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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.


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.