Rural Health Care Issue Much Deeper Than Medicaid Expansion

February 17, 2014 10:00 am

by Charlie · 37 comments

This week’s Courier Herald Column

On Thursday of last week, the “news” was focused on melting snow in Georgia and the lingering problems of power outages from south metro Atlanta to Augusta.  During a briefing on the matter from Governor Nathan Deal, the AJC’s Jim Galloway managed to slip in a question about a problem that will linger long after the lights were turned back on.

The Governor was asked about a move within the legislature to require their authorization before committing the state to Medicaid expansion (and the long term funding commitment that comes with it).  The Governor replied “I’m fine with that”.

Instantly, the answer was crystalized as a campaign issue.  Democratic presumptive nominee Jason Carter charged the Governor with passing the buck.  Governor Deal’s campaign responded with a suggestion that Carter would prefer a backroom Deal with President Obama rather than to give the representatives of the people a say in how their tax dollars are spent.

Lost in the fray was the announcement that Lower Oconee Community Hospital in the Wheeler County town of Glenwood was closing its doors.  It is the fourth rural Georgia hospital to close its doors in two years.  There will likely be more.  Wheeler County residents will now face a 30-plus minute trip to Dublin, Vidalia, or Eastman for their medical care.

“Medicaid expansion” will likely remain the political question of the day.  It gives Democrats the opportunity to say that Georgia is turning down “free money” from Uncle Sam.  It gives Republicans the opportunity to demonstrate that they are actively fighting Obamacare at the state level along with future unfunded liabilities.

It gives both sides the opportunity to demonstrate they’re fighting for something, without having to examine critical structural issues facing rural healthcare delivery in Georgia.   It is yet another example demonstrating that campaigning is easy, but governing is hard.

The economics of Wheeler County resemble that of much of rural Georgia.  According to Georgia Health News, “The Wheeler County area had a 23 percent uninsured rate, and 10 percent of citizens are unemployed…Forty-one percent of the county’s children live in poverty.”  That indicates much of the population is likely already eligible for Medicaid.  Add in that 26.5% of the county’s residents are over 65 and you’ll see that Medicare is also a huge factor in health care delivery for the area.

The problem – with or without the expansion of Medicaid – becomes one of costs versus revenue.  According to one Georgia hospital executive, Medicaid reimburses roughly 87% of costs to his hospital.  Medicare is slightly better, but still less than actual delivery costs of services.  A “Critical Access Hospital” – one such as Lower Oconee that agrees to limit its size to no more than 25 beds – is eligible to receive up to 100% reimbursement on Medicare patients.

In much of rural Georgia, there are barely enough patients to keep a facility operating to begin with.  Add in a population base served by government backed insurance programs that have “bent the cost curve” by reimbursing at or less than the costs of services provided, and it becomes obvious of the cause and effect.

The problem for rural health care is only exacerbated when you consider that area hospitals often are the backbone for local physicians.  Georgia now has roughly one third of its counties without a general practitioner.  Roughly half lack a pediatrician.  Doctors face the same problems that hospitals do.  After a decade of expensive school and residency training, they’re unlikely to re-locate to an area where they will lose money on almost every patient they see.

It’s easy to make expanding Medicaid a fix-all boogeyman.  But even if expanded to cover a relatively small portion of those who don’t already qualify, the hospital and other health care professionals are left with the same problem:  The vast majority of the patients they see will never cover their basic operating costs, must less yield a profit.  And without profits, there is a systemic disincentive to deliver services.

That part of the problem is very real. But it’s not something that fits very well on a bumper sticker.

Fixing it will require more than a sound bite.  Instead, we’re likely to see short term political battles continue to cloud the long term problem.  And even more importantly, potential solutions.

{ 37 comments… read them below or add one }

Jon Lester February 17, 2014 at 10:35 am

Democrats really shouldn’t use the phrase “free money” as a talking point. We know there’s no such thing, that federal money comes from us, too, yet I’m hearing those words from people who should know better.

Brother February 17, 2014 at 3:51 pm

It is not “free money.” It is money that Georgia taxpayers have paid into Federal taxes. Do we see the state turning down Federal funds for transportation and public safety the way they do for education and health care?

