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Justifying Cruelty

As yesterday’s post pointed out, Perry and the Texas GOP Left Me Out, there are many hard working Texans who are being denied Medicaid because of ideology. GOP state Sen. Charles Schwertner’s recent Op-Ed is an attempt to try and justify the cruel decision of the GOP to deny expanding Medicaid in Texas.

Schwertner focuses mainly on one aspect of the study relating to emergency room visits.

Earlier this month, Science magazine published the results of a randomized, peer-reviewed study detailing Oregon’s experience in expanding Medicaid to the same population of independent, able-bodied adults that Texas is now asked to consider. Despite showing no improvement in measurable health outcomes over the study’s two-year timeframe, those enrolled in Medicaid were actually shown to use their local emergency room 40 percent more frequently than a control group of the uninsured. The factors driving this result are twofold — convenience and a lack of access to alternative primary care.

An uncomfortable truth of American health care is that, while most people only use the emergency room for legitimate medical emergencies, many also use it for the same reason they use fast food drive-thrus and video-on-demand — it’s convenient. Despite their considerable expense, emergency rooms will treat anyone who walks through the door, require no appointments, and are open 24 hours a day, something of great importance to those who are either unwilling or unable to seek primary care during normal business hours. Since Medicaid enrollees share no cost burden for their medical care, they also have no incentive to seek that care in a less costly setting.

While that’s true, it’s not a surprise, More emergency room use isn’t necessarily bad.

I’ve written about the OHIE so many times, I’m not wasting time praising it. Let me say that I have no problem believing these results. Unlike many others, I’ve never really believed that increasing insurance coverage leads to less ED use.  There are tons of reasons people use the ED over primary care. (See a 2010 post here http://theincidentaleconomist.com/wordpress/when-the-emergency-room-is-your-only-option/).

Improved access will lead to, well, increased access. Emergency room care was never free, no matter what people heard in the media. Telling people that they can NOW go to the emergency room with coverage should lead to MORE people going to the emergency room. Increased access does not always mean decreased spending and more primary care.

Moreover, until someone proves to me that the increased ED use was unnecessary, I don’t know why anyone would assume it’s a bad thing. If our goal is to increase people’s access to the health care system, getting more people insurance (like Medicaid) is a good tool for that. If our goal is to help people make more effective use of the healthcare system, increasing coverage isn’t necessarily going to be as good a tool.

The goal of Obamacare is to help people, and that’s what’s always scared the right wing ideologues.  If people again see that the government can actually help people they’re ideology is doomed.

There was also good news in the study which Paul Krugman pointed out, Medicaid Nonsense.

Busy day, no additional blogging until much later. But you should be reading The Incidental Economist on the Oregon Medicaid study that’s creating a lot of fuss today. Basically, budget woes forced Oregon to allocate Medicaid access by lottery, giving a rare randomized experiment. Those who got Medicaid suffered much less financial distress and less depression; they received more preventive care; but on some (not all dimensions) their health wasn’t significantly better than those who lost out in the lottery.

Somehow, conservatives think this is a big win for their opposition to universal health insurance. Why? What it suggests is that the health benefits of ANY kind of health insurance are somewhat hard to identify over a two year period; so, are you about to give up your own insurance, or is your best bet that having that insurance is still a very good idea? And the financial benefits are a big part of that! Since you are going to treat your illnesses, better not to bankrupt yourself in the process, right?

Oh, and until now the claim of right-wingers has been that Medicaid actually makes you sicker; serious researchers have always said that this was a case of selection bias, because sicker people got Medicaid — and now we have confirmation: those who got Medicaid were at least somewhat healthier than those who didn’t.

Above all, you should bear in mind that if health insurance is a good idea — and you are nuts if you let this study persuade you otherwise — Medicaid is cheaper than private insurance. So where is the downside?

And Ezra Klein had this to say about the study, Here’s what the Oregon Medicaid study really said.

Here’s what we can say with certainty: Medicaid works as health insurance.

That might seem obvious. It’s actually not. A big criticism of Medicaid is that it pays doctors so little that it’s essentially worthless because no doctor will see you. But the Oregon residents who won the Medicaid lottery got much more health care — including preventive health care — than the residents who lost it. They also saw catastrophic health costs basically vanish.


The problem with the Oregon study is that it doesn’t help us figure out how to make health care or health insurance better. We don’t know if the results speak to the health care you get through all health insurance or just Medicaid or if they’re just an artifact of the study’s timeframe and sample size. We don’t know if different ways of designing insurance programs would lead to radically different care outcomes (we actually tried a randomized study on that question in the 70s, and the answer, at least then, was “not really”). And so we don’t know whether we’re seeing a problem in Medicaid, an inconvenient truth about medical care, or something else. Worse, we don’t know what to do next.

