Hey, Governor, How About the Rest of Us?

by James A. Bacon

Having expanded Medicaid coverage for more than 325,000 Virginians, Governor Ralph Northam now has issued an executive order directing actions to increase the number of Virginians enrolled in “quality, affordable health care coverage.” Secretary of Health and Human Resources Daniel Carey will explore ways to expand Medicaid enrollment, reduce insurance premiums, increase transparency of insurance choices, and develop a “data-driven strategy to create efficiencies in coverage and improve outcomes” with a special focus on “vulnerable” populations.

We won’t know what these initiatives will cost the non-vulnerable (the vast majority of Virginians) until we see the proposals. But as Carey undertakes his inquiries, he and the Governor would be well advised to remember how much health care in the form of Medicaid is already costing the state.

State General Fund spending on Medicaid services has increased from $2.29 billion in Fiscal 2010 to $4.88 billion in Fiscal 2019, according to a recent update on state spending by the Joint Legislative Audit and Review Commission. That was an annual growth rate of 9% yearly, and it accounted for 39% of the growth of all General Fund spending, crowding out other priorities.

Meanwhile, the Kaiser Family Foundation has found that the average cost of employer-provided family health care coverage now exceeds $20,000 a year, with workers paying slightly more than $6,000. That’s a 5% increase from last year — and it doesn’t take into account steadily rising deductibles and co-pays. Middle-class Virginia households are caught in a triple whammy — supporting ever-inflating Medicaid costs, paying more for their own insurance, and paying more out-of-pocket.

Here’s a question I’ve never heard Gov. Northam ask (he certainly doesn’t address it in his new executive order): How come medical insurance costs for employed middle-class Americans increase so much year after year… after year… after year?

Yeah, yeah, I know pharmaceutical costs are going through the roof. Except they’re not, actually. Prescription spending actually fell 0.3% in 2017, according to the Peterson-Kaiser Health System Tracker. Peterson-Kaiser was expecting a 2.4% increase in 2018 and 3.7% increase in 2019. Yeah, yeah, I know, the population is getting older, and old people have higher medical bills. Except that’s not relevant because old people (65 and over) get Medicare. Well, then, the workforce is getting older. Sure. The average age increased from 41.2 years in 2008 to a whopping 41.9 years in 20018, according to the Bureau of Labor Statistics. Maybe that’s a factor but it’s a tiny one.

How about cost shifting? Do doctors and hospitals charge patients with private insurance plans more than they charge Medicare and Medicaid patients? More to the point, are they charging private-pay patients more in order to cover losses on Medicare and Medicaid patients? Apparently the academic evidence on that is mixed and controversial. But it might be worth digging to the bottom of that question in Virginia.

If cost shifting is not a driver of higher private-pay insurance, what is pushing medical costs higher? How about looking into that?

Why are administrative costs so high, and what can be done about it? How about looking into that?

Why are hospital profits so high? Are they justified? And how are hospitals re-investing those profits? How about looking into that?

How does health care in Virginia’s benchmark against other states for productivity, outcomes, and innovation? How about looking into that?

Instead of focusing mainly on poor Virginians, how about dealing with health care issues affecting all Virginians, including the “vulnerable” and those who happen to be pay the taxes and pay their own insurance premiums? That would be a refreshing change.

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18 responses to “Hey, Governor, How About the Rest of Us?

  1. Again, as I noted with the Oxfam Fake Ranking post, this is a political stunt. The Democrats are running on a coordinated set of health care promises, and using a coordinated set of health-care related attacks on their various Republican opponents. The beauty of the issue is, as they know, people actually agree across party lines that rising health care costs are frightening, being uninsured is frightening, people with pre-existing conditions should not be denied coverage etc. There are differences about what to do, not about what the goal is.

    So the simple message is that Republicans will “take away” your health care, just like for five generations Republicans have been accused of wanting to “take away” Social Security or (fill in the blank.) Hey, its a great tactic, so no surprise…Especially when the Republicans just lie back and take it, making no effort to remind people that “mo government” and “one size fits all” might not be the best solutions. On Medicaid expansion, of course, the GOP loses both ways – getting no credit for the members who did make it happen, while much of their base is alienated that they did.

