States moving ahead with ACA Medicaid expansion, and, where poor and uninsured live

Discussion in 'Politics, Religion, Social Issues' started by jnpy!$4g3cwk, Dec 1, 2013.

  1. jnpy!$4g3cwk, Dec 1, 2013
    Last edited: Dec 1, 2013

    jnpy!$4g3cwk macrumors 65816

    jnpy!$4g3cwk

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    #1
    The following article/table gives somewhat current status of states moving ahead with the Medicaid expansion. Presumably, better states to live in if you are poor and in need of medical care:

    http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

    Legislation authorizing the Medicaid expansion has been signed into law:

    Arizona
    Arkansas
    California
    Colorado
    Connecticut
    Illinois
    Iowa
    Maryland
    Massachusetts
    Michigan
    Minnesota
    New Jersey
    New Mexico
    New York
    North Dakota
    Ohio
    Rhode Island
    Washington


    Moving forward, governor supportive:

    Delaware
    District of Columbia
    Hawaii
    Kentucky
    Nevada
    Oregon
    Vermont
    West Virginia



    Not moving forward at this time:

    Alabama
    Alaska
    Florida
    Georgia
    Idaho
    Indiana
    Kansas
    Louisiana
    Maine
    Mississippi
    Missouri
    Montana
    Nebraska
    New Hampshire
    North Carolina
    Oklahoma
    Pennsylvania
    South Carolina
    South Dakota
    Tennessee
    Texas
    Utah
    Virginia
    Wisconsin
    Wyoming
    Here is a pointer to a series on the NPR website on the ACA:

    http://www.npr.org/series/231423897/the-affordable-care-act-explained

    An article in the NYT on where the poor and uninsured live, by state, and, their occupations:

    http://www.nytimes.com/interactive/2013/10/02/us/uninsured-americans-map.html


    [​IMG]
     
  2. localoid macrumors 68020

    localoid

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    #2
    Interesting article and map.

    Can't wait to hear the comments from the Free Market proponents about the job groups cited in the graphic below and the bootstraps blah-blah bootstraps speeches...
     

    Attached Files:

  3. VulchR macrumors 68020

    VulchR

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    #3
    Interesting graphic, but I do not like the colors used in the heat map. There should be one color in the percentage ramp in order to portray the pattern honestly. The way the map is shown now artificially contrasts the red and green areas, and the choice of the white midpoint could be set easily to emphasize patterns that are very weak. We get this kind of distortion a lot in my field of neuroscience, particularly when people fiddle with color ramps of heat-map-style brain scan images.
     
  4. jnpy!$4g3cwk thread starter macrumors 65816

    jnpy!$4g3cwk

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    #4
    A nice list of Mitt Romney's "takers": all the people in all those dirty jobs, getting paid minimally for it, and needing healthcare subsidies.


    I agree. I don't think the colors do justice to the data. You have to look carefully at that graphic to see what it really means.
     
  5. erickkoch macrumors 6502a

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    #5
    Medicaid expansion is not the happy solution many of you seem to think it is. One of the problems is that it tries to control costs using "price control" or caps on reimbursement for medical services that do no cover actual costs. Costs and Price are not the same thing. As medicaid expands (along with its reimbursement caps) more hospitals will lose money. Already about 1/3 hospitals in the US lose money. I work for one of those.

    Also not mentioned is the fact that the US is facing a doctor shortage and more doctors are leaving private practice or retiring, fed up with reimbursement rates that do no cover costs (shortage of 50,000-60,000 MD's I think). Adding 20-30 million more people to the system is not going to help. Healthcare quality will deteriorate, it takes about 10 years to train a typical doctor, 4-6 years for an RN (not sure how long it takes to plan and build a hospital). Without new doctors, each MD will spend less time with their patients, this is unavoidable. RN's and Nurse Practitioners will be pressed into service. Combine this with the fact that an increasing number of doctors are not accepting medicaid patients and HMO private insurance because of low and/or delayed reimbursement (for example, my podiatrist is one of those, good thing I have PPO insurance).

