what we have with health care in the US is govt policies that favor certain folks – like employer-provided and Medicare … and a lack of similar policies to benefit others – who work but their employers do not offer health insurance.

    the folks that have it – essentially are opposed to providing that same benefit to those that don’t have it often stated as “they don’t deserve it and I’ll have to pay more for it”.

    in other words – they do not buy the idea that they’re already paying for it anyhow and they think will be less costly to them if they deny that care to those that need it.

    that’s the mindset of many these days – in a nutshell

    and then we have folks who think the free market will help the folks that don’t have it.. as if someone with cancer or heart disease or a child with congenital defects will be taken care of by the free market and competition.

  17. re: reducing costs under MedicAid expansion

    going on your thinking – we should get rid of MedicAid all together – correct?

    re: controlling human behavior..and rocket science.

    I think I was referring not to controlling human behavior so much as I was alluding to the fact that when a country has health care for all citizens and that means they all have access to early screenings for disease – that they’ll catch it and treat it more cheaply than if they don’t have those screenings for everyone and many will get those diseases that will be far more expensive to treat once they advance.

    to me – that realization is not “rocket science” but more along the lines of common sense.

    TMT thinks the cost of the additional screenings will increase overall costs and no savings will accrue….. apparently…

    yes we’ll see more visits to the ER – but less charity care for advanced diseases…. and in turn less costs that are transferred to others.

    • Larry, the idea that spending more on preventive medicine will catch medical problems in their early stages and save money down the road is intuitively appealing, but it has not always panned out in practice. A good example is breast cancer screenings. There is a cost to running millions of scans. There is also a cost to false positives. There also is a cost to treating diseases earlier and more aggressively — think mastectomies — than ideal. After years of advocating more and earlier breast cancer exams, the experts have reversed themselves.

      What’s true of breast cancer is not necessarily true of a different disease, but it’s a good illustration of the complexities involved. As TMT observed above, the expansion of Medicaid in Oregon did not result in the system-wide savings that were widely predicted.

      • Medicaid expansion actually wasn’t expected to reduce overall medical costs – the argument was that it would reduce ER costs, not all costs. However, ER costs did not go down in Oregon.

        The Oregon Medicaid expansion saved the life of a friend of mine, so I’m not remotely arguing against it – but Medicaid expansion isn’t a cost-saving measure. You can make a moral argument for it, but the fiscal argument isn’t backed up by reality.

        • vgal2 – Hospital Charity care – not just ER costs.

          there is a soundbite view that the uninsured only go to ERs and never get admitted to the hospital which is not true.

          the bigger costs are not the ERs – it’s when someone goes to the ER with an advanced disease and has to be admitted to the hospital and treated – and the patient has no money nor insurance.

          we’ll have to await more studies to determine what the costs are in the expansion states but fundamentally – when you do not screen for disease and treat it earlier – you’re going to have much more expensive advanced disease that needs heroic financial efforts to treat. When that happens to people who do not have insurance – it’s much more than an ER visit – it’s called Charity Care.

          lower costs WERE anticipated – to wit:

          INDIGENT AND CHARITY CARE
          PROVIDED BY HOSPITALS

          Joint Commission on Health Care
          November 3, 2010

          | In 2008, Virginia hospitals provided $400 million in
          charity care

          STUDY SUMMARY

          | Non-profit hospitals provide more charity care than forprofit
          hospitals as a percentage of revenues

          | Federal health care reform is expected to decrease the
          need for charity care in 2014″

          http://services.dlas.virginia.gov/User_db/frmView.aspx?ViewId=928

          and here’s the bigger problem in my view –

          people CHOOSE to not be informed on the issue and instead prefer to be lazy and rely on sound bites including propaganda from those opposed ….

          MedicAid costs are out of control – precisely because MedicAid in Va does not cover those who work but can’t afford insurance.

          what happens to them? they get sick – they lose their job and they go on Medicaid as an indigent.

          without access to insurance and health care – folks in that group don’t get screenings, don’t see primary care for early diagnosis and treatment of diabetes, and other conditions that can be detected and treated…

          at some point – the become “disabled” and the state then pays for a doctor to certify that they have an advanced disease that makes them eligible for basic MedicAid …

          that’s how Virginia’s basic MedicAid costs are growing out of control..

          I’m going to follow with another link in the next posts that shows that between 2008 and 2015 – uncompensated charity care grew from 400 million in 2008 to 1.2 billion in 2015 – it TRIPLED!