  2. In trying to think deeply about why it is so hard to get good health care via anchor services outside a few major cities, the revelation flashed that heath care as built today is not about serving the best interests of America’s patients, it is instead overwhelmingly built to serve the best interests of those who control healthcare, the senior Administrators and top specialists. All health systems now are built around maximizing the convenience, income, control, power and monopoly of those running the industry.

    So, next time, we you consider each new and rising problem confronting patients and their paying families, their causes, and solutions, look at it through at this new reality.

    In short, the awful facts of American Healthcare are driven by the same general problems that afflict American Higher Education, every higher prices for middle class, every lower results for all but rich, powerful and influential.

  3. So the GOP will take away your health care and the Dems will take away your guns and kill babies?

    But are you talking about the 90+ percent of the GOP who staunchly opposed the Medicaid expansion all along and lost anyhow when some on their side “defected” – you want “credit” for that?

    😉

    Does anyone really think the GOP has offered any real solutions and just staunch opposition to what the Dems advocate?

    You know, if the GOP actually had a REAL proposal – one that did actually cover people with pre-existing conditions – and at an affordable price – they WIN BIG – no question! Instead they are perceived as being in favor of denial of insurance for preexisting conditions or other foolishness like offering “crap” (bogus) policies that don’t cover anything …

  4. With high percentage increases it is right to ask why … but I would like to know how the per person expenditure stands in line with similar states. Did VA have to do some ‘catch up’ in terms of providing good coverage?

  5. You know – we are the ONLY developed country with this problem. And the GOP has had years to formulate an alternative approach.

    I do not think the Dems approach is perfect. There are lots of problems but I don’t see the unfettered market as fixing them and to be perfectly honest, I don’t think the GOP has a clue about what to do other than attack the Dems proposals.

  6. This idea that health care services and outcomes and customer satisfaction are far superior in every other developed country bears exploration. My guess is, one set of problems is replaced by another, with long waits and even denials probably more common. No question a fair number of Canadians cross the border for care here, if they have the money (and it would be a great reform to let American’s go there and buy drugs at the Canadian price.) Outside a campaign atmosphere, where Larry just wants to score partisan points, that would be an interesting exercise. I remember on one of my European trips a fellow traveler with an issue insisted on returning to the US, refusing to be treated in France. (Which struck me as odd knowing a century ago American docs flooded Europe for training….)

    I have been told that overseas this business of having two, three, four or more rounds of expensive and usually futile cancer treatments is far more rare than here in the U.S. But start talking about wasted spending on “end of life” and you get campaign ads about death panels. On health care, really, we’ve met the enemy and it’s us. Bad food, drugs, no exercise, too much to drink, and why can’t you cure me, doc? Fix it now!

    • Yes, there are some docs and some institutions that are patient centered, and this includes patient centered serving the wealthy and poor alike. Often you can tell these places when you walk in the door. A prime example is National Rehabilitation Center in Washington DC.

      Of course, America offers in many cases the most advanced and best care in the world no doubt, but this does not negate my general premise above, in fact it often explains and buttresses that premise, so it’s not a paradox. Larry’s country by country overall health statistics below also supports my premise, given that the cost of our health care on average far exceeds its average performance level, per those longevity records.

      Another evidence of this premise, and related to it, is that American health care is very good doing what pays the most, and very poor at what does not pay so much. Recall the fine article that led off the Wall Street Journal Weekend Section a few weeks back. Written by long time prominent cancer researcher, whose husband (also prominent researcher) came down with cancer and died painfully in his late 60s. In a very powerful commentary, she opined the much cancer research over past 50 years has been wasted because it was concentrated almost exclusively on curing or delaying long advanced cancers, instead of finding and curing those cancers inchoate but extant years earlier, so as to avoid high cost of much later treatments that far too often only postpone death for relatively short periods of time at great cost, pain, and risk to the patient. Same holds true for American health care’s long ignoring the possible many iterations of preventive care and conservative treatment care, that can be far more productive, curative, and humane for the patient at far less cost, suffering, and risk to patient.

