(05-10-2015 05:34 PM)dawgitall Wrote:  Me defect! Heck every time I try to get a discussion going you deflect to your tried and true doctor shortage point.

Because it is the biggest and most glaring failure of the ACA... and the primary reason it should more than likely be repealed rather than just 'amended'. You don't HAVE to repeal it, but you have to make so much of it moot to fix it that you may as well... for clarity if nothing else.

FTR, 2/3rds of my post (and I am frequently chastised for being verbose) wasn't related to doctors shortages but instead from corrections to 'how you think' healthcare reimbursement works.

Quote:Hospitals got some $ indirectly from the Feds through the states before the ACA but that wasn't Medicaid as in those individuals were on Medicaid. That funding ended because all the states were suppose to expand Medicaid and the ones that didn't like mine have left hospitals, especially rural ones in a very bad position.

Wrong. I've corrected you numerous times and pointed out that I do this for a living, but you keep insisting that you know what you're talking about. Kindly tell me what your experience/knowledge base is? My office is 15 feet from an ER nurses station... The director of Nursing is in the next office. I have a dozen Physician's coats and stethoscopes in my office closet and I just finished reconciling the weekend's billing after interviewing a physician this weekend and running through the financials with him. But go ahead, tell me how hospitals get paid.

I'm in a state that expanded Medicaid, and rural hospitals (like mine) are struggling here BECAUSE of the ACA, not in spite of it.... and the funding didn't end if they didn't expand Medicaid.... it merely transferred those people to ACA subsidized policies.

As someone who works in a rural hospital, predominantly in finance... in a heavily democratic state that expanded medicaid... we CAN have different perspectives on priorities or on 'how we say' things.... but there isn't much you're going to tell me about what the ACA does.

Quote:I probably shouldn't have used the word indigent but instead low to moderate income in my above post.

Are you telling me that the ACA doesn't provide subsidies for low to moderate income people to get insurance, unless it is through expanded medicaid? That just isn't remotely true. Are you saying that Medicaid is better for the insured than the 'free' ACA policy? If so, that's just another failure of the ACA. I understand some people think Medicaid (single payer) is better than an ACA policy (which is STILL ultimately/arguably single payer)... but the amount of coverage isn't the issue... because the government set the standards.

(05-11-2015 07:09 AM)Owl 69/70/75 Wrote:  

(05-11-2015 07:05 AM)UCF08 Wrote:  Do you not blame anything on the opposing party for instead of trying to better the law or improve it, just obstinately trying to repeal it over and over?

I've made my preference for Bismarck very clear, and have consistently criticized republicans for not going that direction.

With that in mind, the current law really cannot be bettered or improved. It is fundamentally flawed because it ignores basic principles of economics. You can't improve it without addressing that, and you can't address that without blowing up the current law.

This.

Owl and I differ on some specifics, but I don't think either of us wouldn't be willing to reach some compromise on those issues. The bottom lines are that you must address the lack of supply of primary care if you are to improve 'wellness' and thus decrease the need for the more severe/expensive care.... which is the driving force behind healthcare reform/the aca. The framers of the ACA said it understood this, but then it became a political animal seeking 'control' rather than a healthcare animal seeking wellness. 'Wellness' doesn't translate well into votes... but 'insurance' does.

There are dozens of ways to solve the issues... there IS no single 'right' way... but they ALL start NOT with increasing insurance... which increases demand for healthcare relative to supply, but with increasing supply relative to demand.

(05-11-2015 10:53 AM)Hambone10 Wrote:  

(05-11-2015 07:09 AM)Owl 69/70/75 Wrote:  

(05-11-2015 07:05 AM)UCF08 Wrote:  Do you not blame anything on the opposing party for instead of trying to better the law or improve it, just obstinately trying to repeal it over and over?

I've made my preference for Bismarck very clear, and have consistently criticized republicans for not going that direction.

With that in mind, the current law really cannot be bettered or improved. It is fundamentally flawed because it ignores basic principles of economics. You can't improve it without addressing that, and you can't address that without blowing up the current law.

This.