        • I’ve attended meetings in Fairfax County where Democratic legislators have said that expanding Medicaid would cut costs for both taxpayers and insurance premium payers. And, of course, the WaPo editorial board regularly makes the argument. I don’t think it’s true based on what I’ve read. I’ve been pushing back at what I see as a false argument.

          I can appreciate the moral argument. But then I’d like to see the legislators be honest enough to say they support expanding Medicaid at all costs and that they are also hypocritical when they make their “moral” arguments, but sneer at those who make different ones.

      • Jim – like TMT -you choose to cherry-pick what you want to believe rather than deal with the facts and realities.

        30 other countries PROVE that screening more of the population for more diseases than just the one you named actually does reduce costs because it DOES detect diseases earlier and treats them before they get far more expensive.

        the fact that these other 30+ countries all have better life expectancies is – again – factual proof – not what folks want to believe.

        second the folks who love to cite the Oregon study for some reason totally ignore the later Colorado study. why?

        are you just looking for the studies that support your bias or are you truly trying to be informed on the issue – because there are MORE studies than JUST the Oregon Study – however when you read the right-leaning commentaries – it”s never mentioned.

        ” Impact of Medicaid Expansion on Hospital Volumes

        Executive Summary

         The Medicaid proportion of patient volume at hospitals in states that expanded Medicaid increased substantially in the first quarter of 2014. At the same time, the proportion of selfpay and overall charity care declined in expansion-state hospitals.

         Medicaid, self-pay and charity care showed no change outside normal variation for hospitals in non-expansion states in 2014.

         The increase in Medicaid volume, which occurred only in expansion states, is due to Medicaid expansion. The parallel decrease in self-pay and charity care shows that previously uninsured patients are now enrolled in Medicaid.

        http://www.cha.com/Documents/Press-Releases/CHA-Medicaid-Expansion-Study-June-2014.aspx

        please take a minute and read this and then come back and comment.

        • Breast cancer/PSA screening costs more than people they catch. In terms of prostate cancer they die of other things rather than that.

          They detect it earlier but that doesn’t mean people will get the screening. In my case, there is no need to screen for breast or colon cancer every year/5 years. Why pay for what is not called for?

          My father had heart conditions and died in his 70’s from it. I have had HDL levels over 100 for several years. So why pay for screening for certain items? There are some heart issues that I need to be watched for, but not all. So why waste money on it?

          What about false positives? I know someone who became pregnant, very healthy but she is tiny. The ob/gyn got her all flipped out because the baby is small. The momma to be eats extremely healthy, nothing wrong with her. The problem was she got put thru testing and the like, when a woman not even 100 pounds and 5 ft in pregnancy is expected to have a baby of 8-9 pounds and 24 inches. Please! Common sense should have said the baby is going to be smaller. Even medical advice said that but the ob/gyn didn’t read and think. So money wasted, stress the momma out, all for unnecessary testing.

  18. ” HOSPITAL UNCOMPENSATED CARE COSTS IN VIRGINIA
    POLICY BRIEF . SEPTEMBER 2015

    Uncompensated care reflects the overall cost to hospitals
    of providing unpaid services to patients. Uncompensated
    care includes charity care, defined as free or discounted
    care provided to those in need that the hospital never
    expected payment from; and bad debt, defined as payment
    the hospital expected but did not receive. Bad debt
    includes both the costs of uninsured people who cannot
    pay for their care but do not apply for financial assistance
    and unpaid deductibles, copays, and uncovered services
    for insured people.

    Half of all hospital uncompensated care costs in the state
    is incurred by only 10 hospitals—or about 10 percent of all
    acute-care hospitals in Virginia. Hospitals with the largest
    uncompensated care burden include the two large academic
    medical centers (Virginia Commonwealth University and
    University of Virginia health systems) as well as mostly large
    not-for-profit hospitals in urban areas that serve as major
    regional providers for the uninsured and other patients.
    The percentage of total hospital costs accounted for by
    uncompensated care is a common way of assessing
    the financial burden on hospitals of providing care to the
    uninsured and underinsured. In 2013, uncompensated care
    comprised 6.9 percent of total costs among Virginia hospitals,
    up from 6.0 percent in 2008 and 6.5 percent in 2010. The
    upturn in uncompensated care burden likely reflects the
    increase in uninsured state residents, which has increased by
    about 11 percent to almost 1 million people.