But we could find out. Studies like this one don’t need to be so rare. The government could put a very small amount of money — say, one percent of the federal budget — toward designing and conducting them across all areas of public policy and the results would help us spend the rest of our dollars much more wisely. There’s no reason the Oregon experiment has to be a unicorn.

I think that’s a great point, we need more studies to see how things are actually working.  No one thinks Obamacare is perfect, and as most government programs, will be changed going forward.  All the ideologues have been calling it a failure since it passed. That Schwertner and the like would discount the good news in the study – of how people are actually being helped – and overly focus on the negative is not surprising. That’s what they do when they’re trying to justify cruelty.


Perry and the Texas GOP Left Me Out

Movements are what bring keep hope alive and bring about change.  That’s why what Texas Left Me Out (TLMO) is doing is so important.  Highlighting Texans and their families that are purposefully being left without health care because of a cruel right wing ideology.

Via the CPPP’s press release yesterday announcing that More Than 40 Health and Community Organizations Launch Campaign to Collect Stories and Engage with Uninsured Texans Left in the Coverage.

Today more than 40 Texas health care advocacy organizations, faith and community groups, including the Center for Public Policy Priorities, launched Texas Left Me Out, a campaign in English and Spanish to collect stories from uninsured Texans left in the coverage gap and connect them with available health care options and advocacy efforts.

While thousands of Texans living above the poverty line are successfully purchasing health plans on the Marketplace and getting help to pay for them, more than one million of Texas’ poorest adults are still being left out due to Texas’ choice to refuse billions of federal dollars to extend coverage to them.

“All of us know the people being left out of coverage; they are the working poor and we work with them every day,” said Sister JT Dwyer of Seton Healthcare Family. “It’s the veteran and his wife, the construction worker who helped build your neighborhood, the person that takes care of your child at the nursery and the health attendant that helps you care for your aging parents.”

Irma Aguilar is just one of more than one million Texans left with nowhere to turn for affordable health coverage. A 28-year-old mother of four from San Antonio, Aguilar is an assistant manager at Pizza Hut but still does not make enough money to qualify for financial assistance in the Marketplace. She has damaged disks in her neck and suffers from high blood pressure that makes her dizzy, but she’s unable to afford treatment.

“I need to be able to keep working and providing for my family, but every single day I worry about what would happen if I had to stop working because of my health conditions,” she said.

Health care navigators and certified application counselors at in-person enrollment sites all over the state are turning away hardworking Texans hoping to get health insurance because they make too little to qualify for financial assistance. Elizabeth Colvin with Insure Central Texas and her staff are having those tough conversations every day.

“We have been left with an awkward situation—a single parent of two earning $17,000 a year will receive no financial assistance for health coverage, while a second uninsured parent of two earning $20,000 a year will qualify for full health coverage for $33-per-month or less,” Colvin said. “We have to tell people that they have no options and there is no worse feeling when you know someone desperately needs a surgery or medical attention. We have to deliver the news that our society has left them out.”

That’s cruel, wrong, and if the Perry and the Texas GOP would have expanded Medicaid in Texas it wouldn’t be happening.

Here’s more from a letter TLMO sent to Texas legislators.

Dear State Legislator,

We are writing as members of Cover Texas Now – a coalition of consumer and faith – based organizations – and other supportive partners that desire to see the state of Texas implement a sustainable health care system and provide quality affordable health coverage to its citizens.

W e are writing to announce the launch of our latest campaign , Texas Left Me Out.

Texas has the highest rate of uninsured people in the United States – over six million Texans are uninsured. And consistent with the nation’s new health law ’ s purposes to improve health outcomes and reduce costs , every person is to have a way to access affordable and quality health care. But Texas’ decision that resulted in the loss of billions of federal dollars that could have expanded health coverage left more than one million Texans in a coverage gap . Texas adults above the poverty line will get publicly funded financial assistance for their health coverage, while those Texans below the poverty line will qualify for nothing.

The letter also has the list of 40 plus organizations involved.  These Texans need help, it’s available, but their elected leaders won’t allow it.  The group should be more aptly named – Perry and the Texas GOP Left Me Out.

Further Reading:
Inequality is un-American, Why Thomas Jefferson Favored Profit Sharing.

The Texas GOP left them out

The human cost of the Texas GOP’s unwillingness to expand Medicaid, keeping people uninsured for ideological reasons, is cruel. Via TPM, Americans In Medicaid Gap Enlisted To Fight Back Against GOP Guvs.