Owl and I differ on some specifics, but I don't think either of us wouldn't be willing to reach some compromise on those issues. The bottom lines are that you must address the lack of supply of primary care if you are to improve 'wellness' and thus decrease the need for the more severe/expensive care.... which is the driving force behind healthcare reform/the aca. The framers of the ACA said it understood this, but then it became a political animal seeking 'control' rather than a healthcare animal seeking wellness. 'Wellness' doesn't translate well into votes... but 'insurance' does.

There are dozens of ways to solve the issues... there IS no single 'right' way... but they ALL start NOT with increasing insurance... which increases demand for healthcare relative to supply, but with increasing supply relative to demand.

And some of what constitutes improving "wellness" has zero to do with healthcare and everything to do with better lifestyle choices which also doesn't translate well into votes.

People don't want to be told they have to give up their smokes, drink, eat their vegetables, exercise, not have unprotected sex, etc.

(05-11-2015 10:53 AM)Hambone10 Wrote:  Owl and I differ on some specifics, but I don't think either of us wouldn't be willing to reach some compromise on those issues.

I don't think there's anything that I would support that you wouldn't, or vice versa.

(05-11-2015 10:26 AM)Hambone10 Wrote:  

(05-10-2015 05:34 PM)dawgitall Wrote:  Me defect! Heck every time I try to get a discussion going you deflect to your tried and true doctor shortage point.

Because it is the biggest and most glaring failure of the ACA... and the primary reason it should more than likely be repealed rather than just 'amended'. You don't HAVE to repeal it, but you have to make so much of it moot to fix it that you may as well... for clarity if nothing else.

FTR, 2/3rds of my post (and I am frequently chastised for being verbose) wasn't related to doctors shortages but instead from corrections to 'how you think' healthcare reimbursement works.

Quote:Hospitals got some $ indirectly from the Feds through the states before the ACA but that wasn't Medicaid as in those individuals were on Medicaid. That funding ended because all the states were suppose to expand Medicaid and the ones that didn't like mine have left hospitals, especially rural ones in a very bad position.

Wrong. I've corrected you numerous times and pointed out that I do this for a living, but you keep insisting that you know what you're talking about. Kindly tell me what your experience/knowledge base is? My office is 15 feet from an ER nurses station... The director of Nursing is in the next office. I have a dozen Physician's coats and stethoscopes in my office closet and I just finished reconciling the weekend's billing after interviewing a physician this weekend and running through the financials with him. But go ahead, tell me how hospitals get paid.

I'm in a state that expanded Medicaid, and rural hospitals (like mine) are struggling here BECAUSE of the ACA, not in spite of it.... and the funding didn't end if they didn't expand Medicaid.... it merely transferred those people to ACA subsidized policies.

As someone who works in a rural hospital, predominantly in finance... in a heavily democratic state that expanded medicaid... we CAN have different perspectives on priorities or on 'how we say' things.... but there isn't much you're going to tell me about what the ACA does.

Quote:I probably shouldn't have used the word indigent but instead low to moderate income in my above post.

Are you telling me that the ACA doesn't provide subsidies for low to moderate income people to get insurance, unless it is through expanded medicaid? That just isn't remotely true. Are you saying that Medicaid is better for the insured than the 'free' ACA policy? If so, that's just another failure of the ACA. I understand some people think Medicaid (single payer) is better than an ACA policy (which is STILL ultimately/arguably single payer)... but the amount of coverage isn't the issue... because the government set the standards.

Do you deny that DSH payments to hospitals were cut significantly (I misspoke when I said it was completely eliminated) based on the assumption that expanded Medicaid would be approved in all the states and thus hospitals in those states that didn't expand are significantly hurt by this? I agree that the funding moved over to the subsidies but those people that would have been covered under expanded Medicaid didn't move over to subsidized ACA policies! They are the people in the gap between Medicaid and subsidized insurance! You are the professional, how did you get that wrong!

That isn't remotely what I was saying. I was saying that low and moderate income people are the ones prior to the ACA that didn't have insurance at all and couldn't pay their medical bills, avoided going to a doctor, went untreated etc. Tax credits have made it possible for them to begin to improve their health and not stay in deep medical bill debt. Private, subsidized health insurance is far better than medicaid and medicaid is far better than nothing.

(05-05-2015 02:08 PM)VA49er Wrote:  It takes that long to get a primary care physician?

LoL I moved to another state and had one within an hour.