    Cost to Virginia hospitals for providing uncompensated
    care in 2013: 1.2 BILLION DOLLARS

    http://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_DHBP_HUCC_WEB.pdf

    I would assert to you Vgal2 that this is CLEARLY a fiscal issue…

    who do you think is paying that 1.2 billion dollars?

    what folks need to do is get the facts – resist the urge to believe sound bites like the Oregon study which is cited over and over by opponents of the expansion as they purposely ignore other facts and data…

    it’s not ER visits – that perception is a give-away that one is not informed about “charity care” which is the 600 lb elephant in the room.

    Finally – no reform or change is going to be able to give ironclad guarantees as to outcomes but if you never try the reforms – you’ll never know.

    If the reform does not pan out – you get out of it.

    and if your bottom line benchmark is flawless solutions then you’re in the wrong business to begin with. No program – govt or private is without flaws and not in need of more changes…

    you go forward by changing things – to cite potential failings as a reason not to make changes is basically a blind adherence to the status quo.

    Jim says folks don’t have provide alternatives. Basically he hammers the system for not working then he turns around and says – “we don’t like their proposals but we do not have to present alternatives – we can just block what we disagree with”.

    this is coming from folks who claim to be fiscal conservatives.. and I would assert they’ve lost the “fiscal” part and replaced it with ideology.

    this is not a moral issue. It’s a fiscal one -of catastrophic proportions and we’re in denial about it. we choose to believe what we want to believe and ignore the realities.

    • The studies so far in expansion states – particularly Oregon, which expanded prior to the ACA – are that it doesn’t reduce costs. I used ER as shorthand, but I am talking about all charity care.

      Much needed care just isn’t provided in the absence of Medicaid and in the absence of the ACA. This isn’t about moving from charity care to Medicaid – it’s about not getting care before, and being able to get care after.

      Slightly off topic, but – it isn’t all that easy to become “disabled.” You make it sound simple and smooth. It isn’t.

      There isn’t good data showing that early screenings saves money, in the US or elsewhere, and there’s some evidence they can be counter-productive re health. That’s why screenings are being cut back substantially.

      Uncompensated care is a reality. That doesn’t equate to Medicaid expansion saving money. Two entirely different things. The data indicates Medicaid expansion doesn’t save money. It probably does save lives.

      I mention Oregon because I have a friend who is on Medicaid in Oregon, whose life was probably saved by Medicaid expansion, and who could not get care prior to her enrollment. There is no question she would have died otherwise.

      In other words, I have a personal connection to the situation as well as a concrete, real life example of what I’m talking about.

      It is a moral issue. I don’t think it’s going to save money, and if you hang your hat on it saving money, you’re not going to have Medicaid expansion for long.

      • re: ” are that it doesn’t reduce costs. I used ER as shorthand, but I am talking about all charity care.”

        can you cite something that addresses costs vs ER visits?

        re: disability –

        have you seen the data for Social Security Disability?

        “Report: Social Security disability fund to run dry next year”

        re: screenings – again – have you actually read more in depth on the screenings ? the questions are not about things like glucose sugar and blood pressure – etc… which do indeed detect latent heart disease and type II diabetes… the issue with screenings is about things like imaging for breast cancer …

        re: uncompensated care and reality. How do you deal with the uncompensated care if you do not make changes and stick with the status quo?

        you have to go forward – keeping what works and discarding what does not. To use uncertainty as a reason to do nothing is dumb.

        • What I have seen is data, from Oregon, looking at their early Medicaid expansion. Essentially, it does not show a cost savings, and it shows limited health improvements. From personal exposure to someone admitted to the system, I believe that the latter is an artifact due to many of the people qualifying have long delayed medical needs – often very large ones. People are often limited in getting medical care without insurance – not just in paying for it, but actual access to care.

          I have seen the data for Social Security Disability. I also have a family member that should have, but did not, qualify for it. I would describe the process as arbitrary, expensive, and excruciatingly difficult and stressful. It is not simple and it certainly is not easy.

          We should deal with uncompensated care in the best way possible. However, that doesn’t mean making claims for cost savings that are unlikely to occur and that have not panned out with similar experiments elsewhere. That is also part of going forward – looking at reality rather than wishful thinking.

          • Reed Fawell 3rd

            Bingo! Bingo! Bingo!

            Excuse the exuberance but it takes more words than simply “Bingo” to get by the Robotic Censors.