    The bottom line is this issue us much more complex than any of us realize and simply putting millions of people on some kind of government insurance program is not a panacea.

    It would be good to hear from other medical workers on this forum and get their perspective. I work in a hospital lab.
     
  6. lannister80 macrumors 6502

    lannister80

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    #6
    But it works pretty damn well in most other first-world countries. What makes the US different in that Single Payer (medicaid for all) can't work here?
     
  7. MacNut macrumors Core

    MacNut

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    #7
    There are already bed shortages in hospitals and Dr offices are jammed packed. Can we handle the uptick in demand?
     
  8. Huntn, Dec 4, 2013
    Last edited: Dec 4, 2013

    Huntn macrumors G5

    Huntn

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    #8
    Is there a solution in your view?

    Do we stop people from getting free emergency room care? I'd rather see a program where everyone or at least a higher percentage is covered instead of passing these costs on to a smaller number who do have insurance.

    Why is Health Care so expensive in the U.S. as compared to the rest of the world? Is it because it's a for-profit business, with lobbyists and politician's in corporation pockets? It appears to me, this is what the GOP is currently defending.

    I can tell you from my wife's experience- 45 minute gall bladder operation (2010), bill from surgeon alone: $22,000. Of course I did not pay that, Blue Cross knocked it down to a measly $9000. Not bad for 45 minutes of work... :p Note, this was just the surgeon's bill and did not include the other participants or the hospital bills. I paid a total of $2000. Blue Cross paid the rest.

    Can anyone offer a reasonable excuse why heart bypass surgery is 900% more expensive in the U.S. as compared to Argentina?

    Huffington Post: Why U.S. Health Care Is Obscenely Expensive, In 12 Charts

    1 of 12 charts:
    [​IMG]

    6 of 12 charts:
    [​IMG]

    8 of 12 charts:
    [​IMG]
     
  9. MacNut macrumors Core

    MacNut

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    #9
    A lot of people go to the ER when there is no reason too. The common cold, a headache. Leave the Hospital for the real dire emergencies. This is why the system is so stressed.
     
  10. zioxide macrumors 603

    zioxide

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    #10
    Many of these hospitals are losing money because they're treating tons of people who are uninsured, many of them for simple ailments that they could just get taken care of at a general practitioner if they had insurance.

    Getting these people insurance so they can just go see their local primary care physician instead of going to the ER when they have a cold, bronchitis, the flu, an ear infection, etc etc. will save tons of money since ER visits in many places cost 10 times (or more) what a visit to a GP costs.
     
  11. MacNut macrumors Core

    MacNut

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    #11
    Do we know the breakdown of people who are insured that still waste hospital resources?
     
  12. erickkoch macrumors 6502a

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    #12
    Does it? What is the quality/quantity of healthcare in these countries vs cost? Take England for example. I've read that the doctor shortage there is so acute that they are bringing in physicians from India (any of our English members want to confirm this?) Why do Canadians travel to the US for healthcare but rarely to US patients go to Canada for treatment? Why do Japanese give "gifts" to doctors to be move up in queue for treatment?

    In addition to under the table or off book costs such as sacrifices in quantity (shorter visits) or quality (from imported doctors) the long waits for treatment are another cost.

    For example, it's well known that in some of these first world countries (England and Canada, I think) it can take many months or even a few years before you can get a knee or hip replacements vs a few weeks in the US. What are the costs in pain and suffering, lost wages from calling out sick from work, decreased productivity or being disabled pending surgery?

    These and many other things are "costs" that are never really tabulated when we think about healthcare. Merely presenting a chart showing how much citizens pay a year for healthcare in other countries and comparing it to the US is meaningless unless you factor these and many other things in.

    Healthcare issues are not as simple as just putting someone on insurance. This is a very complex issue.
     
  13. erickkoch macrumors 6502a

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    #13
    This is what is sometimes referred to as "stage one thinking." We have to think about "stage two", "stage three", etc.