Man, that was the toughest hour of my life!

(05-11-2015 02:09 PM)dawgitall Wrote:  Do you deny that DSH payments to hospitals were cut significantly (I misspoke when I said it was completely eliminated) based on the assumption that expanded Medicaid would be approved in all the states and thus hospitals in those states that didn't expand are significantly hurt by this? I agree that the funding moved over to the subsidies but those people that would have been covered under expanded Medicaid didn't move over to subsidized ACA policies! They are the people in the gap between Medicaid and subsidized insurance! You are the professional, how did you get that wrong!

Friend, you just don't understand... and I can explain it to you, but I can't understand it for you.

First, let's start with the fact that DSH is the Federal plan that gives states money for indigent care... Those monies are administered by the states, like medicaid. When I say Medicaid, I am actually talking about ALL of the different means of getting reimbursed through the state for healthcare. SOME states subsidize those monies with other taxes, including their medicaid funds.

Your comment implies that someone who earns between 100% and 138% of the FPL in a state that doesn't expand Medicaid is somehow not eligible for the Obamacare Tax credits that are only eligible for people who earn between 100% and 400% of the FPL. This simply isn't true. It also ignores that many states that didn't expand Medicare already had eligibility thresholds in excess of the 'expanded' definitions.

Example... Alabama (the lowest rank)... Before O-care, jobless parents had to be VERY poor to qualify, but pregnant women and children were generally covered up to 133% of the FPL. Expanded Medicaid means jobless parents will get coverage as well... so the amount of money needed in what you refer to as DSH is less than before... though obviously it still costs money to insure those people.... It's just a different pocket.... Medicaid instead of DSH.

Minnesota on the other hand (#1) covered parents AND children up to 275% of the FPL... and now they only have to cover them to 133%. BIG saving for Minn.

SO yes... the DSH payments were cut, but that is because that money was redirected either to expanded medicaid, OR an ACA subsidy. It is merely a matter of which pocket you are taking the money out of.

Note that I am neither pro nor con medicaid expansion... the 'right' choice is different for different places and situations... I am merely correcting your inference that it either a) by definition provides coverage to more people (it provides coverage to fewer in places like Minn) or b) that providers who treated these people before didn't get paid.

Neither of those inferences is true.

Quote:That isn't remotely what I was saying. I was saying that low and moderate income people are the ones prior to the ACA that didn't have insurance at all and couldn't pay their medical bills, avoided going to a doctor, went untreated etc. Tax credits have made it possible for them to begin to improve their health and not stay in deep medical bill debt. Private, subsidized health insurance is far better than medicaid and medicaid is far better than nothing.

Yet you can't actually point to any improvements in their physical NOR financial health... and sorry, but it comes back to the number of doctors... The fact is that unless you are arguing that people with insurance were going to the doctors when they didn't need to... or that doctors had empty waiting rooms begging for patients... then without increasing the number of doctors, you're only taking a visit away from someone else to supply these people with visits. It is certainly better for some people as you note, but identically worse for others. This is the very simple truth that you continually ignore.

On a different but related point, your belief of 'what is better than nothing' is a non-sequitur. ANYTHING That spends $1 trillion more per year forever should be 'better' than before... and I have repeatedly said that by far, the best thing about the ACA is that we now have more money to spend on healthcare... but that doesn't in any way mean that the ACA is even remotely close to the 'best' way to spend that money. The money should be spent on more doctors/supply (especially PCPs), not on more demand. If doctors had empty waiting rooms because of too many doctors, they would be more willing to take less and see indigent patients, accepting the DSH payments instead of refusing Medicaid patients, much less DSH ones.... or if PCP physicians were paid better than say allergists or dermatologists... A trillion dollars pays for a TON of primary care... and we're only (really) re-arranging the already available care.

(05-11-2015 02:46 PM)ECUGrad07 Wrote:  

(05-05-2015 02:08 PM)VA49er Wrote:  It takes that long to get a primary care physician?

LoL I moved to another state and had one within an hour.

Man, that was the toughest hour of my life!

He obviously means get an appointment to see one.