            This nonsense is kinda of like “Oregon’s Medicaid Expansion” And US Social Security Disability. Both programs are very stupid, rigid, mindless, unfair and totally unfit for the task they are said erroneously to perform. Indeed now these programs are part of reason why the life expectancy of our citizens (in this time of miraculous medical renovations) for the first time in our nation’s history are rapidly declining rather than rising.

          • Reed Fawell 3rd

            Life expectancy in Victorian Britain was in the mid 30’s for the average citizen. Only 6% of Victorians lived beyond the age of 65. These were the mean facts of lives in the world’s most advanced industrial society in the 19th century.

            So, but for improved medicine and lifestyles over the past 130 years, a huge number of us alive today in the United States would be dead. Incurable maladies, causing great suffering and inconvenience, would dog many of the rest of us still alive today, making us miserable for the rest of our lives.

            So now our life expectancy is roughly 80 years, even higher and rapidly improving, for certain segments of our society.

            Yet now, for the first of time in our history, we are seeing the health of many of our people declining at an alarming rate. For them the dream is going in reverse. And doing so ever faster while an ever smaller group of our citizens are receiving the best health care ever imagined.

            Indeed now, an ever shrinking group of our people living are living ever longer and ever more productive and functional lives as if that elite group has been tapped into a fountain of youth coupled with the great power of wealth, wisdom and age.

            Why are these two counter trends emerging? Why are they gaining ever more momentum? Why are they splinting our society apart? Why are they dividing us into those who have great abundances of health, and wealth, and power, and stealing from everyone else, leaving an ever growing group of us with relatively little or none of the above?

            Why? Why is this happening. And happening so fast?

            This reminds me of the automobile.

            Do you remember how that automobile freed the vast majority of the people in this country after WW11? How the automobile brought unimaginable wealth and freedom and dignity to “EveryMan” in this country. How it built for him his wealth and his health and his freedom and his family everywhere, spreading it all around and mixing it all up.

            Why did this happen? What’s happened now? Why has this dreamed died for so many?

            The reasons are complex. But chief among them is that the powerful, the wealthy, the politically connected, gained control of the automobile, and its use and its function that benefited others. This elite learned how to game that system that gave so much to so many. That elite learned how to suck all that benefit from those other people and to take it for themselves (yes steal it) for their own private benefit, so as to become unimaginable rich themselves at the expense of every one else. Yes, I know, its a complex story, full of paradox, and unintended consequences, but this is in practical affect what happened. And it is the primary reason why the horrible consequences, however “unintended” never get fixed. The entrenched elite refuse to fix them. Instead the entrenched elite find ever more ways to avoid those ugly consequences for themselves why living grandly beyond their wildest imaginations, off the suffering and pain of everyone else. They cannot stop. Even as Rome burns.

            The best example of this is Northern Virginia, Tyson’s Corner most especially.

            The adverse consequences have been growing there in Northern Virginia for decades. But the powerful elite there kept doubling down because they were making so much money off those increasingly afflicted by the growing problems caused of the elites own misconduct (how they were gaming the systems for their own advantage.

            So now in Northern Virginia we have reached the tipping point. Travel by car, even and especially on interstates, is now totally unreliable 24/7, reaching gridlock. Traffic now is shutting our society down. It’s walling ever smaller islands of land and people off from one another. It’s destroying our middle classes ability to work, to earn a living, to marry, to raise and support a family. Its been going on and rising more awful for decades without solution.

            But now there is an important difference. Now the wealthy elite (those in control of the problem) are caught in gridlock too. Now even they are inconvenienced. So what do they do? They impose huge tolls on the roads that will grow ever higher until soon only they will be able to afford those toll. Breaking the bank for most families, forcing them off functioning roads, wasting their lives and bank accounts gridlock, the wealthy who made their wealth creating the problem, will escape it altogether again, speeding along in the private toll roads. It is their perfect solution, allowing them to avoid the ever increasing pain and inconvenience that now they can continue to inflict on everyone else.

            So toll roads, and Medicine, what is happening to both, is like Yin and Yang. They both fit together, along with what is happening in Education and so much else in this country today caught in the grip of the elite pulling all the levers that keep them on top at the expense of everyone else.

            So now too we are seeing this happen in medicine. The medical industry and the powerful elites getting richer and healthier, off a system that inflicts ever more pain and dysfunction on everyone else. This should not surprise. It’s common as mud. It’s the way history now works. And the way history always has.

          • Reed Fawell 3rd

            One of the most fascinating aspects of the political maneuvering by the political class to maintain power, control, and wealth is how cleverly they disguise their actions and motivations. How they forever argue that their intentions are to serve the public good while their actions far too often achieve precisely the reverse.

