West of the Rotunda

There are uncounted benefits for Medicaid Expansion.

When I served on the Governor’s first workgroup that studied and recommended Medicaid Expansion for the State of Idaho, I sat on the panel next to a former director of the Idaho Department of Corrections. I had previous experience working as a physician in the Idaho prisons and we had discussed this in the past. After one long day of presentations from experts with graphs, tables, numbers and projections as we were getting up from our chairs to go he bent over and whispered to me, “I hate that Obamacare, but this Medicaid expansion would sure be a benefit for my guys.” I nodded, but after he left I wondered if he meant by “my guys” the recently incarcerated and released, or the guards who work at the prison. Knowing the low pay for prison staff, he may have meant both.

The next day when the summary was being provided about the costs and benefits of Medicaid expansion, I asked the expert if they had figured in any savings from criminal justice costs. They said, no, such calculations would just be too hard to do. I argue they would be substantial. You can’t count what you don’t see.

People in custody (county jail or state prison) are not eligible for Medicaid health insurance to pay for their health care. That cost comes right out of the Idaho general fund. Right now, the charge for folks in prison is over $16/day, almost $6000 per prisoner per year; a total of $48M dollars a year we can’t spend on schools or roads.

My short time working as a doctor in the Idaho prison taught me a lot. I was expecting to see lots of healthy young men with a history of behavioral and substance issues. I was surprised how many middle aged and older inmates there were with chronic disease. Over 65% of the inmates were on chronic medications; many were on psychiatric meds. Imagine what happens to these folks when they are released to the community with no access to health care and a $6000/year health care habit. We are being stupid about how we treat people. Idaho pays 100% of their health care costs in prison, then because they are not eligible for health insurance in Idaho, we pay 0% when they are released. If we expanded Medicaid eligibility we would pay 10% of the costs. Seems a good investment to me.

Right now, the legislatures Justice Reinvestment Oversight Committee (JROC) is hearing testimony from “experts” as to why we need to spend $500M to build a new prison here in Idaho. That’s what the Board of Corrections has recommended. Prosecutors are saying, “It’s not our fault our prison population is exploding. We are just enforcing the laws you legislators write.”  The easiest, cheapest recommendation the JROC could make to the legislature and the governor, easier than sentencing reform, cheaper than building a new prison, would be to say what the former director said to me: “We hate that Obamacare, but expanding Medicaid would sure be a good thing for our people.”

Photo by David Rauzi, Idaho Free Press

Dear Brad,

I hear you say that you favor doing “something” for Idahoans in “The Gap”. These folks make less money than people who can go on the Idaho health insurance exchange (Your Health Idaho, YHI) so they can’t afford health insurance. You presided over the bitter debates in the Idaho Senate about establishing YHI. Governor Otter bravely fought for this and continues to support it; do you? You know the current system where we pay for the uninsured through catastrophic care, but then liens are filed and they are bankrupt.  Some even die for postponing their care. It’s costing Idaho Counties tens of millions and The Idaho General Fund as much or more. I want to know your plan for getting health coverage for our working poor citizens, since you seem reluctant to support the Medicaid Expansion Initiative.

I know you know the numbers. You know how much Medicaid Expansion would mean to rural hospitals and clinics. So explain to me why more expensive half-measures like PCAP or this year’s double waiver plans make sense to you. You supported these plans, but you say you didn’t support the Medicaid Expansion Initiative, which covers more people and costs Idaho taxpayers less. You didn’t sign the petition.

I’ve read your support for returning to the High Risk Pool model, where we tax all health insurance premiums to pay for those who can’t get health insurance. Before the ACA when preexisting conditions were a reason to be denied health insurance, they seemed a reasonable solution. The goal was to get everybody covered by a health insurance plan, as it should be. Explain to me why this is a better option than Medicaid Expansion.

Maybe you aren’t willing to fight the well-funded and very vocal far-right Freedom Foundation who believes only “free market” health care solutions should be considered. That YHI fight in the legislature sure was bitter. But Idahoans flocked to the exchange to buy health insurance. And county indigent and state Catastrophic costs plummeted. It was a hard fight, but I think it was worth it.

Governor Otter has appointed at least three “advisory panels” on health care since 2007 and all have made recommendations to promote universal health insurance coverage in Idaho. He also had two “work groups” who recommended Medicaid coverage be expanded. So Governor Otter has had plenty of hand-picked groups give him advice neither he nor the legislature was willing to act on. Is this your plan too?

To be fair, Governor Otter has followed the advice of one group to promote medical education in Idaho. He supported it with budget recommendations. He also followed the advice to work on changing health care delivery through promoting the Primary Care Medical Home Model for Idaho. And Idaho is in the middle of rolling out a State Health Innovation Plan, designed to reform delivery and payment methods for the state. If “Medicaid is broken”, as I have heard in the Idaho statehouse, let’s work to fix it.

Director Cameron’s innovative suggestion to move high-cost patients with certain diagnoses onto Medicaid to lower private insurance costs shows Otter’s appointees can think outside the box.