(05-11-2015 04:03 PM)Hambone10 Wrote:  

(05-11-2015 02:09 PM)dawgitall Wrote:  Do you deny that DSH payments to hospitals were cut significantly (I misspoke when I said it was completely eliminated) based on the assumption that expanded Medicaid would be approved in all the states and thus hospitals in those states that didn't expand are significantly hurt by this? I agree that the funding moved over to the subsidies but those people that would have been covered under expanded Medicaid didn't move over to subsidized ACA policies! They are the people in the gap between Medicaid and subsidized insurance! You are the professional, how did you get that wrong!

Friend, you just don't understand... and I can explain it to you, but I can't understand it for you.

First, let's start with the fact that DSH is the Federal plan that gives states money for indigent care... Those monies are administered by the states, like medicaid. When I say Medicaid, I am actually talking about ALL of the different means of getting reimbursed through the state for healthcare. SOME states subsidize those monies with other taxes, including their medicaid funds.

Your comment implies that someone who earns between 100% and 138% of the FPL in a state that doesn't expand Medicaid is somehow not eligible for the Obamacare Tax credits that are only eligible for people who earn between 100% and 400% of the FPL. This simply isn't true. It also ignores that many states that didn't expand Medicare already had eligibility thresholds in excess of the 'expanded' definitions.

Example... Alabama (the lowest rank)... Before O-care, jobless parents had to be VERY poor to qualify, but pregnant women and children were generally covered up to 133% of the FPL. Expanded Medicaid means jobless parents will get coverage as well... so the amount of money needed in what you refer to as DSH is less than before... though obviously it still costs money to insure those people.... It's just a different pocket.... Medicaid instead of DSH.

Minnesota on the other hand (#1) covered parents AND children up to 275% of the FPL... and now they only have to cover them to 133%. BIG saving for Minn.

SO yes... the DSH payments were cut, but that is because that money was redirected either to expanded medicaid, OR an ACA subsidy. It is merely a matter of which pocket you are taking the money out of.

Note that I am neither pro nor con medicaid expansion... the 'right' choice is different for different places and situations... I am merely correcting your inference that it either a) by definition provides coverage to more people (it provides coverage to fewer in places like Minn) or b) that providers who treated these people before didn't get paid.

Neither of those inferences is true.

Quote:That isn't remotely what I was saying. I was saying that low and moderate income people are the ones prior to the ACA that didn't have insurance at all and couldn't pay their medical bills, avoided going to a doctor, went untreated etc. Tax credits have made it possible for them to begin to improve their health and not stay in deep medical bill debt. Private, subsidized health insurance is far better than medicaid and medicaid is far better than nothing.

Yet you can't actually point to any improvements in their physical NOR financial health... and sorry, but it comes back to the number of doctors... The fact is that unless you are arguing that people with insurance were going to the doctors when they didn't need to... or that doctors had empty waiting rooms begging for patients... then without increasing the number of doctors, you're only taking a visit away from someone else to supply these people with visits. It is certainly better for some people as you note, but identically worse for others. This is the very simple truth that you continually ignore.

On a different but related point, your belief of 'what is better than nothing' is a non-sequitur. ANYTHING That spends $1 trillion more per year forever should be 'better' than before... and I have repeatedly said that by far, the best thing about the ACA is that we now have more money to spend on healthcare... but that doesn't in any way mean that the ACA is even remotely close to the 'best' way to spend that money. The money should be spent on more doctors/supply (especially PCPs), not on more demand. If doctors had empty waiting rooms because of too many doctors, they would be more willing to take less and see indigent patients, accepting the DSH payments instead of refusing Medicaid patients, much less DSH ones.... or if PCP physicians were paid better than say allergists or dermatologists... A trillion dollars pays for a TON of primary care... and we're only (really) re-arranging the already available care.

(05-11-2015 02:46 PM)ECUGrad07 Wrote:  

(05-05-2015 02:08 PM)VA49er Wrote:  It takes that long to get a primary care physician?

LoL I moved to another state and had one within an hour.

Man, that was the toughest hour of my life!

He obviously means get an appointment to see one.

You are cherry picking. There are almost 4 million people in the US that are in the gap! Ten percent of them are in my own state. They don't qualify for medicaid and they can't utilize the tax credits.

Quote:Nationally, nearly four million poor uninsured adults 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.