            Go back and read old papers. The false promises are never ending. Professor Jonathan Gruber’s efforts on our governments behalf to hide the tax imposed on our health plans, or our Presidents assurances that “if like your doctor you can keep him” are tips of icebergs.

            Go back and read all the assurances given over the decades that every massive expenditure on roads in Northern Virginia was going to fix the traffic problem. Or how the takeover of the Dulles Toll Road would not result in raising tolls for years, and even after, by more than the rate of inflation. All these false promises made at the time (2004-2007) in response to public hearing after hearing before a skeptical public.

            And read all the promises today. How our public control and overhaul of the nations health industry is going the fix the problem. Plainly it will make problems far worse, save only for those who are managing and controlling the “solutions.”

          • Virginiagal2. You are making my points. I’ve gone to community meetings with local legislators. The Democrats always claim that expanding Medicaid in Virginia would save costs for taxpayers and premium payers. I’ve raised the Washington and Oregon situations, only to be told that those states are different because Virginia would use managed care, never minding that so did those two states.

            It is my belief that at least a couple of our local Democratic legislators want Medicaid expansion at any cost. If so, they should say so. It’s the same ones that argue for increasing funding for Virginia’s colleges and universities. The song is spend more, spend more, and let’s not talk about the results.

      • vgal2 – it is truly a fiscal issue when the State of Virginia refuses to take billions in Federal dollars that will cover 100% of the costs initially and gradually reduces to 90% over 10 years.

        In other words – Virginia’s costs are 10%.

        the argument being used against it is that the Feds “might” go broke with the Federal Deficit. Medicaid expansion money does NOT come from general revenues.

        Let me ask you – do you KNOW where the expansion money comes from? Have you read in Bacon’s Rebellion where it comes from ? Has Jim informed folks via his blog where the money comes from – as opposed to continuing to support the State GOP argument that in the future the money “might” go away because of the deficit.

        isn’t this a totally dishonest narrative coming from the GOP and being accepted here in BR without correcting the record?

        you want more hypocrisy?

        how about this:

        ” Virginia eyes federal funds to help Medicaid’s costliest patients”

        “Vrginia wants to tap $1 billion from a federal pool of money – and put up a similar sum itself – to change the way Medicaid handles the few thousand Virginians who account for more than half of the program’s costs.

        The aim is to set up groups of medical, psychiatric and long-term care providers to concentrate on the costliest 1 to 5 percent of Medicaid recipients, according to records of the state Department of Medical Assistance Services.”

        http://www.dailypress.com/news/dp-nws-medicaid-dsrip-20151215-story.html

        are we turning down MedicAid money or not?

    • Attempting to post this response:

      http://www.npr.org/2014/12/19/371202059/when-a-hospital-bill-becomes-a-decade-long-pay-cut

      In the cities of Norfolk, Chesapeake, and Virginia Beach, there are hundreds of cases of warrant in debts and garnishments. http://www.dacbond.com/dacContent/doc.jsp?id=0900bbc780113110 indicates Sentara has a healthy balance sheet, as does http://www.guidestar.org/PartnerReport.aspx?ein=54-1917649&Partner=Amex and https://www.citizenaudit.org/541917649/, http://www.guidestar.org/organizations/54-1917649/sentara-enterprises.asp, x. http://www.guidestar.org/PartnerReport.aspx?ein=54-1917649&Partner=Amex indicates that you are a 501c3 Public Charity. These also indicate Sentara has lobbying activites and transfers funds to exempt non-charitable orgs.

    • Seems to me that there is more than enough profit to buy lobbyists, places on the state medical board, legislators … (TIC).

      Look at how many health care personnel involved in direct patient care have > 6 figure salaries, compared to non health care personnel. I can guarentee you the non profits are not hurting and could do more charity care.

      Sentara, AFAIK, doesn’t take Medicaid. They throw that to Bon Secours, who is in a worse financial position than they are, with only a few hospitals, less than half of Sentara’s.

  19. Part 2 of a letter sent to Sentara, the largest healthcare corporation in Hampton Roads:

    1) As a public charity, why is there so much funds & manpower spent to garnishments and warrents in debt?
    2) Is all income, meaning funds from patients, used to promote lobbying activities?
    3) Could you please verify that yes or no, the ifnromation shown above is correct?
    D)
    http://www.wsj.com/articles/SB120726201815287955 discusses “Northwestern Memorial spent $20.8 million on charity care — less than 2% of its revenues and a fraction of what it received in tax breaks.”