The economic impact of the $30B the Governor is rejecting is only slightly less than the Gate Market Price of all agricultural commodities produced in Georgia (about $13B- 2008.) While Medicaid funds follow the patient, with the level of poverty and low incomes in much of Georgia south of I20, the use of these funds to shore up existing healthcare facilities, employment of healthcare professionals, and healthier citizens would allow an economic impact comparable to an industry locating in those communities.

Now with HB 990, he and the legislature are putting up another barrier up to providing for the citizens of this state for the sake of political ideology. Jesus said “That you did for the least of these my people, you also did for me.”

Turning your back on Federal monies that your citizens paid, and denying those less fortunate, while letting communities in the state lose critical assets like hospitals and doctors is just wrong.

notsplost February 18, 2014 at 7:44 am

Since the Federal Govt spends hundreds of billions more than it takes in in taxes, it is more likely that the money for Medicaid expansion comes from the Federal Reserve’s Quantitative Easing program, a.k.a. raw printing.

The cost of which shows up at the grocery store and the gas pump. Things that poor people feel more than the wealthy.

By turning it down Gov. Deal is actually showing some rare fiscal restraint.

griftdrift February 17, 2014 at 10:43 am

On the flip side, in this particular situation, Republicans shouldn’t use “free market” because it’s just as pollyannish.

Jon Lester February 17, 2014 at 10:49 am

That’s right, a literal “free market” hasn’t really existed in practice, and neither has true communism.

In principle, I don’t think anything or anyone should be subsidized by the state for any reason, but I also don’t think I’ll live to see that become reality, and I have a few decades ahead of me yet.

MattMD February 17, 2014 at 11:06 pm

I think he is referring to medicine in general and he is right, it is a rigged market.

To your principle, I grew out of Ayn Rand philosophies when I was around 20. Some libertarian policies are good (i.e. on the social aspect) others are completely impractical and will never happen, even if you lived to a 1000.

griftdrift February 17, 2014 at 11:03 am

More to my point, as I mentioned in another thread, no one has come up with a business model that solves the rural healthcare crisis. Pre-Obamacare or Post-Obamacare.

Anyone who simply says “free market” is being disingenuous”. With no business model, the market will not “move” to fill the gap.

The solution is going to require some government intervention. If we can’t get past that polemical point, it will never be solved.

Where different philosophies can come into play is the vector of that government intervention. Democratic solutions (Medicaid expansions, single payer, etc.) or Republican solutions (less regulation on PAs, incentives for primary care centers, etc)

Chris Huttman February 17, 2014 at 12:02 pm

Open up a streamlined med school for general practice that starts paying people $50k/year with no debt to go to med school/residency and then requires them to practice for 10 years in an underserved part of the state or else their license will be revoked. Use Medicare/Medicaid to guarantee them $150k/income after they graduate and start practicing. Structure it so they could make more – I have a friend who has a practice near Jacksonville that has a guaranteed payment contract with the hospital they work for. Not that hard to structure.

No one can explain to me why the medical profession seems to be exempt from the rules of supply and demand. Look how many lawyers we produce that are now making $45k a year – good for the individual lawyers? No, but good for everyone that needs to hire a lawyer – probably.

Why do we pay doctors the same way we pay NFL or NBA players?

Chris Huttman February 17, 2014 at 12:17 pm

To add some additional context, the total number of active physicians per 1,000 persons went from 1.9 in 1980 to 2.5 by 1997. Since 1997, it has stayed relatively flat between 2.5 and 2.8. Based on 2012 population estimates it is 2.7. This is from Kaiser data.

According to the World Bank, the number is 2.4. A few countries that also have similar standards as the US are at or lower to our number (Japan, Canada, Korea, Singapore) but other countries like France, Germany and Sweden have significantly more (3.4,3.7,3.8).

1 in 370 people in America are a practicing physician, would it really reduce the quality if that number were 1 in 310?

MattMD February 17, 2014 at 11:16 pm

Mercer Medical School was developed to help combat the issue of the under-served rural areas but there is no teeth in that agreement. You can apply, recite some well-meaning wish to help out impoverished areas and then go into a plastic surgery residency and move to Atlanta. I know a guy who did exactly this. (Note: Plastics is an important field, especially for reconstructive surgery but my point still stands.)