Obamacare advocates are actively recruiting those left out of the Medicaid expansion in Republican-controlled states to lobby state officials to change their minds and participate in that key provision of the health care reform law.

So far, the effort is most organized in Texas, which is also the state with the most people in that Medicaid expansion gap: 1 million. But it’s likely to pick up elsewhere as the Obama administration and outside advocates apply pressure to the 25 states that have resisted expansion for the first year.

Texas Left Me Out, the combined effort of several community groups, is a website designed to collect those people’s stories and organize them into a cohesive political action constituency. It asks those in the Medicaid gap to sign a petition to stay informed about advocacy events and share their story on the site.

Are they going to turn Texas blue on the backs of people who have traditionally been ignored by Republicans? Are they going to convince an anti-Obamacare stalwart like Rick Perry to buy into the law? That’s a tough sell. But they’re going to try.

“When you personalize a policy, when you make it real, it’s always much more powerful. It’s always going to resonate,” Tiffany Hogue, state health care campaign coordinator at the Texas Organizing Project, one of the groups involved with the campaign, told TPM. “People have really have awakened to the fact that people really are getting left behind.”


The strategy is simple: sheer political force. They’ll ask people to turn up at legislative committee hearings and stage protests at the state capitol. Conference calls and press conferences will be the norm. They aren’t waiting for 2015 either. A group is going to a state insurance department meeting Dec. 20 to rally for expansion.

Those left out of the expansion are receptive to the effort. Irma Aguilar, a separated mother of four who lives in San Antonio and has been recruited by the Texas groups, said it was a “a real shocker” when an Obamacare canvasser came to her house to explain her options to her under the law, only to find out that her income as an assistant manager at Pizza Hut was too low to qualify for financial assistance to purchase private insurance and she couldn’t sign up for Medicaid because Perry and the GOP-led legislature had rejected the expansion.

“They didn’t want to take that extra money to help us poor people back here,” she told TPM. “What about us back here? It’s really hard. I thought with this law, they would try to work to help everybody, but apparently not. They just think of themselves. They’ve just let us struggle.” [Emphasis added]

A 28-year-old with high blood pressure and back problems, Arguilar’s story is exactly the kind that advocates hope to use to persuade Republican state leaders. It might not work on its own — it didn’t in 2013 — but that human interest angle paired with the business case that high-powered lobbying groups like the Texas Hospital Association will make is seen as a potentially winning formula by those pushing for expansion. They’ll be arguing that drawing down on billions in federal funds will be a boon for the state’s economy.

It’s likely to spread beyond Texas, too. The White House has already called out 11 non-expanding states in conference calls and events with local officials, using the two-pronged argument of extending health coverage to the uninsured as well as bringing in those billions of Medicaid dollars to advocate for expansion.

They just think of themselves, they just let us struggle. That’s the cruelty inherent in the GOP’s decision not to expand Medicaid. As BOR points out Gregg Abbott has no plan whatsoever to help the poor get health coverage, Even Greg Abbott’s Advisors Lack Answers For Texas’ Uninsured.  As this recent article in the Texas Observer shows, The Money Behind the Fight to Undermine Medicaid, the people who make GOP policy in Texas won’t allow it.

On April 1, Texas’ most powerful elected officials gathered at the state Capitol to rail against Medicaid. In a packed press conference room with protesters shouting outside the door, Republican Gov. Rick Perry, Lt. Gov. David Dewhurst, and U.S. Sens. John Cornyn and Ted Cruz made clear to reporters that Texas—the state with the nation’s largest uninsured population—wouldn’t expand the program that provides health insurance to the poor and disabled.

pphflagUnder the Affordable Care Act, the federal government would have largely paid for Medicaid to cover an additional 1.5 million Texans. But the state’s Republican leaders instead called for the federal government to “block grant” Medicaid, giving them a lump sum of money to run the program as they see fit. Dewhurst compared expanding the current Medicaid system to drug addiction. “Would you consider expanding a broken system? Of course not, of course not,” Dewhurst said. “It’s like a drug dealer. You give them their first hit free and then they’re hooked for years and years.”

The group that organized the press conference and supplied the policy prescription was the Texas Public Policy Foundation (TPPF), an influential think tank funded largely by right-wing foundations, corporations and wealthy Texans. TPPF has been instrumental in preventing increased spending on Medicaid and other social welfare programs in Texas. Perry, Cruz, Cornyn and other politicians frequently turn to TPPF to help make the intellectual case for reducing government involvement in health care. The press conference was part of TPPF’s multi-year strategy to remake Medicaid in accordance with free-market principles. The think tank would later claim credit for helping block Medicaid expansion in Texas under Obamacare.

