If the grade (A-F) criteria were limited to 1) pre-ACA Medicaid eligible percentage enrolled (more is better) and 2) acceptance of the ACA Medicaid expansion, guess which state is at the top of the heap and bottom.
To help you out, here’s the kff Medicaid expansion table by state.
Two states would have ranked #1 and #3 if they hadn’t rejected Medicaid expansion. So, they fall to #25 and #26.
About #50 — it’s a small state. And it gets a considerable amount of attention on leftie blogs. Favorable attention.
Would it surprise you to know that many of the states that rejected Medicaid expansion we’re scoring higher on Medicaid eligible and many states that accepted the expansion? IOW many states with the least to lose and the most to gain, rejected the expansion. Dumb, dumb, dumb.
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In dead last (Grade F) is Montana. Maybe if he were still Governor, Brian Schweitzer would have gotten the legislature to go along with the Medicaid expansion. However, with 21.7% of pre-ACA eligible Medicaid beneficiaries not enrolled, his eight year role as Montana’s executive is nothing to be proud of. Forty-nine other states did better; although with 20.6% eligible and not enrolled, Nevada has nothing to brag about.
In general, the “reddest” and poorest states were performing better than “blue” states. Oklahoma with only 4.5% not enrolled was at #3.
The worst “blue” state at 15.4% not enrolled and ranking #48 was — get ready for this one — New Jersey. Accepting the Medicaid expansion will catapult NJ to at least in the middle of the pack.
At 3.2% Maine was #1. Alas, they are currently stuck with a governor that vetoed the expansion.
The winner pre-ACA Medicaid unenrollment of 3.5% and approval of Medicaid expansion is — drum roll please — West Virginia. Ta dah! Still comfortable with federal socialism even if the residents have stopped voting for it.
Check it out in this cool interactive map.
Slowly killing off public – safety net of last resort – hospitals and clinics. Many, if not all, have been struggling more than they ever did since the Clinton era Medicaid changes that allowed states to outsource Medicaid to private PPO and HMO insurance companies and to choose private, instead of public, medical care providers. It’s entirely possible that this change was revenue neutral for government Medicaid funding. If it’s correct that private hospital/doctor get the same reimbursement dollars as public hospital/doctor. What tends to make the news is that few private hospital/doctor accept Medicaid patients.
That, however, can’t be true as public hospitals such as LA County-USC began experiencing a decline in Medicaid reimbursement dollars when the change went into effect and as several public health doctors in Boston have been forewarning us, the financial position of public health hospitals will worsen with the ACA as it did in Boston with “Romneycare.”
Medicaid And A Tale Of Two Miami Hospitals by Sammy Mack, WLRN & HealthyState.org is a rare report on this shift.
While this is an informative report, it doesn’t explain why UM is competing for low reimbursement rate Medicaid patients. Neo-liberal politicians would say that it proves that competition works. Simple answers from simpletons.
The thing that always gets me is that we’re complaining that we pay too much for care; the prices, so to speak, are too high. So if that’s the case we should obviously be expanding free health clinics, federalizing Medicaid, and then expanding it (possibly even giving it back to true control rather than contracting it out as we do now with both Medicare and Medicaid).
However, then we’d get doctors and hospitals complaining that reimbursement rates are too low; something that I see resonating with both the left and the right. But the problem is prices are too damn high! So reimbursements NEED to be lower. What am I missing?
It’s all a total and costly mess. Finland’s health care model (developed after those UHC systems in western Europe and the UK) is uniquely robust. A key was local public health management/control and federal funding and macro-goals and quality oversight.
Granted that Finland is a small country, but several US states are smaller and their health care systems may be among the worst in this country.
I think that is the only answer that’s capable of working here because of how large and sparse the country is. We might even have to allow more dense centers to subsidize the more rural areas, similar to the Postal Service.
Plus, lots of European countries are small, but some areas aren’t exactly densely populated; they’re rural countrysides! Not as far-out as, say, Texas, but close enough to where the differences should be minimal.
I don’t mind “decentralization,” it just depends on how it’s done. Funding can only be done in a more centralized way; delivery? Go for more local control.
Also I like your diaries a lot. Keep writing them, please.
Just wanted to piggyback on this and say “me too.” Marie, Frank, and Oui consistently produce high-quality, well-thought-out diaries. Your work is appreciated. 🙂
Thank you. Even I need a bit of encouragement every once on a while.
No guesses on the state that earns an “A” and the one that flunked?
Jersey would have to have the highest enrolled pre-ACA. They had (and still have) the highest income eligibility requirements (highest meaning you can make a lot more and still qualify).
I know Alabama was something like $5k to enroll, which put it at dead last. Mississippi has to be close. I think Texas probably had the most to gain, given it’s got the highest uninsured…but I don’t remember their requirements.
You’re not even close to being correct.
Ha, doesn’t surprise me. Jersey people make a decent amount so maybe not many people need to be on it. I just don’t know the people number. I know California is gaining the most money and Florida stands to lose the most, that’s about it.
And on the note of reimbursement, my girlfriend’s father is a Republican doctor who owns his own practice. It’s just him, two nurses, and I think they’re bringing on a PA soon.
She agrees we need single-payer or some sort of more liberal reform than what we got, but we constantly get into arguments over reimbursement because she brings up his own finances that he “doesn’t make much for a doctor.” Apparently after expenses, he brings in $100k (he’s wealthy, but makes his real money from assets in the market rather from his practice). Apparently he takes in a lot of Medicaid/Tricare/Medicare patients, more than the usual, which is to blame for his lower pay for a doctor. I can’t say I sympathize much, as $100k in salary isn’t anything to sneeze at, but when you throw in MedSchool costs in there, it’s not really all that much. I think what eats into a lot of his overhead is malpractice insurance; I assume malpractice insurance would be a thing of the past with a more universal program and that expense would go away, though I’m not sure how much higher his salary would be as a result. And for all I know he (or she, which I doubt; prolly just repeating what he says) could be exaggerating his income to lower than it actually is.