I don’t know if this has changed but the mission needs some teeth into it. I don’t know how you do this legally.

I have got to be missing your point: doctors get paid like NBA players? BWHAHAHA! You must be drinking. This country through television pays any talented moron millions upon millions of dollars to throw balls through a hoop. I have much respect for the NFL though, it is a pretty vicious sport.

Chris Huttman February 18, 2014 at 12:20 pm

I mean that in the sense that there is a fixed pool of money in the NBA/NFL and the players union negotiates with the owners over what % of that revenue they will get and then they divide it among a fixed number of players that can not grow or shrink.

Now – in medical spending, there is a total amount of revenues, doctors (players) negotiate with insurance companies (owners) for a percentage of revenue they will get and then they divide it among a fixed number of doctors that can not grow or shrink because it is incredibly complicated to open up a new med school, and they use lobbyists in many states to lobby against nurse practicioners and others being able to alleviate some of the demand – the same way that there are X number of NBA/NFL teams who each have Y number of players and X*Y is constant.

Compare the doctor shortage with what has happened with lawyers over the last 30 years – there was (arguably) a lawyer shortage, so new law schools opened up and expanded, people who had the skills to become a lawyer saw how much money existing lawyers were making, expanded the ranks of lawyers, and now there are too many lawyers – which is bad for people who became lawyers because they aren’t making as much money as they thought they would – but is good for everyone else because now you can hire a lawyer at $50/hour instead of $200 or whatever to write up your will.

The legal profession may think this is a problem, but society at large does not – and I just don’t understand why a similar increase in the number of doctors and decrease in cost for medical services for the rest of the population seems to rub people the wrong way – I understand why doctors personally would not like it but what about everyone else?

Max Power February 17, 2014 at 1:38 pm

According to Georgia Health News, “The Wheeler County area had a 23 percent uninsured rate, and 10 percent of citizens are unemployed…Forty-one percent of the county’s children live in poverty.” That indicates much of the population is likely already eligible for Medicaid.

Charlie feel free to correct me if I’m wrong on this but I thought the income limits for Georgia’s low income medicaid was so low, that even if you’re unemployed and drawing UI you still make too much to qualify for medicaid. I seem to remember the income limit being something like $3,000 a year for one person.

Chris Huttman February 17, 2014 at 4:04 pm

You are correct and that’s a pretty bad error. An adult in a family of 4 is only eligible for Medicaid if they make less than $6,000 / year – which is insane. Pregnant women and those nursing infants can qualify up to 200% of the poverty line, so a family of four the pregnant/new mom could qualify up to $47k.

I know we’re supposed to pretend like Medicaid expansion isn’t a big part of the solution here – but if you’re a doctor or healthcare provider thinking of relocating to Wheeler County, would you rather get reimbursed for giving care to ~20% of the population at 87% of your cost or 0% of your cost?

Chris Huttman February 17, 2014 at 4:13 pm

And if you’re in the 80% of the population that doesn’t qualify for Medicaid, would you rather the charge you or your insurance company pays be 3.3% higher (to cover that 13% shortfall for the Medicaid people) or 25% higher (to cover the 100% shortfall for completely uncompensated care).

Now further – if you own a business and pay federal taxes, would you rather pay 25% higher healthcare costs AND have your taxes go up to pay for Medicaid which isn’t being delivered here AND pay a penalty (eventually) when your employees who can’t afford the workplace plan but are eligible for Medicaid instead choose to go without because there’s no affordable option?

SmyrnaModerate February 17, 2014 at 7:48 pm

And I think this points out a big part of the problem or perception with expanding medicaid. I think most Georgians would think that someone who is unemployed or otherwise has no sources of income would easily qualify for Medicaid when in fact they overwhelmingly do not.

Charlie February 17, 2014 at 8:38 pm

The fact remains that if you put more people into a system that pay below cost you’re still contributing to a supplier problem that already exists, and makes it worse.

Joseph February 18, 2014 at 7:04 am

Absolutely spot on Charlie. Chris – I respect your opinions as they are thought out and well written, but I must disagree with your last comment. As a business person, I will absolutely stick with serving 0 people and losing 0 money versus serving 87% of people and losing any amount of money to do it. An individual doctor particularly does not have the personal financial capacity to cover the gap not paid to them. Also, please remember, this “free money” Or more correctly stated by Chris – Georgia taxpayer’s money – is withdrawn after a certain period of time. That federal money is not a permanent funding source.