The financial cost to Texas is high as well, this policy is costing Texas billions. It was clear during the last legislative session that if Republicans in The Lege had wanted to try and get to a Texas “solution” to expand Medicaid, the Obama administration was willing to work with Texas.  They were not going to “block grant” the money, but they could have worked out something like Arkansas did. 

What that means is that the leaders of the Texas GOP made a conscious and calculated decision not to expand Medicaid and keep over a million Texans without health insurance coverage for ideological reasons. 

Which leads us back to the same place we always get to eventually in Texas.  We have to elect people who will do things for the people and not wealthy right wing donors and corporations only.  Democrats and specifically Wendy Davis, are committed to expanding Medicaid.  Having a Governor that will not veto legislation to expand Medicaid is key to getting it enacted in Texas.  If Abbott is elected we will just get more of the same and these people will stay left out, without health care, unnecessarily for years to come.  If Wendy Davis is elected they will be almost guaranteed of getting the health insurance the Texas GOP is denying them.

Texas Democrats must provide a contrast to the Texas GOP’s cruel conservatism

There’s no doubt that two women, one a Latina, at the top of the Democratic ticket will be a sharp contrast with the white male GOP to of the ticket. But it’s also more of a middle class, average Texan ticket which is a contrast tot he GOP side, Texas Democrats offering stark contrast.

Texas voters won’t have a hard time telling the difference between the Republican and Democratic candidates next year.

With the addition of San Antonio Sen. Leticia Van de Putte, attorney Sam Houston and party activist Steve Brown last week, the Democratic slate offers a vivid contrast to the Republican ticket, both in demographics and politics. And there are more announcements to come.

So far, Democrats are offering a diverse roster with most running unopposed on a strong progressive record, not unlike the so-called Dream Team in 2002. Republicans are more conservative than ever, with a ticket that is predominantly white and male.

By now most Texans should know Wendy Davis’ working class, worked her way up biography.

Both parties will draw stark contrasts next year, each side confident they reflect the views of the majority of Texans. Republicans argue, based on their winning streak, that Texas is a conservative state that will always elect Republicans.

Texas also has the lowest voter turnout in the nation, Democrats say, and the majority of eligible Texas voters are either minorities or liberals. They say getting more Texans to vote is the key to their victory, and Republican policies will help them accomplish that.

The result has been two very different tactics during primary season. The Davis campaign brags about making 100,000 phone calls to potential voters. Battleground Texas, the PAC hoping to turn Texas blue, is training thousands of field organizers and voter registrars.

While the Democrats, thus far, seem to be getting the organizing going well, they need to an issue or two to hang their hat on. Something that might get some of those folks out to vote that don’t usually vote. Via Burka.

One of the problems for Democrats is that in counties with large Hispanic populations, particularly in South Texas, the primary is where the action is, not the general election. In the Rio Grande Valley, the races that motivate are those for local positions — city councils, school boards, and courthouse jobs. The elections frequently come down to a battle of one prominent family against another. The winner gains power and something else that is very important in areas that suffer from poverty: good-paying jobs. Another issue for Democrats is that the Hispanic vote is by no means unilaterally Democratic. Republican candidates such as John Cornyn and Rick Perry have always been able to count on a third or so of the Hispanic vote. A lot of Hispanic voters are small business operators who are traditional conservatives.

And then there is the problem of history. Hispanics emigrated to America from a country whose government seldom did things FOR people, but rather did things TO people. In such circumstances, the degree of trust or belief in government and politicians was, and remains, negligible. All too easily, the culture of Mexican politics was transplanted to the Texas side of the border.

Van de Putte’s job, then, is to motivate Hispanics to vote. If she and Davis can do it, they have a chance to transform Texas politics. But Democrats have been waiting for the so-called “brown wave” to roll over Texas for generations, and no such event has appeared. At the very least, she will be a strong running mate for Davis and she can be a strong advocate for the Democratic ticket as well. It’s still going to be an uphill battle, at best.

If what Burka says is accurate, it might be good for Democrats – all over the state – to start talking again about how government can do things for people, to help them. One place they could start is by showing how cruel the Texas GOP’s decision not to expand Medicaid and withhold health insurance for more that 1 Million Texans is. It’s also a really good deal and would help Texas tremendously. The CPPP sums it up this way.