      Similar issues have also recently been highlighted in growing prevalence of inhumane treatments in palliative care, and other types of undue extensions of end of life care, where much money is wasted for little apparent reason except pursuit of profits. The was highlighted in recent UVA article.

      I do not believe this is a political problem, but an ethical problem in our collapsing culture, particularly its ethics and sense of humanity.

    • Now, if one focuses on building new health care systems, and their constituent parts, that are first and foremost patient centered systems, and building them into anchors serving places that are now particularly ill served, like for example, Virginia’s Eastern Shore, and Virginia’s Shenandoah Valley, then we will suddenly begin to create holistic, alive, and vibrant places. Communities that not only greatly and deeply engage and serve their populations in many important ways, but that are then strong and dynamic marketing tools that will attract great growth, health and wealth to these places, all built on these strong anchor foundations?

      Of course, we will do this? Why would we not? But we will rebuild these places exponentially, by then piling these anchor uses one atop the other in these places, more different kinds of student centered, patient centered, and customer centered anchors within these places. Once then the hardest part is done, but the job in far from over. Next comes the wonderfully vibrant under-story, the life and vitality uses that spring up when creative, optimistic, and motivated citizens, new and old, flood these places, like has happened in to many other American places all over America.

    • I have done little serious investigation into the competency of health care in Virginia’s Eastern Shore, or the Shenandoah Valley.

      That being said, let us assume that there is a good (indeed fine) hospital in Winchester and Roanoke. But that the rest of the 90 mile long valley is a “healthcare desert.”

      Why does the rest of the valley have to be a healthcare desert. After all Virginia spends $5 Billion on coal ash removal? If it spends so much to take care of coal ash, why cannot Virginia find ways to provide urgent care centers within a fifteen minute drive of most every resident within the valley? Why cannot these Urgent Care centers handle say up to 50% of most short term medical visits that otherwise would have to go to a hospital, or typical doctors offices, or not go at all?

      Why cannot three “local” hospitals be located in the valley between Roanoke and Winchester that can handle most all but the most difficult cases, incl. hospital stays’, and that are within 30 minutes of most all citizens in the valley.

      Why cannot these urgent care centers and hospitals be patient centered facilities that concentrate solely on the best interest of the patient and their families, instead of the best interests of those who run the hospitals and centers, and that hence in all but the most difficult of cases provide their patients and families with far better holistic care and attention that hospitals like UVa and many other elite facilities, do not and will not provide? How many ways can the services of these valley health care providers and allies who are also patient centered, be expanded continuously based on best practices being newly deployed throughout the nation?

      • Stop and think about our turning the Shenandoah Valley from a Health Care Desert into a Healthcare Garden of Eden! What’s it look like? How does it benefit everyone there?

        Stop and think about it.

        It can be done. If done, people would come in droves to stay and thrive, and/ or to visit again and again. The entire dynamic of the Valley’s inevitable Renaissance would be turbo charged and enhanced for the great advantage of everyone there. Virginia can do this. And Virginia can do it in many iterations, indeed Virginia can do it in endless iterations.

  7. The idea of “long waits” and Canadians coming here is proven to be hyperbole when you look at life expediencies at all these other countries.

    All those other countries have smokers and obese and bad habits also!

    These are the GOP talking points, however… this is pretty much their response to the health care issues.. and that’s why they’re in trouble with voters.

    • That chart could also prove my point about the unhealthy lifestyle beloved by too many Americans. But look at those Eastern Bloc countries with their long history of government-provided care! And that chart is ranked by the female lifespan, but the US would look a little better if ranked on the male outcome. Going forward I guess we’ll need a dozen gender results, right? 🙂

      • I don’t know about gender but in the bigger context, the claim that they have longer wait times and don’t get treated for cancer soon enough is just balderdash.

        It’s just more lame GOP talking points to deflect from OUR health care issues which they dismiss as “bad lifestyles”… and other bogus foolishness.

        You’d think, listening to the GOP that health care is not the issue but personal lifestyle is…

        and that’s how it goes – they just evade and run away from the issue – and yes.. voters do notice that.

        come on Steve – you KNOW this!!!! you’re making excuses for them!