Back to the reimbursement rate though, I am curious to learn what “cost” is – I have a feeling, particularly on the hospital-side, “cost” is a fluid definition. While not decending into the “free market” realm or to sound like I am demeaning capitalism and people making a profit – the cost of healthcare delivery is highly distorted – particularly now with the implementation of ACA and the continued expansion of the Medi programs.

Again, well said Charlie!

Chris Huttman February 18, 2014 at 12:42 pm

Well let’s talk about the actual law – Georgia’s share of “free money” starts at 100% and reduces to 90% and as it is currently written stays at that level and they raised the taxes to pay for it. So the money is being extracted from Georgia’s wealthier taxpayers and businesses and we’re not taking it back.

Now as far as the free care – in a normal business I would say certainly I would rather have 0 customers who can’t pay than 1 customer who only pays 87%. But practicing medicine is not the same as selling iPhones, and today’s 13% “loss” on writing a prescription to treat a bad cold is tomorrow’s 100% loss on treating a serious pneumonia infection.

I also want to make a distinction between GP’s and specialists. A 2008 study showed that the average orthopedist would go from making about $500k/year to $400k/year if all of their commercial insurance payments were substituted for Medicaid payments (the average orthopedist started with roughly 1/3 Medicaid/re payments, 1/3 commercial insurance and 1/3 other payment sources). This type of doctor will surely tell you that they “lose money” on Medicaid patients, but that’s clearly not the case.

GP’s make much less to start with, overhead is a higher percentage of their total revenue and if they had all of their commercial insurance payments replaced by Medicaid they’d be looking at an average salary going from $189k to $137k after the fact. And there may well be many people out there who aren’t willing to do the time and the work for $137k – and I would not blame them.

But this all just goes to my greater argument for deregulating the supply of doctors. $137k or even $189k to run a business with huge overhead and putting in doctor time and hours is not that attractive of a proposition. But I know many smart people who would gladly do 6 years of med school and residency where they drew a salary of say $50k for those 6 years and then worked for a state run clinic making $137k after the fact with no actual risk of running a business. I probably know at least 10 people in my peer group who are lawyers not making anywhere near $137k now that would have taken this path instead if it existed.

Charlie February 18, 2014 at 1:05 pm

When I started talking to doctors about tuition reimbursement programs for rural service, they have each rejected it quickly as a non-starter. The reason: it’s been tried before and it doesn’t work.

Why doesn’t it work: Because they know that they’re committing the best part of their working years to building a client base that will never be able to pay for their services. Ever.

Chris Huttman February 18, 2014 at 4:07 pm

That’s a cop-out. What about doctors that work for something like Kaiser or the MANY doctors that work in emergency rooms. Are they building up their client base?

I am saying we need to grow the base of doctors from more than ~2.7/1,000 people, not that we need to redistribute existing doctors. Of course the kind of people who are currently doctors in the existing system won’t think it’s a good idea – I don’t expect them to. I’m trying to think outside the box. I think there are places in the US/world where tuition reimbursement and rural health clinics works, or they are at least trying.

Charlie February 18, 2014 at 4:47 pm

Not responding to your political point of view the way you want me to doesn’t make something a cop out.

Yes we need to grow the base of doctors. But guess what Sherlock, the policies you’ve been promoting have a distinct disincentive to do that. When I’ve brought it up before, you’ve replied with things like “doctors make ‘enough’ money”. I’m using this article to point out that in many areas, especially rural ones, they do not.

Sorry you don’t like the facts, but not playing to your script hardly makes it a cop out.

Chris Huttman February 18, 2014 at 4:33 pm

And the whole point of the thing I’m proposing is maybe best illustrated by thinking about it this way: About 16,000 people graduate from med schools each year. That means four years prior, some number >16,000 applied. There is surely a difference between the people at the top of the list (the first 50 or so) who will go on to be neurosurgeons and the bottom 50 who will go on to GP or pediatrician or whatever.