We have an opportunity to provide a regular source of health care for more than 1 million of our poorest adults—many of them raising children—while reducing local uncompensated health care that today forces providers to charge more to patients with insurance, increasing premiums for everyone, and increasing local property taxes to pay for indigent care. Expanding Medicaid will also make our mental health, criminal justice and child protection systems more effective as the adults they serve gain access to mental health care and substance abuse treatment. Criminal justice systems would also be relieved of significant medical costs. Expansion would be affordable, with the federal government covering 100 percent of the costs for the first three years, phasing down to 90 percent after that. Over the first four years, for $1.3 billion in state dollars, Texas would get $24 billion in federal dollars infused into our health care system, creating hundreds of thousands of new jobs. As other states have proposed, if the federal government reduced its financial commitment, Texas could reverse the expansion. In the meantime, the massive increase in federal money would build our health care workforce and strengthen our system. [Emphasis added]

Not only is it morally right, it’s a good deal too!  This is also a huge issue for rural Texas, Rural Hospitals Struggling In Texas.

In Texas, rural hospitals treat 15 percent of the population, but cover 85 percent of the state (see below for 10 facts on rural hospitals in Texas). In rural areas, patients are generally older, less healthy, and have less access to insurance.

The Affordable Care Act was supposed to benefit both rural hospitals and rural patients – by providing access to insurance for folks in small towns the idea was that hospitals would recoup costs they spend on indigent care. But some people aren’t so sure it’ll work out that way.

Dr. Howard Dickey is a family medicine doctor in west-central Texas at Comanche County Community Clinic – one of Texas’ so-called critical access hospitals.

“I would hope that [Obamacare] would be favorable,” he says, “but I may end up working somewhere else when it’s all said and done.”

One of the reasons Obamacare may not benefit rural hospitals in Texas is because Governor Rick Perry decided not to expand Medicaid in the state. That means poor people who end up using the emergency room still won’t have any type of insurance to help cover the cost of their care.

Critical access hospitals rely more heavily on Medicaid and Medicare reimbursements than their urban counterparts. Without the chance for additional Medicaid money, and decreasing Medicare reimbursements, Dickey says his clinic’s tight budget might snap.

It’s really hard to see an issue that would provide more contrast between the two parties. Because this truly is a life and death situation.

Beyond the economics and politics, lives are at stake. Lack of insurance will certainly mean more deaths. How many more? Approximately 9,000 a year, according to Dr. Howard Brody, director of the Institute for Medical Humanities at the University of Texas Medical Branch in Galveston. Brody calculated that figure by extrapolating from a recent Harvard University study published in The New England Journal of Medicine that found that states that expanded Medicaid saw a 6.1 percent reduction in the death rate among adults below 65 who qualified for the program. In a recent op-ed in the Galveston Daily News Brody wrote, “This means that we can predict, with reasonable confidence, if we fail to expand Medicaid . . . 9,000 Texans will die each year for the next several years as a result.” [Emphasis added]

This is not the only issue facing Texas, but this issue must be central to the every Democratic campaign in Texas in 2014.  Texas Democrats must provide a contrast to the Texas GOP’s cruel conservatism.

Further Reading:
Kuff has More on LVdP for Lite Guv.
The Cruelty of Republican States in One Chart.
Faith Communities, Hospital Groups, And Business Leaders All Urge Texas Governor To Expand Medicaid.
The Battle Over Expanding Medicaid In Texas.

The way forward on health care

The most valid place to start when criticizing the Affordable Care Act is from the left. Kevin Zeese and Margaret Flowers do a great job of that, Obamacare: The Biggest Insurance Scam in History.

The fundamental flaw of the ACA is that it entrenches a market-based system that treats health care as a commodity and profit center for Wall Street. The big drivers of the rising cost of health care – insurance, pharmaceuticals and for-profit hospitals – continue. The wealth divide that is a major byproduct of neoliberal economics is institutionalized by law under the ACA. Some, like Senator Ted Cruz, will receive the best health care from their employer, in Cruz’s case his wife’s employer, Goldman Sachs. Others, forced into the individual insurance marketplace, will be divided in four classes based on wealth, and millions will be in Medicaid, the inadequate health plan for the poor. Thus, after a high-stakes partisan battle, we’ve made no progress in confronting the fundamental problems in US health care. Indeed we have made some of them worse.

There was an easier route and a more politically popular route. All that President Obama had to do was to push for what he used to believe in, Medicare for all. By just dropping two words, “over 65,” the United States would not have needed the 2,200-page ACA. Then the country could have worked to gradually improve Medicare so that the United States moved toward the best health care in the world, rather than being mired at the bottom.

To replace Obamacare with the single-payer system, we need to be clear about the shortcomings of the law, especially its fundamental flaw of making a human right, one of many human rights Americans do not realize they have, into a commodity like a cellphone. We need to recognize that ending the corporate domination of health care is part of breaking the domination of big business over the US government and the economy. Health care is at the center of the conflict of our times, the battle between the people and corporate interests, the battle to put people and planet before profits.