Adults left in the coverage gap due to current state decisions not to expand Medicaid are spread across the states not expanding their Medicaid programs but are concentrated in states with the largest uninsured populations (Table 1). A quarter of people in the coverage gap reside in Texas, which has both a large uninsured population and very limited Medicaid eligibility (Figure 2). Eighteen percent live in Florida, ten percent North Carolina, and eight percent in Georgia. There are no uninsured adults in the coverage gap in Wisconsin because the state is providing Medicaid eligibility to adults up to the poverty level.

The ACA Medicaid expansion was designed to address the high uninsured rates among adults living below poverty, providing a coverage option for people who had limited access to employer coverage and limited income to purchase coverage on their own. However, with many states opting not to implement the Medicaid expansion, millions of adults will remain outside the reach of the ACA and continue to have limited, if any, options for health coverage: they are ineligible for publicly-financed coverage in their state, most do not have access to employer-based coverage through a job, and all have limited income available to purchase coverage on their own.

The majority of people in the coverage gap are working poor—that is, employed either part-time or full-time but still living below the poverty line. Given the characteristics of their employment, it is likely that many will continue to lack access to coverage through their job even after the ACA provisions for employer responsibility for coverage are effective in 2015.7 Further, even if they do receive an offer from their employer that meets ACA requirements, many will find their share of the cost to be unaffordable. Because this population is generally exempt from the individual mandate, and because firms will not face a penalty for these workers remaining uninsured, they will continue to fall between the cracks in the employer-based system.

It is unlikely that people who fall into the coverage gap will be able to afford ACA coverage without financial assistance: in 2015, the national average premium for a 40-year-old individual purchasing coverage through the Marketplace was $276 per month for a silver plan and $213 per month for a bronze plan,8 which equates to about half of income for those at the lower income range of people in the gap and about a quarter of income for those at the higher income range of people in the gap. Further, people in the coverage gap are ineligible for cost-sharing subsidies for Marketplace plans and could face additional out-of-pocket costs up to $6,600 a year if they were to purchase Marketplace coverage. Given the limited budgets of people in the coverage gap, these costs are likely prohibitively expensive. Thus, it is most likely that adults in the coverage gap will remain uninsured, even after the ACA is fully implemented.

http://kff.org/health-reform/issue-brief...an-update/

(05-11-2015 05:31 PM)dawgitall Wrote:  You are cherry picking. There are almost 4 million people in the US that are in the gap! Ten percent of them are in my own state. They don't qualify for medicaid and they can't utilize the tax credits.

NO friend, YOU are cherry picking. I admit that these 4mm people exist.... in states like my Alabama example (that didn't expand). YOU don't admit that in states like Minnesota where they USED to cover people under medicaid to 275% of the FPL, and now they only cover to 133% are people in exactly the opposite position. As I said, the BEST answer isn't the same for every state.... and YOUR sources are only looking at one subset.

HOWEVER, those 4mm people you note are STILL covered by funds like those authorized by DSH and other state funds for 'free' clinics (my mother is still a volunteer nurse in one of those). In Texas, they not only provide care to the 1mm working poor you mention, but to AT LEAST that many illegal aliens. Texas COULD expand medicaid, but then they would have less money to care for the numerous millions of illegals. Now, you may disagree with that choice... but that isn't your call.

I'd also point out that California is quite similar to Texas in both size and the number of poor and illegals... and California is projecting a $78mm deficit for Covered-California 2015-2016 as a result of the ACA, and State law prohibits them from using general state funds to cover it.... so while you might argue that California is 'better' than Texas for expanding medicaid, one could just as easily argue that Texas is 'better' than California for not creating such a large unfunded mandate. It seems obvious that California could be forced to decrease coverage or decrease reimbursements for that coverage in order to close this gap.... OR charge these poor people an even higher enrollment fee. Texas made a different decision.

The plans are different... and all your sources are doing is looking at those who would be better off... IGNORING those who would be worse off.

The entire reason why Medicaid is administered by the states is because different states have different priorities. It should be very obvious that states like Minnesota cared a WHOLE LOT about coverage for the poor and states like Alabama only really cared that much about poor children and pregnant women. That could also mean that Alabama covered almost EVERYTHING for their children, while Minnesota perhaps only covered a few things.