Now – consider the persons from 16,001 to 17,000 for example. They didn’t get into med school. Other than dumb luck, I doubt there is much difference between #16,000 (gets in) and #16,001. So let’s think about #16,001 – this person will never be committing the best part of their working years to building a client base that will never be able to pay for their services. Because they AREN’T becoming a doctor.

So what does the person at 16,001 or 17,000 or even 20,000 who never becomes a doctor end up doing with their life? I would bet their median income ends up being nowhere near what even a poorly paid Medicaid accepting doctor is.

So while it isn’t an overnight bandaid, I don’t see why it’s so easily dismissed to say that there are people out there that are capable of being general practicioners who you could pay something like $120k/year to work in a state run clinic.

To me asking a current doctor whether they would do this is kind of like asking a major league baseball player with a fat contract what he thinks of playing in the minors at the league minimum for a few years. Of course an established doctor doesn’t think it’s a good idea – he’s made it into a system that rewards someone for trying to go out and make as much money as they can. I’m suggesting we expand the system and create new incentives to fill needed holes.

Charlie February 18, 2014 at 4:49 pm

So now we’re back into the theoretical with a mythical “someone” paying these doctors $120K/year. Who?

Who is funding it, and how. Because that is the billion dollar question.

Because the policies that we have right now, and that would still be in place whether or not medicaid is expanded, will still be reimbursing the docs under cost.

Chris Huttman February 18, 2014 at 5:18 pm

Well let’s take Wheeler County for example. Let’s assume 15% would be eligible for Medicaid expansion. The national average amount that Medicaid pays out is $5,563 per patient, but closer to $3,000 for non-elderly/disabled people. It’s population is 7,939 so we’ll say 1,100 new Medicaid eligible people paying out $3k / year = $3,300,000. At 2.7 doctors per 1,000 people we’re talking 3 new doctors. Now not every dollar spent from Medicaid is going to go to a general or family practice doctor, in 2012 almost exactly 20% of total medical spending went to physician and clinical services.

So – $660,000 of new revenue just from Medicaid, 3 doctors = $220,000 in revenue per doctor. Overhead is typically 60% for GP’s which means we’re left with income of $88,000 / physician. Where are we going to come up with $96,000 per year for Wheeler County to cover the difference to get to $120,000 (assuming that people wouldn’t do it for $88,000 – i’m not so sure). Well they don’t have to take only Medicaid patients, surely they will have some private payers. And I’d also bet that we currently send much more than that to Wheeler County in QBE equalization grants each year, so it’s not like this kind of money doesn’t already move around.

I will throw something out there that may not seem palatable to your ideology but why not just charge doctors who open up shop in non-underserved areas more for their license, or if you prefer on the state and national level we could give doctors that serve in these areas the difference in tax credits that Medicaid or otherwise we can’t pay for.

How did we “afford” to give me $7,500 to buy an electric car last year? When there is a will there is a way to come up with solutions, but Medicaid expansion at the very least would inject a lot of money into places like Wheeler County and whether we come up with some scheme via the tax code or whether we just let doctors from India immigrate more easily, I am guessing someone out there wants a piece of that money, the same way cell phone companies have figured out how to give someone cell phone service for $10 for what they can’t possibly discount below $45 for me.

Charlie February 18, 2014 at 5:37 pm

Instead of me continuing to read paragraph after paragraph of you assuming some numbers to build an excel strawman, let’s get back to a basic point:

Doctors are reimbursed under our current system (with our without a medicaid expansion – and even with full implementation of Obamacare) below their cost of service.

Period. That is the point, and that is a problem. And continuing to obfuscate it by making up numbers doesn’t do anything but apparently give you a hobby.

Chris Huttman February 18, 2014 at 5:39 pm

The Price plan would give everyone eligible for Medicaid $2,000/year to buy insurance. How is this different? That’s also below the cost of what doctors “need to make”.

Am I wrong about the Price plan? Does that $2,000 somehow come from a different pot of money that “we can afford” than Medicaid expansion comes from?

Chris Huttman February 18, 2014 at 5:42 pm

According to this 2008 study…
http://healthaffairs.org/blog/2012/10/02/do-medicare-and-medicaid-payment-rates-really-threaten-physicians-with-bankruptcy/

Even if you replaced all private insurance payments with Medicaid, orthopedists (especially) and primary care physicians would still have INCOMES that would put them in the top 5% of all US earners.