The problem is that neither party is working toward a real solution like that, which the people favor. While it’s clear that the right wing wants to stop the ACA, they have no solution other than some free-market scheme like we had before.

One part of the fight between the right wing and President Obama that’s so disturbing, especially in Texas, is our elected GOP leaders cruel decision not to expand Medicaid.  It’s going to cause unneeded suffering. It’s created the coverage gap and will effect over 1 million Texans.

Nationally, nearly five million poor uninsured adults will fall into the “coverage gap” that results from state decisions not to expand Medicaid, meaning their income is above current Medicaid eligibility but below the lower limit for Marketplace premium tax credits. These individuals would have been newly-eligible for Medicaid had their state chosen to expand coverage. More than a fifth of people in the coverage gap reside in Texas, which has both a large uninsured population and very limited Medicaid eligibility. Sixteen percent live in Florida, eight percent in Georgia, seven percent live in North Carolina, and six percent live in Pennsylvania.

The interesting thing is that the Medicaid expansion part may be the most beneficial to the Democrats in the future. Toward the end of this this recent Evan Smith interview with Jonathan Alter, Alter talks about how Texas suffer, because of this decision in the near future. In essence saying that people may see Texas as a risky place to live, as opposed to a state where they can get health care.

Not to mention the cruelty of the decision, Romneycare/Obamacare Architect Jonathan Gruber Blasts ‘Disgusting’ Refusal To Expand Medicaid.

Sattler: Is the refusal of 25 states to expand Medicaid distorting the market?

Gruber: I think in those states, by my own estimates, it’s going to raise premiums by about 15 percent in the exchange because sicker people will be in the exchange. I think it’s really disgusting that these states aren’t providing their poorest residents free insurance [financed] by the federal government. It’s pretty amazing that they can get away with that.

Sattler: What do you think about the right-wing argument that having no insurance at all is better than Medicaid?

Gruber:  It’s just incorrect. There’s no credible evidence to support that. There have been dozens of studies over the years that show that giving Medicaid to patients improves their health. Most recently a study I was involved with in Oregon just sort of randomly assigned Medicaid to people and found significant improvements in mental health.

Sattler: Do you expect more states to expand their Medicaid programs?

Gruber: Right now we’re at about half the states expanding. That’s going to grow over time. But we’re going to have a hardcore group of states that don’t want to expand, and I hope there’s pressure to do so.

The ACA is what we have to work with right now. If it’s repealed we’re likely in a worse place then when we started. The criticism from the left is valid and damning of the ACA. Unfortunately the political will does not exist, and our political system is too corrupted, at this time to get something like Medicare for all passed. The best was forward is to elect politicians that are committed to fixing what’s wrong with the ACA, by moving us closer to a single-payer/Medicare for all health care system. And in Texas that must start with electing those who are committed to expanding Medicaid.

Further Reading:
MAP: The 5 Million People The GOP Cut Out Of Obamacare.
Quote: The ACA as redistribution.

EMTALA and our cruel health care system in Texas

There’s much that is being lost in the hyperventilating over the mistake-riddled roll out of the Patient Protection and Affordable Care Act, or ACA.  But the discussion of our health care system comes down to a few simple things.  Before this law was passed our health insurance system was a disaster.  The ACA was not designed to “fix” our health insurance system.  It’s a plan that is palatable enough for the health insurance corporations,  and was therefore allowed to pass through our corrupt political system.  And yes, Obama and the Democratic Party own it.

To show what a cruel disaster the former system was, and will continue to be in Texas – because of the decision not to expand Medicaid – please read this article, Texas’ Other Death Penalty, A Galveston medical student describes life and death in the so-called safety net. The description of how the emergency room law, Emergency Medical Treatment and Labor Act (EMTALA), works is shocking and it’s despicable that we allow this to continue.

There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.

My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.


But UTMB is no longer the state-subsidized charity hospital it used to be. The changes began before Hurricane Ike in 2008. But after the storm, UTMB administrators drastically cut charity care and moved clinics to the mainland, where there are more paying patients. The old motto “Here for the Health of Texas” was replaced by “Working together to work wonders.” Among those wonders are a new surgical tower and a plan to capitalize on Galveston’s semi-tropical charm by attracting wealthy healthcare tourists from abroad. Medical care for the poor is not, apparently, among the wonders. Whereas UTMB accepted 77 percent of charity referrals in 2005, it was only taking 9 percent in 2011.