Using Alabama's numbers as an example... the ONLY area where they weren't already really close to the 'expanded medicaid' rules was for coverage for poor parents (the children had coverage) and poor people without children.... where the cap was something like 25-50% of the FPL. I obviously can't speak for Alabama, but if I were designing such a plan, PART of the reason a state might decide not to cover these people is that the vast majority of them are young and healthy and not in need of much preventative care. It might be a better use of their funds to pay for care for these people in those rare instances where they need it through 'indigent care' funds, state run clinics (often tied to state funded teaching hospitals) or through charity organizations. If this is the premise around which you'd already built your healthcare system, then 'expanding medicaid' would only serve to gut all of that funding and all of those facilities that you have likely paid for using public funds. If you gut that funding, what happens to those facilities?

Your sources are looking at one metric alone (the definition of cherry picking) and ignoring all of they myriad of realities that could result in expanding medicaid to be the WRONG decision for a state or the people in it. 'Expanding' Medicaid in Minnesota actually resulted in a contraction of it. In California, it's resulting in a large unfunded liability. I'm not saying nobody should expand medicaid... I'm merely saying that just because it makes sense in SOME states doesn't mean it makes sense in them all... and just because it doesn't help 4mm people not to do so, doesn't mean that it couldn't hurt AT LEAST that many to do so.

Health insurance =/= covered costs =/= health care.

(05-12-2015 12:08 PM)Hambone10 Wrote:  

(05-11-2015 05:31 PM)dawgitall Wrote:  You are cherry picking. There are almost 4 million people in the US that are in the gap! Ten percent of them are in my own state. They don't qualify for medicaid and they can't utilize the tax credits.

NO friend, YOU are cherry picking. I admit that these 4mm people exist.... in states like my Alabama example (that didn't expand). YOU don't admit that in states like Minnesota where they USED to cover people under medicaid to 275% of the FPL, and now they only cover to 133% are people in exactly the opposite position. As I said, the BEST answer isn't the same for every state.... and YOUR sources are only looking at one subset.

HOWEVER, those 4mm people you note are STILL covered by funds like those authorized by DSH and other state funds for 'free' clinics (my mother is still a volunteer nurse in one of those). In Texas, they not only provide care to the 1mm working poor you mention, but to AT LEAST that many illegal aliens. Texas COULD expand medicaid, but then they would have less money to care for the numerous millions of illegals. Now, you may disagree with that choice... but that isn't your call.

I'd also point out that California is quite similar to Texas in both size and the number of poor and illegals... and California is projecting a $78mm deficit for Covered-California 2015-2016 as a result of the ACA, and State law prohibits them from using general state funds to cover it.... so while you might argue that California is 'better' than Texas for expanding medicaid, one could just as easily argue that Texas is 'better' than California for not creating such a large unfunded mandate. It seems obvious that California could be forced to decrease coverage or decrease reimbursements for that coverage in order to close this gap.... OR charge these poor people an even higher enrollment fee. Texas made a different decision.

The plans are different... and all your sources are doing is looking at those who would be better off... IGNORING those who would be worse off.

The entire reason why Medicaid is administered by the states is because different states have different priorities. It should be very obvious that states like Minnesota cared a WHOLE LOT about coverage for the poor and states like Alabama only really cared that much about poor children and pregnant women. That could also mean that Alabama covered almost EVERYTHING for their children, while Minnesota perhaps only covered a few things.

Using Alabama's numbers as an example... the ONLY area where they weren't already really close to the 'expanded medicaid' rules was for coverage for poor parents (the children had coverage) and poor people without children.... where the cap was something like 25-50% of the FPL. I obviously can't speak for Alabama, but if I were designing such a plan, PART of the reason a state might decide not to cover these people is that the vast majority of them are young and healthy and not in need of much preventative care. It might be a better use of their funds to pay for care for these people in those rare instances where they need it through 'indigent care' funds, state run clinics (often tied to state funded teaching hospitals) or through charity organizations. If this is the premise around which you'd already built your healthcare system, then 'expanding medicaid' would only serve to gut all of that funding and all of those facilities that you have likely paid for using public funds. If you gut that funding, what happens to those facilities?