I think we have different definitions of “below their cost of service.”

griftdrift February 18, 2014 at 4:59 pm

This is why I think doctors is the wrong vector. Want to think outside of the box, think of ways to remove doctors as primary care givers.

Lea Thrace February 18, 2014 at 5:16 pm

People tend to forget about the utility of Nurse Practioners and Physicians Assistants…

Chris Huttman February 18, 2014 at 5:26 pm

Great idea…when I say we should deregulate the supply of care givers I’m ultimately agnostic whether we go more the NP or PA route or we create a new tier of doctors that are more similar to NP/PA but still doctors but the point is there are a lot of options. (And immigration is probably the great unmentioned possibility, at least in this thread)

The point remains that there is no good reason at all for a place like Wheeler County not to have Medicaid expanded. It means (on average) more than $3m in money pumped into that local economy that could go to pay for hospitals, doctors, NP/PAs, prescription drugs etc.

And the absolute worst part of Republican opposition to Medicaid expansion as part of Obamacare is that the alternative plans they support do functionally similar things. The Price plan would give $2,000 to every poor person below 200% FPL to just go out and buy health insurance. If it isn’t worth it to go to a place like Wheeler County and inject $3.3m into the medical economy via Medicaid, please explain to me why it’s preferable to do it as $2.2m?

griftdrift February 19, 2014 at 11:06 am

I can give you two arguable reasons for not expanding it ( and for Price’s plan for that matter ).

1. We’d eventually have to pay a portion of it. Yes it would only be 5% but we would have to pay a share. Now the cost benefit on that 5% is certainly up for debate.

2. More importantly, it papers over the problem. Similar to public housing in the 60s. Sounds odd right? Go with me for a second.

Before the public housing programs of the 60s, we had a need for housing for the poor. We took the logical step of creating public housing. What failed to happen was the next logical step of finding a way to break those in that poverty circle out of that housing tier and the projects eventually devolved into walled off hells.

Money was a good first step but without systemic change, all the money in the world doesn’t matter.

In my mind, Medicaid expansion is analogous. Money alone doesn’t solve the problems Charlie has mentioned. It just provides temporary soothing.

What we could do ( if there was any political will on either side ) is trade off Medicaid expansion for a deal on deregulating PA/NPs or probably more importantly Certificate of Need.

Everybody wins?

Well maybe not. Because right now it is more politically efficient for Republicans to scream they are stopping Obamacare and for Democrats to scream that Republicans are killing poor people.

Lea Thrace February 19, 2014 at 11:17 am

Mr. Griftdrift,

I have never seen #2 explained in that manner. You definitely make sense with that analogy. Thanks for that. Do you think the PA/NP angle will make that much of a dent though? I am of the mind that part of the issue is that people are just living longer but not healthier. We arent doing enough or much to address that aspect of healthcare costs. End of life care, senior care, and by extension the pharma costs. Those are huge drivers. Not much is being addressed there from what I can see.

griftdrift February 19, 2014 at 11:44 am

I think it’s two discrete problems and we have a tendency to lump everything together. Let me explain.

Let’s take the final years of life first.

There isn’t much of a solution to our living longer and having more advanced treatment to keep us alive than to throw money at it. That’s why we already have single payer in this country and it’s called Medicare.

I’ll detour into a personal story to hopefully amplify this point.

My mother was diagnosed with cancer. Fortunately, she had gold plated medical insurance and Medicare picked up the rest. Otherwise our options would have been limited or we could have been financially devastated. She received the best, including experimental care, for two years. And we got a good outcome but not the outcome any of us hoped for.

Two years later, the cancer spread rapidly and we lost her in a matter of weeks. You know what a doctor friend told us afterward? He said, “She got her two years. She lived happily, saw her great grand children and got things in order”.

He did not say this to be callous. But as a matter of fact that two additional years was a good expected outcome.

Now if we lived in a rational, actuarial world where cost benefit analysis ruled, hundreds of thousands of dollars for two additional years would probably not make sense.

But fortunately, we don’t live in that world. We live in a world where thankfully, sometimes irrationally, sons love their mothers and want them to stay as long as possible. This is a chasm we will never re-cross and it is the world we have to live in and manage.