  20. 1) What percentage of income is spent on charity care (especially as you do not accept Medicaid, with 7 hospitals and Bon Secours only 3, that is less than half the choices for the poorest people)?

    2) As the article states, “But many hospitals include other expenses in their community-benefit accounting to the Internal Revenue Service, including unpaid patient bills. Often, hospitals also include the difference between the list prices of treatment they provide and what they are paid by Medicaid and Medicare, the government programs for the poor, disabled and elderly. Excluding those other expenses, many hospitals spend less on charity care than they get in tax breaks, studies by various counties and states show.”
    does the amount spent on patient care by Sentara include or exclude items like this?

    3) This article states: “demanding upfront payments from patients; hiking list prices for procedures and services to several times their actual cost; selling patients’ debts to collection companies; focusing on expensive procedures; and issuing tax-exempt bonds and investing the proceeds in higher-yielding securities”, can you please tell me what activities Sentara engages in of these?

    4) The article discusses advertising dollars spent. Does Sentara talk about the TV and Virginian Pilot ad dollars and how much it spends? I note no other hospital system does this, especially in terms of the bariatric surgery programs, where a 40-45% profit margin is recognized in literature. The amount spent on Covidien and their consulting services would not have been spent unless a profit was realized. How many funds has been spent on patient safety for the same group, or in terms of education as the center is not able to handle anything other than weight regain issues or labeling patients with psychological issues?

    5) The article discusses the benefits and pay for the UPMC CEO, so would Sentara answer as to why they go after people who obviously have trouble paying their bills (see above), not only making the need for more lawyers, administrative personnel that are not involved in direct patient care, and what the procedures are for working things out with people vs. the vast amount of legal work done in the case lists I see listed online? Also in terms of the tax breaks Sentara receives for being a non profit corporation?

    6)
    http://www.citizen-times.com/story/opinion/contributors/2014/02/17/lets-face-it-todays-gigantic-hospitals-are-ripping-us-off/5493643/ makes mention about the chargemaster list. Is this open to the public so we can compare costs?

    7)
    In regards to http://www.propublica.org/article/in-alabama-a-public-hospital-serves-the-poor-with-lawsuits, is there any comment from a non profit hospital that is a public charity?

    8) As medical bills are the major issue in terms of bankruptcies and Sentara doesn’t take Medicaid (for the poorest), does Sentara transfer patients who have Medicaid where they just do stabiliziation and leave other hospitals to pick up the costs of the care?

    http://www.cnbc.com/id/100840148

  21. re: who takes MedicAid – MedicAid IS voluntary and so is Medicare but hospitals that do not take MedicAid cannot be reimbursed with Medicare either per Federal rules – and while folks might think this would be okay – the reality is that most hospitals rely heavily on Medicare reimbursements – as do many doctors and other providers.

  22. “Agreed, We Can’t Risk…” expanding Medicaid.

    This statement represents what is so wrong with this blog:

    (1) “Agreed,” who is “Agreeing?” Not me or thousands of others.
    .
    (2) “We Can’t Risk.” We can’t risk giving 400,000 lower-income Medicaid tax benefits that have been already bought and paid for by federal taxes? What kind of insufferable nonsense is this. Who gets to say it is too “risky?” A blogger who lives in a very comfortable part of Henrico County and has all of his health care bills pay for with private insurance?

    (3) Why don’t we say that all the corporate welfare doled out in Virginia to Dominion, Alpha Natural Resources, Altria-Philip Morris USA and so on is “too risky.”

    This logic is highly infuriating.

  23. Mr. Fawell:

    I like your analogy with Virginia transportation because I agree that the final result of toll roads will be like “Cadilac” insurance policies.

    But I support toll roads. Not because they are the BEST solution but that they are the only politically-conceivable solution in a culture with a “love affair with the automobile” where not a single politician (of any stripe) is willing to “lead” because, due to love affair, there is “no parade for that politician to get in front of.” There’s another definition of political leadership that comes into play: Politics is “the art of the possible.”

    It is possible to toll. It’s not politically possible to build a “congestion zone” or tax by mileage or — and Ryan totally took this off the table — rationally tax by raising the 18.4 cent per gallon federal tax.

    Americans drive in excess of 3 trillion miles a year. D.C. is the worst congested city in America. MOST of that congestion is from drivers who do not live in, or even near, D.C. The city, Virginia’s counties, etc. cannot do anything about the traffic which moves into and through them except agree to toll their main roads.