Your sources are looking at one metric alone (the definition of cherry picking) and ignoring all of they myriad of realities that could result in expanding medicaid to be the WRONG decision for a state or the people in it. 'Expanding' Medicaid in Minnesota actually resulted in a contraction of it. In California, it's resulting in a large unfunded liability. I'm not saying nobody should expand medicaid... I'm merely saying that just because it makes sense in SOME states doesn't mean it makes sense in them all... and just because it doesn't help 4mm people not to do so, doesn't mean that it couldn't hurt AT LEAST that many to do so.

My source is the one you pointed to earlier as one of your sources. Did you even read it? The states that the bulk of these gap people come from are the very states offer the least in the way of Medicaid benefits and have some of the highest uninsured rates. Try as you might but your argument that these people and these states are somehow better off without expanded Medicaid is nothing short of ludicrous!!!!

(05-12-2015 02:42 PM)dawgitall Wrote:  

(05-12-2015 12:08 PM)Hambone10 Wrote:  

(05-11-2015 05:31 PM)dawgitall Wrote:  You are cherry picking. There are almost 4 million people in the US that are in the gap! Ten percent of them are in my own state. They don't qualify for medicaid and they can't utilize the tax credits.

NO friend, YOU are cherry picking. I admit that these 4mm people exist.... in states like my Alabama example (that didn't expand). YOU don't admit that in states like Minnesota where they USED to cover people under medicaid to 275% of the FPL, and now they only cover to 133% are people in exactly the opposite position. As I said, the BEST answer isn't the same for every state.... and YOUR sources are only looking at one subset.

HOWEVER, those 4mm people you note are STILL covered by funds like those authorized by DSH and other state funds for 'free' clinics (my mother is still a volunteer nurse in one of those). In Texas, they not only provide care to the 1mm working poor you mention, but to AT LEAST that many illegal aliens. Texas COULD expand medicaid, but then they would have less money to care for the numerous millions of illegals. Now, you may disagree with that choice... but that isn't your call.

I'd also point out that California is quite similar to Texas in both size and the number of poor and illegals... and California is projecting a $78mm deficit for Covered-California 2015-2016 as a result of the ACA, and State law prohibits them from using general state funds to cover it.... so while you might argue that California is 'better' than Texas for expanding medicaid, one could just as easily argue that Texas is 'better' than California for not creating such a large unfunded mandate. It seems obvious that California could be forced to decrease coverage or decrease reimbursements for that coverage in order to close this gap.... OR charge these poor people an even higher enrollment fee. Texas made a different decision.

The plans are different... and all your sources are doing is looking at those who would be better off... IGNORING those who would be worse off.

The entire reason why Medicaid is administered by the states is because different states have different priorities. It should be very obvious that states like Minnesota cared a WHOLE LOT about coverage for the poor and states like Alabama only really cared that much about poor children and pregnant women. That could also mean that Alabama covered almost EVERYTHING for their children, while Minnesota perhaps only covered a few things.

Using Alabama's numbers as an example... the ONLY area where they weren't already really close to the 'expanded medicaid' rules was for coverage for poor parents (the children had coverage) and poor people without children.... where the cap was something like 25-50% of the FPL. I obviously can't speak for Alabama, but if I were designing such a plan, PART of the reason a state might decide not to cover these people is that the vast majority of them are young and healthy and not in need of much preventative care. It might be a better use of their funds to pay for care for these people in those rare instances where they need it through 'indigent care' funds, state run clinics (often tied to state funded teaching hospitals) or through charity organizations. If this is the premise around which you'd already built your healthcare system, then 'expanding medicaid' would only serve to gut all of that funding and all of those facilities that you have likely paid for using public funds. If you gut that funding, what happens to those facilities?

Your sources are looking at one metric alone (the definition of cherry picking) and ignoring all of they myriad of realities that could result in expanding medicaid to be the WRONG decision for a state or the people in it. 'Expanding' Medicaid in Minnesota actually resulted in a contraction of it. In California, it's resulting in a large unfunded liability. I'm not saying nobody should expand medicaid... I'm merely saying that just because it makes sense in SOME states doesn't mean it makes sense in them all... and just because it doesn't help 4mm people not to do so, doesn't mean that it couldn't hurt AT LEAST that many to do so.