    Insurance isn't the issue. Costs have to be paid. Medicaid doesn't cover all to the costs so the costs have to be shifted when they can. Charging more for insured patients, for example, or cutting quality and quantity. So, merely getting everybody insured won't fix the problem if it does't cover the costs.

    But now think about "stage two". When an uninsured person suddenly has insurance they will typically go to a primary care physician instead of the ER (which would save lots of money). But, they go to the doctor for lots of other things and more often. This is where the costs start to increase. Many will say, "good, that's what insurance is for", but it drives overall healthcare costs up because it is increasing the overall use of the healthcare system. In France this problem has inundated it's healthcare system with elderly seeking medical treatment for every ache and pain when what they really want is attention and human contact.

    I have no problem with sick people going to the doctor when they need to (no reasonable person would) but the costs have to be paid. This is the part where we are burying our heads in the sand.
     
  14. zioxide macrumors 603

    zioxide

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    #14
    Because the US has some of the very best hospitals in the world?

    Of course, just because we have the best hospitals doesn't mean we have the best system to pay for them.

    By all indications, we have one of the worst. When you pay double as a percentage of GDP as your most comparable nations, you can't deny there's a major problem.

    But preventative care is a hell of a lot cheaper than emergency care. The idea is to get people going to the GP regularly to stay healthy and prevent them from needing emergency treatments that cost way more.

    Obviously you'll never eliminate all people needing emergency treatment, but there's so many people who have conditions that they need emergency treatment for that could have easily been prevented if they had a regular doctor that they saw every year.
     
  15. MyMac1976 macrumors 6502

    MyMac1976

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    #15
    There is universal healthcare in more than just the UK..
     
  16. MacNut macrumors Core

    MacNut

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    #16
    So where is all that money going and how do we stop it. If we can make the healthcare system cost less we would not be in this mess. Even with the government in charge there will still be cost overruns
     
  17. VulchR, Dec 4, 2013
    Last edited: Dec 4, 2013

    VulchR macrumors 68020

    VulchR

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    #17
    First, if there is a shortage of doctors then why not allow qualified doctors from India or any other place in the world immigrate? The insinuation that India's doctors aren't up to our standard is ironic since a family member of mine who lives in the US but who is uninsured had to travel to India for knee replacements. He did so because the complication rate was lower in the Indian hospital than the local ones around DC, and it was cheaper to fly there first class and have the surgery done than to get it done in the US. Anyway, one of the reasons why the market fails in the US is that the AMA has a stranglehold on physician licensing. Why should they allow foreign doctors compete with them? The AMA is worse than any labor union in artificially jacking up their wages.

    Second, in the UK life expectancy was higher than the US a few years back. It's roughly even now, but the UK spends about one-half per person on medical care than the US. That's right, the same outcome for half the price. Also for the record, the US spends about as much per person of public funds for medical as does the UK. Put frankly, the US is not getting value for money in its health care. American exceptionalism indeed....

    Third, with respect to the waiting times in the UK, the policy is the maximum is 18 weeks. Due to the right-wing government budget cuts, though, sometimes hospitals use bureaucracy to circumvent this rule. However, if there is an emergency and the suffering is acute, triage allows for shorter waiting times (as low as one week in one case I know of). Finally, if one does not want to wait in the UK system, one can use private health care, including care that is provided by private insurance. In the UK we get all the benefits of public and private health care, yet in the US we (I am a US citizen) are denied the benefits of universal public health care.

    Fourth, your point about lost days and suffering are absolutely valid. Indeed, one of the criticisms of Obamacare is that the cost of the insurance companies provide for workers has increased, so one would think that the argument against universal health care based on business economics would be strong. However, companies in the UK do not have to worry about providing health cover because there is universal health care paid for by taxes. Moreover, I'd like to know what the economic costs of lost days are in the US from people unable to work because they cannot afford medical insurance to pay for treatment - are you really sure that economic loss in the US due to illness is less than in the UK? Have you factored in that health care in the US is twice as expensive as it is in any other developed country?