  8. You know if the govt got out of employer-provided health insurance – i.e. did not require that insurance companies cover all employers – no matter their health condition – if the govt got out of that – and the govt let the health insurance companies choose who they would insure or not – ALL heckfire would ensue!

    And that’s the irony – all those folks on govt-protected employer-provided health insurance feel free to toss rocks at those who are not protected and more vulnerable.

    A principled position would advocate that EVERYONE get the same treatment from the govt and that there be no special protections for just some folks while none or far less for others.

  9. Well, the reality is the government will not get out, and the government is the main source now for Medicare, Medicaid, Tricare, the VA, the Indian reservations, and probably plenty of others. The VA and the Indian health services do not make your case….And the reality is that no Republican is trying to gut any of those, but election after election the charge is made. But what we have is a big giant mess, and if I were messaging for this election it would be that your “from each according to his means, to each according to his needs” is a “principled” approach we have a name for, with a track record of failure around the world.

    And you read my earlier post poorly (or intend to mislead), because what I said is that in many other countries, once it is clear that continued cancer treatment is futile, it stops. In this country we spend a fortune on treatment after treatment with virtually no chance of success. This I know from a professional in the field, and an extra month of life is a good thing, I guess, but at $250,000? We go to the system you want, a more realist approach to end of life treatment will result – with many people furious.

  10. The reason we have such a mélange of different programs is that the GOP pretty much opposes more universal type approaches, and we end up with smaller “fixes” that is harder for them to oppose – like CHIPS for kids. Who would oppose that – but it becomes yet another SILO!

    We talk about “failure” but many people are fine with their employer-provided as well as Medicare and many on the VA like it. There are vocal folks who do not but many/most of them are, in fact, GOP type folks who SAY they don’t want “government health care”.

    Most folks just want the system to work better, NOT try to undermine and harm it or let it “fail” which is what most folks perceive the GOP’s main actions. They do NOT come back with ways to IMPROVE IT – instead they talk about how bad it is because government is doing it and they OPPOSE Obamacare and Medicaid – both the original and the expansion.

    That’s WHY the GOP is vulnerable on health care in elections – and their stock response to that is to attack the Dems as “socialists”.

    You can’t win like that. You KNOW THAT!

    The reason I have liked the GOP in the past was that they DID work for improvements – cost-effective improvements.. make it better – type improvements but now they just basically lie about their opposition to preexisting conditions – they say they support it but when they vote – like they vote FOR “crap” policies that essentially do not cover preexisting conditions more than a minimal amount before the coverage max is reached – that’s NOT dealing with the preexisting condition problem – and voters KNOW THAT.

    The GOP needs to put up or shut up on health care and take a beating at the polls if they cannot or will not deal honestly with the issues.

  11. This is an example of the GOP vs Dem on heath care in Virginia Elections:

    Health care is key issue as Ross challenges Vogel in Virginia’s 27th District Senate race

    Three-term state Sen. Jill Vogel and challenger Ronnie Ross III both see health care as a top priority for Virginia’s 27th Senate District, but disagree on the right answer.

    Democrat Ross, a 33-year-old political newcomer, supports expanded Medicaid. Vogel has been working in the General Assembly to make coverage more affordable for small businesses and their employees through short-term and catastrophic insurance plans.

    IS what Vogel is advocating a real answer for people who need health insurance and what is the purpose of it if workers qualify for the Medicaid Expansion? What’s the point? Why would a worker choose this if they can get the Medicaid Expansion?

    it’s like Vogel wants to go back and not have the expansion and her proposal would be the replacement?

  12. Larry, you won’t care what the answer is, you don’t care about the actual bills involved. Please.

    The message against Vogel is the same theme with the same rhetoric in every part of Virginia, with little or no consideration of how that individual Republican actually voted. You haven’t got a clue what Vogel’s votes or positions are, so like the Democrats across the state you just make stuff up and throw it against the wall. Like I said, given the weak GOP response, it is probably working well. It is the kind of coordinated, reinforcing message across various media and districts that we pro-fessional spin doctors aspire to.

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