For that reason, we have few choices except to throw money at elderly care. That does not mean we should do nothing. All systems can be improved and we should continue to propose things like better end of life directives and using technology in a positive, not just a possible, manner.

The problem is Obamacare, Hillarycare, Tom Price and everyone else are trying to solve is not the last 20 years. It’s the first 60 years.

And it’s a triage problem.

People rapidly signing up on the exchanges right now are people who do not and maybe have never had insurance.

They mostly are not concerned about PET scans, imaging and end of life directives. They have kids with fevers and they desperately want someone to tell them what to do.

It’s the primary care conundrum that will create the “walled off hellholes” of Southwest Georgia and West Virginia and every other place with an unhealthy population and few doctors.

What we need to do is figure out a cost effective way to have these people see someone that will say, this is serious or, hopefully, not serious, and then either send them on their way with a prescription or a referral to a specialist.

And there should be a way to have that person be competent, trustworthy, effective and not have a half million dollars in debt hanging around their neck.

There’s room here for creativity, compromise and consensus. All the things that lead to good governance. If only the politics could stand aside for a short time.

DeKalb Wonkette February 18, 2014 at 9:07 am

Just a few points:

All rural areas are not equal. The late Doug Bachtel would remind us that there are 5 Georgias and among the rural ones, some are “inclining” (think NE GA Mountains, attractive because of its natural beauty) while some are “declining” (think rural SW GA, inside the persistent poverty zone). So a one-size -fits-all solution won’t work.

It’s the declining rural areas that pose the most significant policy challenges. Getting it right is important or else the persistent poverty is going to become a lot more persistent. The end result should include a labor force that is willing and qualified to work, thus attracting jobs and economic development, which in turn could support health care providers.

The Georgia Health Policy Center has studied these issues for many years and would have much insight to offer. Another place to look is neighboring states that seem to have had success such as Community Care of NC http://www.communitycarenc.com/

Blake February 25, 2014 at 4:12 pm

This column is Charlie Harper at his worst. On the surface, the argument appears reasonable, as usual gently chiding “both sides” for getting it wrong and hand-wringingly hoping for better.

Here’s the key weakness: He states over and over again that Medicaid (and Medicare) compensate providers “below cost.” The reality is quite different.

http://healthaffairs.org/blog/2012/10/02/do-medicare-and-medicaid-payment-rates-really-threaten-physicians-with-bankruptcy/

Also conveniently elided is that the historical problematic Medicaid underpayment is addressed in the ACA, bringing it up to the level of Medicare through the end of this year. The GOP House can demonstrate they have some interest in governing by extending it into the future (if, you know, they’re interested in being grown-ups).

Charlie’s approach gives political cover to Governor Deal for not accepting the Medicaid expansion by essentially claiming that even if he did, it wouldn’t matter. The truth is otherwise. A fair case can be made that the Medicaid expansion wouldn’t solve all problems, but 1) this isn’t it and 2) the expansion would beat the snot out of the status quo alternative.

griftdrift February 25, 2014 at 4:26 pm

I let Charlie respond to the meat, if he wishes, but the article you cite weakens your own argument in the context of southwest Georgia, where I’m sure the concern is less about orthopedic specialists and more about primary care doctors.

From your article:

“However, unlike payment cuts for specialty physician who would still earn close to half a million dollars from all-Medicare-and-Medicaid practices, further reimbursement reductions to general practitioners would be very challenging, especially considering the long hours that all doctors work, educational debt, and the costs of new practice infrastructure.

Therefore, the argument that further cuts to Medicare or Medicaid might bankrupt a physician’s practice is significantly more compelling when coming from primary care doctors. These physicians will require higher reimbursement to achieve the laudable goal of developing their practices into medical homes, and payment reform efforts must address their needs”

Blake February 27, 2014 at 12:52 pm

As I originally said, there’s a fair case to be made that accepting Medicaid expansion in Georgia would not solve all problems, but 1) Charlie didn’t make it and 2) it’s a damn sight better than nothing. Charlie could have said that the expansion wouldn’t help GP practices in southwest Georgia. He didn’t. He said it wouldn’t help anything, including the wave of rural hospital closures. Unless Georgia’s rural hospitals are composed entirely of general practitioners with no specialists, I fail to take his point.