    Because I care about my country, I beg of you, do some research and educate yourself. There is an article about US health care costs based on OECD data here. An OECD publication describes briefly the UK health care system (see here).
     
  18. erickkoch macrumors 6502a

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    #18
    You bring up some valid points but I'll reply to some of your concerns.

    As for Indian doctors, this issue is not one I created but has been brought up in the UK itself. Here is just one article from the Telegraph in the UK bringing up this concern.

    Source: http://www.telegraph.co.uk/health/healthnews/10261859/Fears-over-patient-safety-if-cut-price-doctors-hired-from-India.html

    I don't have a problem with Indian doctors per se, my primary care physician is from India and my anesthesiologist used by my podiatrist is one also, the point is that the physician shortage in the UK is pushing this trend towards importing doctors from 3rd world countries where the quality of their is not so easy to monitor as one educated and licensed in the UK or US.

    As for the AMA, I tend to agree with you, you make a good point.

    As for life expectancy being higher in the UK or other EU countries, this is not so cut and dry. The problem here is that you are confusing Medical Care with Healthcare (I myself use the terms interchangeably). The issue is that life expectancy has much to do with diet, exercise, smoking, drinking, medical care, genetics, crime and violence, etc. What would the life expectancy be in the US if Americans stopped smoking, ate a Mediterranean diet, became more active, were less violent, or had the genetics of Ashkenazi Jews? Do you see my point?

    Your 3rd point about wait times. I googled "wait times in the UK vs US" and came across some rather unflattering articles about both systems but my criticism stands. Having a policy of 18 weeks maximum wait is not always a reality but it's good to see that the UK is trying to do something about it.

    As to your 4th point, it is a common misunderstanding to think that not having insurance means you don't have medical care. An unemployed friend of mine with no money or insurance was hit on his bike by a car and got full medical treatment. People without medical insurance get healthcare all the time, I worked for a time at a Los Angeles County hospital. The treatment they got was not so great, long waits (sometimes waiting all day to see a doctor) but by law, nobody in the US can be turned away. The costs are passed on to the rest of us through taxes and higher insurance premiums. At my hospital patients who have no insurance are sent to a financial counselor to assess ability to pay, if they can't pay anything the costs are written off as bad dept.

    You do make a good point about economic loses from uninsured being sick and not getting timely treatment or not seeing a doctor at all. This affects productivity as much as long waits in the UK. I never thought about that. Just goes to show you that these are complex issues.

    I looked at your link, it's statistics I've seen before, price comparisons are meaningless unless you include all pertinent factors of quality, quantity, subsidies, drug costs (the US subsidizes the lower costs to much of the world, hidden costs like bribery and gratuities, black market medicine, so many other things.
     
  19. erickkoch macrumors 6502a

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    #19
    There are no solutions in an absolute sense, only tradeoffs. We can require no elimination for preexistent conditions, but it's going to costs more, include mental health, but it's going to cost more, not lifetime caps, but it's going to cost more, coverage for sex reassignment surgery, but it's going to cost more, you get the idea.

    The problem is that the govt has promised more healthcare at lower costs. It can't do this with our current medical infrastructure. It needs to be honest about how much MORE it will costs so we can make a rational decision as to what we are willing to pay for with regards to quality and quantity of healthcare.

    As to the issue of why it costs more 900% more in the US for surgery than Argentina, that's more complex. The costs for surgery are related to hundreds of thing, costs of the building, surgical equipment, energy, drugs, personnel training and education, taxes, regulatory requirements, imaging equipment, and a hundred other things.
     
  20. Huntn macrumors G5

    Huntn

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    #20
    Right! We have to look at why we have the highest health care costs in the world, which I don't see anyone tackling that, especially not the big corp GOP. Dems are not blameless, but as long as medicine is for profit, big profits, we'll have big problems. Yes, I know easy for me to whine. Easier to spot a problem than fix it.
     