    Please consider the “inner” and “outer” Beltway toll plan for I-66 as a package. The present I-66 toll plan (not the badly done I-95 or 495 toll lanes) provides massive opportunities for all work commuters to get off the roadway rather than face expensive tolls. To avoid the heavy tolls, driving commuters can honestly carpool (unlike the faux carpools today on I-66); non DC resident drivers can park-n-ride from five different lots; drivers can take transit and only those people who demand to drive by themselves along I-66 will pay the tolls. This will decrease traffic throughout the area and that’s what America HAS to do if we, for example, want to address our health issues; our air and noise pollution issues; our parking problems; our congestion issues; our need to pay $30 million DAILY to keep carriers in the Persian Gulf to ensure the international oil supply; our desire to possibly destroy our drinking water through fracking; and most importantly have some chance of actually decreasing our greenhouse emissions.

    Transportation dumps about 25 percent of America’s C02 into the atmosphere and about 70 percent of that is from automobiles. American cars and trucks produce half the entire world’s CO2 automotive emissions yet we are less than one in five of the world’s population.

    Unless we are going to ground the airlines and destroy trucking, in short, America has to address our habitual driving culture, even if no politician will say this. All conceivable solar panels and wind turbines, electric cars, alternative fuels, fluorescent light bulbs, etc. will not overcome the issues created by our driving.

    America has got to start thinking about our driving and the only present politically-feasible way is through tolling. (I actually support an entirely different approach but nobody is listening to me…)

    Again, toll roads are NOT the best way and I submit, again, that “public private partnership” toll roads are a scam on taxpayers.

    Here is another negative of toll roads that you either neglected to mention or didn’t know about. They are not-so-jokingly called “Lexus Lanes” because the tolls are generally tax deductible by the rich and always a cost of doing business for company cars. In short, middle class taxes generally cover the tolls for the rich.

    Consider this short op-ed, Mr. Fawell: http://www.styleweekly.com/richmond/hired-hypocrisy-sustainability-is-the-word-of-the-day-but-not-for-the-rich-and-famous/Content?oid=2272749

    • Hello salz –

      Your reply to my comment is one I appreciate.

      I agree with much of what you say. I disagree with some of the rest, and believe other comments you make take too narrow a view of the problem and possible solutions where a more holistic, multi-faceted approach is needed. I also do not wholly agree with some of your history and premises.

      The only way I can do some justice to your comments, however, is to break up my response into parts over time. Meantime we divert the conversation here from medicine to roads, yet I suspect the solutions now being imposed on both are in many ways similarly flawed and bound to fail.

      If so, than terminally false solutions to roads have relevance to the ongoing terminal false solutions we are now imposing on healthcare. And the wonderful comments above on current healthcare behavior as pointed out by V N (for example), have relevance to other governance areas such as roads.

      For our failures are systemic within a growing plague, namely, our nations rapidly expanding crony capitalism, predator non-profit industries, and incestuous private public partnerships, in league with our governments.

      These metastasizing mongrel arrangements now feed voraciously at the public trough. And they do so by enriching those elites who control access to that trough at the expense and detriment of the middle class, while they also inject a narcotic into our poor, disadvantaged, and growing idle class. This locks the latter group into submission for generations, ready, willing and able to be milked for the votes and anger their masters (the public, private, non profit cabal, all working together in a devils bargain) need to maintain their wealth, power, and advantage over everyone else. This I believe is the current state of much of our affairs today in America.

      These modern and rapidly expanding institutional structures plague most of what we do today now as concerns roads, health care, education, research allocation and much else.

      To be continued.

      • Correction – last phase above should be “… as concerns roads, health care, education, resource and funding allocation of public monies and much else.”

      • Reed wrote: “These metastasizing mongrel arrangements now feed voraciously at the public trough. And they do so by enriching those elites who control access to that trough at the expense and detriment of the middle class while they also inject a narcotic into the poor, disadvantaged, and growing idle class. “

        Very nicely put. This is the story of 21st century America.

      • Thanks, Mr. Fawell. I’ve always thought that the most interesting character in Atlas Shrugged was not one of the two protagonists, but rather Dagny Taggert’s brother, the actual president of the railroad.

        Remember, he saw his job, not as running the railroad, but getting favors from government. He wasn’t evil or particularly stupid. He was just doing “his job” as he understood it.

        We now, of course, call that “crony capitalism.” I think you’ve described the big picture fairly well.