My source is the one you pointed to earlier as one of your sources. Did you even read it? The states that the bulk of these gap people come from are the very states offer the least in the way of Medicaid benefits and have some of the highest uninsured rates. Try as you might but your argument that these people and these states are somehow better off without expanded Medicaid is nothing short of ludicrous!!!!

While I am no expert like Ham, my first question to the above would be: "Did we reallly need this monstrosity that is the ACA when the main argument surely appears to be "Expanded Medicaid"?

Just raise taxes some and - expand medicaid. All the other is unnecessary unless the real end game is increased government influence and power at the federal level.

Oh yeah, not attempting to address the PCP doctor shortage makes all the other gyrations all but useless AND the reason why people are using ER's more now than before.

This law has done EXACTLY what Democrats at the federal level intended - increase their power and solidify a voting bloc. It's done very little to "solve the nation's healthcare problems" - but I'd surmise the Pelosi and company never intended to solve the problem.

(05-12-2015 02:42 PM)dawgitall Wrote:  My source is the one you pointed to earlier as one of your sources. Did you even read it? The states that the bulk of these gap people come from are the very states offer the least in the way of Medicaid benefits and have some of the highest uninsured rates. Try as you might but your argument that these people and these states are somehow better off without expanded Medicaid is nothing short of ludicrous!!!!

Of course I read it.

The difference between you and me is that I understand what it says.

You don't know enough to draw the conclusions you are drawing... and you're ignoring that the ACA takes medicaid away from people in states like Minnesota (and even much of the subsidies). Further, you assume that if they don't have medicaid, they don't have anything... while simultaneously talking about Federal funds (much less state funds) earmarked specifically for those people (like DSH) that are being reduced to pay for this.

Let me educate you a little more.

Texas covers newborns up to 198% of the FPL, 1-5 at 144% and 6-18 at 133% Pregnant women are also covered to 198%. Expanded medicaid would cap these all at 133%... meaning it would take coverage away from pregnant women and children that are between 133, 144 and 198% of the FPL (depending on the age of the child). You ignore these people in your calculation... focusing solely on those adults between 15% and 100% of the FPL not covered by Medicaid. You also ignore that those adults that earn 198% of the poverty level wouldn't qualify for a fully subsidized ACA policy... so they too would lose coverage... and you ignore it.

Now in exchange for that, it WOULD offer medicaid for those parents earning up to 133% of the FPL... and your link says this is 1mm people.

I don't know how many pregnant mothers and children under 5 you would be losing coverage for, but it is far > 0. That is a choice that you are ignoring. As I said, when you consider that unlike young children and pregnant women, most of those earning below 100% of the FPL don't need much healthcare (because by definition they aren't old or disabled, and almost by definition they are young)... I think that this is a pretty reasonable trade-off.. You can fairly disagree... but that isn't a ludicrous decision...

You are also ignoring California's example that these expansions are not without costs to the state. In California, it is estimated to cost $78mm more than they have allocated this year alone.

Oh, and surprise surprise... if you earn less than 100% of the FPL and YOU don't qualify, but one of your family members does (meaning you have a child or a pregnant wife), Texas (and most states) has HIPP, which is a STATE program to help you buy insurance (like the ACA subsidies) funded in part by (you guessed it) DSH payments.

In other words... while yes, many people will still fall through the cracks, it is usually so that you can cover others (mothers and children or the disabled) or investigate why a healthy adult can't earn above the FPL (less than 12k per year for an individual) before handing them 'free' stuff without question.

I'm not saying it is undeniably the right thing to do (not expand medicaid)... I'm merely laying flat your contention that it is ludicrous

What is ludicrous is that you have absolutely zero formal knowledge in this arena, getting all your information from news articles, yet you seem to think you know more than people who work in the industry.

(05-12-2015 03:37 PM)Hambone10 Wrote:  

(05-12-2015 02:42 PM)dawgitall Wrote:  My source is the one you pointed to earlier as one of your sources. Did you even read it? The states that the bulk of these gap people come from are the very states offer the least in the way of Medicaid benefits and have some of the highest uninsured rates. Try as you might but your argument that these people and these states are somehow better off without expanded Medicaid is nothing short of ludicrous!!!!

Of course I read it.

The difference between you and me is that I understand what it says.

bazinga!