UTMB ascribes these changes to financial strain from Hurricane Ike, the county’s inability to negotiate a suitable indigent-care contract and loss of state funding. The state blames budget shortfalls. The Affordable Care Act, better known as Obamacare, could have been a huge relief. However, Gov. Rick Perry rejected billions of dollars in federal funding to expand Medicaid, funding that should have brought access to more than a million Texans, including many St. Vincent’s patients.

Perry’s refusal is catastrophic health policy. For patients, it means that seeking medical care will still require risking bankruptcy, and may lead nowhere. For doctors, the message was not only that our patients’ lives don’t matter, but also that medicine—our old profession, so full of people who genuinely want to help others—will continue to be part of the economic machine that entrenches poverty. When the poor seek our help, they often wind up with crippling debt.

Because they can no longer count on UTMB to accept their patients, UTMB doctors now refer many to St. Vincent’s. They’ll treat someone for a heart attack (because that’s an emergency covered by EMTALA), then refer them to us for follow-up, even though we don’t have a cardiologist. They’ll stabilize a patient after her third stroke, put her on blood thinners and send her to us. They once sent us, from the ER, a man with a broken arm. They put the arm in a splint and referred him to us. What did they expect us to do—orthopedic surgery? Put on a cast? We don’t even have an x-ray machine.

I do not think that these referrals are an official policy. Rather, they are the work of doctors and nurses trying to do something for patients who have been refused care through the financial screening process at the hospital. Former St. Vincent’s leader Dr. Merle Lenihan has described the clinic as a “moral safety valve.” It protects UTMB from confronting the consequences of the state’s refusal to provide care. [Emphasis added]

What’s being missed about the hyperventilating over the ACA’s current problems is that many who didn’t have insurance will get it. Except in places like Texas where Medicaid expansion is not happening.

My first patient, the one who died in hospice, might have lived if his cancer had been treated before it had spread from the kidney. But without the Medicaid expansion, the Affordable Care Act wouldn’t help him: As an adult with no dependent children, he wouldn’t qualify for Medicaid now.

In a better medical system, he’d have had a chance at a more dignified experience of illness. He wouldn’t have had to wait for hours in a crowded free clinic, and assume the posture of gratefulness that charity seems to require. He wouldn’t have had to be treated in part by an earnest, but unskilled, first-year medical student. He, like so many Texans, deserved better.

There is much wrong with the ACA. The least of which is that some people who had “junk” health insurance will lose it and have to buy actual health insurance. If we wanted to fix health care in our country there’s an easy way to do it, Expanding Medicare to all can solve health care disaster.

The ACA was an effort to preserve a private health insurance market, using regulation to achieve a better result. As we see, this is very complicated.

There is a third option. If everyone is in the same, large, pool, everything medically necessary is covered, insurers are paid merely to process claims, and premiums are scaled to income, there is enough money to cover everyone at reasonable cost without elaborate, expensive, error-prone computer programs and geniuses to run them. People will be able to choose their doctors and hospitals. (And the rich can always buy more if they want.)

A crazy, wild-eyed socialist nightmare? No, this is Medicare, a familiar, popular, competently-run public insurance system that everyone’s parents or grandparents rely on. Person-for-person, disease-for-disease, Medicare is the cheapest, most efficient health insurance program in the country. (There is virtue in simplicity.)

Medicare already controls health care costs better than private insurers, and with a few tweaks, could do much more, forcing prices down to the level citizens of every other advanced democracy pay, with no sacrifice in quality.

Given the alternatives, maybe Medicare-for-all deserves a second look.

Everyone must understand that the ACA is the Heritage Foundation’s fix for health insurance.  The health care debate never should have been an insider discussion about how best to safeguard health insurance corporation profits. It should have been about how best to take care of the needs of the American people. That discussion almost always leads back to a single-payer, Medicare for all solution. One day, we will get there. Until then expect much more hyperventilating.

But this is a moral issue. For a wealthy country like ours to be allowing this kind of outcome for our citizens is an outrage. We should not allow our corrupt political system to keep us from reforming our cruel health care system, into one that allows our citizens to live and die with dignity.

Further Reading:
Medicaid enrollments surging under Obamacare, and that’s a good thing.
Check out, Health Care for All -Texas.
Via Kaiser Health News, Medicaid Enrollment Progresses Under Health Overhaul.

Going forward, answers to must ask questions

There are fundamental questions going forward that every Texans must ask themselves in the coming months. The main question is do you approve of the status quo? While certain economic conditions are favorable in Texas, a the question must be asked who is really benefitting?

Most GOP elected leaders, when they speak about the economy in Texas, talk about things like low taxes, jobs, and the lack of regulations. Texas’ tax structure overwhelmingly benefits corporations, big business and the wealthy, and therefore makes it harder for poor, working, and middle class Texans to prosper. (See Who Pays Taxes in Texas?)