    • I don’t want to turn this post into a transportation issue, but I must disagree that the I-66 tolling inside the Beltway “will decrease traffic throughout the area.” VDOT is studying a significant number of intersections in Fairfax County to determine whether they will have more congestion once HOV-2 is eliminated and tolls imposed. And they are adding more at the request of citizens groups. It’s been my experience VDOT does not do studies that they deem wasteful – at least not without substantial pushback.

      At a meeting with the project’s manager, she told the McLean Citizens Association’s Transportation Committee that, when HOV-2 is eliminated, VDOT expects 40% of the existing I-66 rush hour commuters to be forced to make a decision whether to pay the tolls or to become legitimate 3 passenger cars. Her unstated message is that VDOT does believe many of these drivers will take other streets to get to or from DC and avoid the tolls. No argument intended. I just want to pass on additional information.

    • Hello salz –

      I’ll try to pick up the tread of our earlier discussion. Before we’re finished we might be in for a wild ride, like found at:

      http://www.baconsrebellion.com/2015/11/can-things-get-any-worse-how-about-declining-life-expectancy-for-middle-aged-whites

      That is because there is much history to discuss. It’s essential to a full understanding of what is going on in No. Virginia today. And how best to address chronic road and highway problems that plague the DC region.

      First, however, I’ll raise two preliminary points.

      1/ I concur in your belief that any workable solution must successfully encourage people to get out of their cars and onto the feet, and bicycles, and into mass transit. The question is how to do this in the short and long term. So as to cause the least harm to all concerned, and garners to best results and greatest benefit for all concerned. THAT MEANS LONG LASTING REAL SOLUTIONS, NOT SHORT TERM FIXES.

      I suggest that history largely explains not only how we got to today gridlock present, but also shows us the most reliable way to fix the problems for good, achieve the best solutions, even in this time of rapidly involving demographics, technologies, lifestyles, and wealth creators.

      One more preliminary point. Earlier you stated: “Here is another negative of toll roads that you either neglected to mention or didn’t know about. They are not-so-jokingly called “Lexus Lanes” because the tolls are generally tax deductible by the rich and always a cost of doing business for company cars. In short, middle class taxes generally cover the tolls for the rich.”

      Perhaps because I brought subject up in an earlier comment that you missed. I totally agree with you here. Indeed this “Lexus Lanes solution” is a primary driver behind my objections to current proposals, and for several reasons. Firstly, it lets those responsible for today’s traffic problem off the hook, allowing them to continue feeding the problem without paying a personal price sufficient to cause them to change their behaviors that for decades has been the root cause of gridlock in Northern Va.

      Tolls ratchet ever higher with ever higher demand, a solution grossly unfair. What is a Prohibitively high bankrupt inducing tolls from most people in No. Virginia a peanuts for the those imposing the tolls. But what they will not tolerate from the selves, namely gridlock, they now apparently willfully impose on others who cannot afford their solution. And they make that imposition without fixing the long term problem that they impose on others by forcing them off the roads.

      In addition, such tolls will not only delay the final solution but make matters worse for those unable to pay. For example witness the proposed Inova / George Mason U. Personalized Care Center just days ago proposed for the old Exxon Merrifield site. I fear this plan will dump massive amounts of new traffic into Ground Zero of Northern Virginia’s traffic Armageddon. I suspect this project and its spin off growth turbo charges traffic at the the worst possible place. And I suspect it relies directly on the new t0lls now being implemented, and that those tolls are designed to serve the traffic that new project requires to make it feasilbe. Hence the tolls don’t solve the gridlock there today but throw flames on the problem instead. Meanwhile the general public endures ever more pain as the traffic grows ever more intractable. And that is the case because the traffic inducing long distance commute demanded by No. Va. suburban development and it’s hi jacking of interstates are never addressed. And this time the new tolls serving to dig the hole deeper.

      • CORRECTION to TYPO’S IN 2ND to last paragraph ABOVE.

        “These new Tolls will ratchet ever higher with ever higher demand, a solution grossly unfair. What is a prohibitively high bankrupt inducing toll for most people in No. Virginia are peanuts to those who now impose the tolls. And what these toll imposing people will not tolerate for themselves, namely the experience of their own gridlock, they now apparently willfully impose on others who cannot afford the solution that causes them no pain. And they make that imposition without fixing the long term problem that they impose on others by forcing them off the roads.”

  24. Metastasizing Mongrels
    Marching
    on Monument Avenue!

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