Not sure where I’m going with this, but these discrepancies between people like her father and, say, specialists, need to be dealt with.
$100,000 is very low for a general practitioner in the US. Even new doctors working in community health clinics earn more than that. Overall IMHO primary care doctors are underpaid in this country — and specialists are overpaid. That has led to too few of the former and too many of the latter. But can’t see how such a rebalancing can be done through private insurance.
Sole practitioner is the least cost effective/efficient model for delivery of primary care. Necessary in small communities, and if integrated with county and/or state systems can be excellent and cost effective care.
Would need far more information to assess the claim of this physician.
Yeah that’s just it: I don’t know enough to truly assess the claims. I also think the $100k figure is extremely low, and likely deflated (even factoring in overhead such as malpractice, it just doesn’t sound right). I know he works with the local hospital, and splits his time between there and the office. Perhaps he’s saying he takes in $100k from his office alone, discounting anything he makes at the hospital as different income. Not sure.
Good guess as they would be separate business units. And if his solo practice is a part-time gig, his income isn’t off-the-charts low.
I think the average is $150K or $160K. The latter is twice Germany’s which is $83K according to that Liberal Rage, Forbes magazine. Also, according to Forbes, they don’t pay for college or Med School and every patient pays because everyone has Health Insurance which is paid by employers or by the State for the unemployed.
Here’s a NYT report.
Probably too many variables to conclude much. For example, are the average hours worked/week and vacation time in the US comparable to that in other countries? Forbes and the NYT shouldn’t be so lazy — they can present the financial value of that free medical school education over twenty years. They also sort of neglect to note that taxpayers in the US do subsidize a lot of the education for doctors, but that’s just another instance of socializing the costs and privatizing the profits.
If you are going to go European (which I heartily encourage) you have to have free MedSchool too.
I think it was actually Nixon (might be wrong) who proposed a ‘Medical School of the Armed Forces’ where poor but promising med school candidates would attend for free (paid for out of Defense budget) in return for X years as a military doctor and thus ending the doctor draft. (If you think 100K is low, look at an Army Captain’s pay). Of course, I’m proposing that the federal government pay the tuition of ALL US med students, perhaps at the Land Grant colleges like U of I only. I wouldn’t want to subsidize Harvard or God Forbid Bob Jones University.
Isn’t it appalling that in many ways Nixon was more Liberal than today’s Democratic Party? And if we accept those Southern Republican “moderates” it will only get worse.
There may not be a single feature of the health care policies in countries with UHC that doesn’t exist in the US. We just prefer to treat is like a cafeteria.
National Service Health Corps.
The physician shortage isn’t a bug but a feature of the US medical system since like forever. Medical schools have long been the gatekeepers.
Yes, Bakke had the wrong complaint. He complained that minority students with lower test scores than he were admitted while he was not. He should have complained that ALL qualified applicants weren’t admitted instead of arguing who should be thrown off the bus, he should have argued for a bigger bus!
We don’t like buses — too socialistic for “middle class” Americans who deserve big ass cars and trucks, but we don’t much mind chipping in a few (always less than needed) bucks to provide limited bus transport for “the poor” to get to jobs cleaning up after us.
We’re also cool with commuter and subway rail services as long as they were built about a century ago. In certain congested pockets where the collective we wants to get some of those damn commuters out of their cars, we bitch and moan so much that projects are delayed a few decades after they should have been built and cost five times more than they would have.
Bakke was raised to expect maximum white male privilege — the rules were slightly changed by the time he went to collect his entitlement. A few seats reserved for minority students made him cry. The competition that most likely bested him that was new were white women. (He was first rejected by two other medical schools based on his age, thirty-two. After winning his suit, he was admitted at age thirty-eight and graduated four years later. Have to wonder it he was cut some slack during training.)
He should have complained about the age discrimination too.
That was way too cutting edge in his time. Claims of “reverse discrimination” were easier because racism beats on in the collective hearts of Americans.
How does the expansion help states that already have requirements going beyond the 133% federal poverty-line baseline? Is it because despite their substantial and generous (relatively) baselines (Minnesota for example qualifies for a family of three with ~$42,000) aren’t enough to enroll everyone who is technically eligible?
Have no idea — but am sure the MN Medicaid administrator and the state treasurer has figured it out.
However, you raise a good point. It’s easy to forget that Medicaid is fifty different programs. It’s likely that the interactive map is only accurate for those states that complied with the pre-ACA federal minimum standards and no more — and some states are reporting enrollment numbers under their more liberal state guidelines.
Medicaid.gov may answer your question.
Do note that:
For the first time the income eligibility level is standardized at 133% of federal poverty level. The larger change under the federal guidelines is that adults can be covered without the need for qualifying individual such as a child. It’s that piece that has possibly opened the door for states to enroll prisoners.
Ah, the child aspect might be the answer indeed. That is why I guessed New Jersey…theirs you need ~$39,000 or less (family of 3) to qualify.
So by the family calculation, NJ is more generous than the new federal standards. However, individually…
“An individual is eligible for community Medicaid in New Jersey if his/her gross monthly income is equal to or less than $903.”
NJ pre-ACA: $10836
NJ post-ACA: $15281.7-15856.2