  21. Eraserhead macrumors G4

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    #21
    But it also costs more than the UK or even the Netherlands where they have a very generous welfare state.
     
  22. VulchR, Dec 5, 2013
    Last edited: Dec 5, 2013

    VulchR macrumors 68020

    VulchR

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    #22
    Interesting post, but just a few things...

    Please understand that the article appears in a right-wing, xenophobic tabloid paper and that it is based on patient anxiety and prejudice rather than any evidence. The last foreign physician that got into trouble that I remember was a German. I know a physician in Switzerland who is the head of a large cosmopolitan hospital's emergency department. He has family in the US, but he cannot practice there because it would require him to start over even if he passed all of the examinations. That makes no sense to me, particularly since rich Americans often fly to Switzerland for his neurology clinics.

    Yes I do. Obesity certainly is a factor that lowers life expectancy in the US (that alone tells us something: not enough preventative approaches are taken in the US, although it sounds to me like this is changing). However, one can look at other statistics, like lower limb amputations form diabetes, or asthma attacks, and still the US appears to be spending more money for outcomes equivalent to countries that spend less money.

    Honestly my personal experience of both the UK and US health system is that both can be frustrating, but if you really need to be seen due to pain or a life-threatening illness, you get seen pretty quick. For everything else, I personally do not mind being triage'd if it means that everybody has a fair chance to get decent healthcare. The only thing that the US really does much better than the UK is provision for the treatment of mental illness (indeed perhaps the US system overreacts in this regard).

    Exactly. The US pays the same from public funds per person for health care as the UK, yet the money does not provide universal health care and it could. Many of the people who are seen in the emergency rooms in the US are there because they cannot afford to have a regular family doctor, of they have conditions that have become life-threatening because they do not get regular medical care. If these people were treated earlier, the costs would go down, which is the experience of many developed countries, not just that of the UK.

    Perhaps. Yet the available evidence suggests that the US is exceptional in paying enormous sums for health care outcomes that do not seem to match that investment. Of course any health care data set is incomplete, prone to errors, and difficult to interpret. However, at some point the weight of evidence is sufficient that failing to accept a conclusion supported by that evidence (e.g., the US health care system is poor value for the money spent) becomes a violation of parsimony.

    FWIW - I apologize for the tone of the previous post, and I am grateful for the tone of yours. This issue really gets to me because of my personal experiences with members of my family. I am frustrated because I believe that the US has enough resources to make sure every citizen gets decent health care rather than just emergency treatment. As a friend of mine once said after visiting the US for the first time 'So many garages for dead [inanimate] cars, so many homeless....'

    EDIT: Link to NYT story on cost of ambulance services in the US can be found here.
     
  23. PracticalMac macrumors 68030

    PracticalMac

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    #23
    Question is:

    Would you rather go back to the way it was before?


    ACA will need to change, but with the BS in Washington, will it be improved?
     
  24. erickkoch macrumors 6502a

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    #24
    I work for a non-profit hospital run by the Catholic Church. Another common misconception is that "non-profit" means the hospital provides medical services "at cost". This is not true. "Non-profit" is a tax status, all hospitals, like all businesses, need to make profit to survive, invest in new capital equipment, infrastructure, recruit personnel, etc. Non-profit hospitals put the profits into these. For-Profit hospitals do the same but also must pay investors/stockholders, etc.

    I've never worked for a profit making hospital before but if non-profit hospitals were significantly cheaper than for-profits the non-profit facilities would dominate and put the for-profit hospitals out of business. This doesn't seem to be happening.
     
  25. erickkoch macrumors 6502a

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    #25
    Sorry, I didn't know the UK had "Right Wing" vs "Left Wing" rags like the US. I can't tell the difference from this side of the pond. I tend to trust overseas news when the source link has "UK" or "BBC" and such.

    Don't worry about the tone, we're here to learn from each other, "Iron sharpens Iron as one man sharpens another," as the Bible says. I too have friends and family without insurance and yes, it is frustrating.
     

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