Anyone who approves of the status quo – those who benefitting from the current economic situation in Texas – will most certainly want to keep a post-Perry Texas looking pretty much like it does now. But those that are still struggling to get by, despite all of the “prosperity”, would rather see things change in a post-Perry Texas.

So while the economic news may be good for the corporations, big business, and the wealthy, it’s the rest of us that are struggling, Texas on the Brink.

In Texas today, the American dream is distant. Texas has the highest percentage of uninsured adults in the nation. Texas is dead last in percentage of high school graduates. Our state generates more hazardous waste and carbon dioxide emissions than any other state in our nation. If we do not change course, for the first time in our history, the Texas generation of tomorrow will be less prosperous than the generation of today.

Texas still has the highest rate without health insurance in the US, something the Affordable Care Act and Medicaid expansion can have a significant impact on. Texas also has a very high rate of poverty. And the jobs that are being created, while welcome, far too many of don’t pay enough to support a family.

The bureau’s annual American Community Survey found that in 2012 about 4.5 million Texans lived in poverty, defined as an annual income of less than $18,480 a year for a family of three. Nationally, the percentage of people living in poverty stands at 15.9 percent. In 2000, Texas’ poverty rate was 15.1 percent.

“Even though Texas has relatively low unemployment, our workers are much more likely to be working in a job paying minimum wage or less compared to most other states,” said Francis Deviney, senior research associate at the Center for Public Policy Priorities, which advocates policies to reduce poverty. “Today, Texas invests an average of $5.78 per adult without a high school diploma/GED for adult basic education and literacy training, compared to $66.20 nationally. These programs are a critical first step to moving low-income Texans into careers that pay family-supporting wages.”

Census data backed up the link between education and poverty, with 30 percent of people without a high school diplomat living in poverty, while the rate was only 4.2 percent for those with a college degree.

And the inequality in Texas is disturbing and is most glaring in the public education system, Experts say state funding is creating inequitable educational environments.

In school districts across the state, classroom sizes have been increasing past state-recommended teacher-student ratios.

In the last legislative session, lawmakers cut $5.4 billion from the Texas education budget. In the wake of the cuts, school districts made sacrifices in various departments while struggling to keep up with the minimum education standards set by the state.

And experts now say that unless Texas figures out how to fund education in a more equitable manner, the state is in danger of creating an increasingly inequitable educational environment.

Executive Director Wayne Pierce of the Texas Equity Center said that the inequity among Texas school districts has become significantly worse in the past seven years since the state overhauled the system in 2006.

Pierce said there is inequity because the state does not fund all children at the same level at which the more powerful districts fund students. “The Legislature’s solution to this point has been to take care of some districts at the expense of children everywhere else.”

It was an education tax system that was overhauled in 2006 to protect business interests. Which created a multi-billion dollar structural budget deficit that allowed Texas Gov. Rick Perry and the tea party to gut public education of $5.4 billion dollars in 2011.

The fundamental question is do we want Texas to be a place where everyone can prosper? If we do, then we can’t continue with the status quo.

Further Reading and Viewing:

Democrats, especially in Texas, would be wise to run on something like this. (Via Digby).

Elements of Victory

Democrats win when they fight for Medicare, Social Security, and the middle class. That leads to economic victories. But Dems will face powerful inducements in coming months to compromise with the austerity economics crowd by agreeing to a menu of further spending cuts, destructive entitlement “reform,” and tax code tinkering that starves the government of needed revenue while protecting corporations and the wealthy.

Elected officials will need to hear from a mobilized public if we are to escape the grim and destructive debate they’ve planned for us. Our political discourse needs to shift away deficit mania and toward those policies the public wants and needs. They include:

  • truly progressive tax reform, in which the wealthy and corporations pay their fair share;

  • investment in jobs, growth, education, and our crumbling infrastructure;

  • a more just economy, with improved social mobility, wage growth for the middle class, and opportunities for every American to better themselves through education and hard work;

  • a line in the sand which protects Medicare, Medicaid and Social Security and strengthens them for future generations;

  • a commitment to protect and defend the programs which care for the most vulnerable among us – children, families, and those who are most in need; and,

  • an end to any tax break which encourages American companies to send jobs overseas.

Jon Stewart Slams ‘Moocher’ States That Won’t Expand Medicaid.

“All but three of those 26 states they represent already take more money from the federal government than they contribute in tax dollars. They are already burdens on the systems,” he later added. “I believe they are referred to by those Republicans as moochers. Moocher states. And if statehood was health care, Mississippi and Missouri would be rejected as having that as a pre-existing condition.”