It looks like Idaho could be poised for some dramatic and innovative health care changes. States could lead with health care innovation. I believe expanding Medicaid eligibility fits well with these. Why don’t you? Let me know.

When the Idaho House chose to not vote on Governor Otter’s “Dual Waiver” plan last week I was not surprised, nor were most Idaho voters. We have come to expect such inaction, such cowardice, such laziness from our elected officials. We forget, they reflect, not just represent us, the people.

We are truly cowards, you and me for not addressing this problem before us: how should health care be paid for? It’s complicated, I’ll admit. That might explain the laziness we have shown. Maybe, since most get their health insurance through their employer they don’t really have to worry too much about it. That’s just another excuse for laziness. But do we aspire to be a lazy nation? Think about how employer based health insurance traps someone with a good idea or some initiative, but maybe a chronic health problem. Or how the brave young entrepreneur fears his wife might have their baby too early and his dreams are dashed with medical bankruptcy. Laziness and cowardice have trapped us. Don’t try to blame your elected representatives. We are the problem.

We want someone to offer a simple answer. I was intrigued by Director Cameron’s innovative idea to put expensive patients on a government health plan. It’s not a revolutionary idea, but it was brave to suggest. We should all have such courage to offer such ideas. But more, we need to listen to each other’s ideas and have conversations. Our leaders have not been good examples at this. But we can do it.

I have been engaged with a group of young activists working to put an initiative on the ballot that would enroll those below the poverty level who cannot now purchase health insurance on the exchange. It is a simple, cost effective plan to get more people enrolled in health insurance. It expands Medicaid eligibility. I am impressed with the broad support and the effort. I have had many good conversations as we ask for signatures. I know it will not be the final answer. But it’s a good start. Sign the petition.

There is much more work to do to make Idaho health care affordable and effective. It gets down to answering the question of how we should pay for healthcare.

Do Idaho lawmakers and voters really believe the Catastrophic and Indigent funds are an appropriate way to pay for health care? If so, then why don’t we just expand that system to cover all? Drop your insurance, pay for what you can and if you can’t afford it, you will be bailed out by taxpayers after the liens are filed and your bankruptcy ensured. This is health care terrorism sanctioned by the state. I hope you never have this experience. But it’s the current Idaho way.

Unfortunately, the CAT and indigent funds have made us a little too comfortable. These meager payments have supported small hospitals that are teetering. And we can pretend these unfortunate folks had some sin that made them deserve cancer or a mental illness or tragic accident.

We need to have the courage to build a system of health care funding that encourages responsible productive citizens. Getting everybody covered, doing away with indigent and catastrophic care is a great first step. Sign the petition.

Idaho leaders are considering plans to carve up the health care market to save you money. You better be sure which side of the health and wealth teeter totter you fall on, because this could be great news for you or catastrophic. Blue Cross of Idaho is already on board. Should you be?

Do you know if you are going to be hit by a drunk driver? Will you have cancer next month? Or will your wife have a baby too early? I’m a doctor, I studied predisposing conditions, risks and genetics, and I can’t say I knew the answers to these questions. Sometimes I did, but it was usually long after any enrollment period.  Insurance companies are multibillion dollar financial betting organizations; they have experts to answer these questions. And they have a bottom line to meet. I figure they know a good deal when they see one. They don’t want expensive patients, and you don’t want expensive patients in your insurance plan.

The fundamental premise of insurance is to pool risk. Before the Affordable Care Act, if insurance companies saw your risk as too great, they could refuse you; no more. They got more customers with the (now repealed) mandate to buy insurance, but they gave up denying folks with preexisting conditions.

The ACA tried to get people to be good shoppers; you would assess your risk, and then chose on the exchange from comparable plans that would suit your needs. It’s been pretty popular here in Idaho, with record enrollments, year after year. Before the ACA, if you wanted to shop for individual plans, it was worse than shopping for jeans that made you look good, with no changing room.

True, the ACA mandated there should be a minimum level of benefits, and limited the range of benefits (Gold, Silver, Lead), but this was to make the marketplace press the insurance companies to cut health care costs. They have barely made a dent, even though Medicare and Medicaid has been effective at containing costs in the last 6 years. They have leverage. Private insurers have not been able to leverage health care providers, or consumers (YOU) to decrease consumption, improve efficiency, and thus lower costs. So now the white knights arrive.

Cameron and Otter suggest more choice; they claim more slices of the insurance pie will lower costs. Well, they will for you if you don’t get hit by a bus or get cancer and you have chosen the right plan that covers such events. If not, then what? Then somebody else pays.

No, these guys embrace the Wild West solution to the health care conundrum. You get to look at the cards in your hand and make a bet.  And if you go bust, the county takes your horse and saddle and your neighbors insurance rates go up.

We need leverage folks, and leverage is in numbers. Splitting us up, as Cameron and Otter propose just weakens our leverage.  It is no mystery that the leading employer in most Idaho counties is a health care institution. It is a huge industry, a huge sector of our economy. If we don’t like how it’s working, we can try to organize and get the leverage to solve the problem. That’s what our leaders should be doing.