Letter: Health reform needs people

As a transplanted New Yorker, I was bemused to read U.S. Rep. Bill Cassidy’s depiction of my home state’s Medicaid expenditures for disabled people as “gaming the system,” and his comparison of Medicaid to “heroin addiction.” (“Cassidy pushes heath plan,” Dec. 9) But if Rep. Cassidy’s ideas can help poor people in Louisiana get Medicaid coverage, then I welcome his remarks.

New York spends a lot on Medicaid, but as a high-income state, the federal share of these expenditures is lower than for other states. Louisiana is a middle-income state and has a higher federal share. But Louisiana is very reluctant to extend Medicaid to poor people and has refused federal money for Medicaid expansion.

The standard by which we can measure the health-care system, including Medicaid, is whether people get the care they need as efficiently as possible. By that standard, U.S. health care does very poorly in comparison with other wealthy countries. Louisiana’s high rate of uninsured residents indicates that many people fail to get the care they need. Also, as Rep. Cassidy reminds us, if doctors refuse to care for indigent patients because they are not paid enough to provide care, this too is a problem.

Rep. Cassidy’s proposal might help states to provide care. But the proposal is puzzling, although perhaps it has not been clearly described. A per capita cap on Medicaid expenditure for disabled people is a bad idea if the cap is too low for disabled people to get the care they need.

Efficiency in health care requires thinking about how people can get the care they need. For example, if Medicare eligibility age is raised from 65 to 67, as has been proposed, more people would die prematurely as a result, and only a small amount of money would be saved, if any. So raising the Medicare eligibility age would be inefficient.

There are basically two ways of cutting health-care costs:

The first is by denying care to people. The second is by changing the system to ensure people get the care they need, and money is not spent for other things, such as unneeded care or insurance company overhead. Various parts of the Affordable Care Act (also known as Obamacare), including accountable-care organizations and the independent payment advisory board, are intended to do the second of these.

But if health-care reform is going to work, this will require the cooperation of both doctors and patients, and that is not done just by making a law.

Aaron Lercher

librarian

Baton Rouge

Comments

1) Comment by bourbon-soda - 16/12/2012

This is not much a conundrum. One criterion for deciding whether correlation is likely to be a manifestation of causation is, is there a plausible mechanism that would explain causation? In the case of debility and death from old age, the Second Law of Thermodynamics works pretty well.

2) Comment by Scrooge - 14/12/2012

Medicare is for the elderly who are at the greatest risk of expense, many ( a majority) would be unable to get affordable coverage if at all. What responsible insurance company would insure certain bad risks? Isn't this a question of social responsibility? Purely objective analysis means putting your dying grandmother out on the street to save money. That's what they do in Somalia with their Somalian educations. Such a wonderful model. Of course, equating old age with health and fatality risk is a correlation vs causation conundrum, right?

3) Comment by bourbon-soda - 14/12/2012

No can't have people taking care of themselves with insurance they think is appropriate, or none. If you can't opt out of Medicare and it's means-tested it's just another graduated redistributionist tax equivalent.

4) Comment by DMJ - 14/12/2012

Well...it's not.

5) Comment by bourbon-soda - 14/12/2012

Hubert Humphrey rejected means-testing of Medicare because in decreases the program's usefulness as a wedge for socialization. The healthy and wealthy, and even the healthy and not so wealthy, might opt out of it, if that remains permissible in the land of the free.

6) Comment by DMJ - 14/12/2012

Pville, I don't want to increase the debt. In fact, I agree with what Mitt Romney and some Congressional Republicans have proposed: means testing Medicare. This would be unpopular with those concerned about taxing the "job creators" but it would be a very progressive step and a needed one, in terms of the spending to revenue ratio for Medicare. And by the way, that "crippling of future generations" would include me. I'm not eligible for Medicare for decades still. I'm more than willing to put my Medicare where my mouth is.

7) Comment by bourbon-soda - 14/12/2012

A lot of people who can understand their work product being taken so people do not die from lack of care, but to try to satisfy everyone is another order of magnitude.

8) Comment by yadodge0501 - 14/12/2012

The British and Australian Single Payer system remains the Ideal health structure by which all others and the US system should be measured. It is not a question of people getting the care or not, dying from lack of care, etc. It is a question of being satisfied with the level of care. People still die and still suffer with or without care. The cheapest and most efficient medical care is still to "cut the head off". But most people here are not satisfied with the care they get and the cost of it. Medicaid, Medicare, Obamacare debacle remain useless creations that take taxpayer money to patch up the uneven Medical system for a few special groups

9) Comment by InPVille - 14/12/2012

@Dawson: Good point about government diminishing compensation for Medical professionals. Big government types typically fail to consider that changes they make cause changes in the behavior of those impacted by their changes. When they make it less profitable to be in a profession, it will discourage people from being in that profession. Given the years of study and the debt taken in to become a doctor or expert in creating the medicines and devices used by the medical profession, if there is little economic reward to be had, fewer people will go into those fields. Instead of having more medical care and the things needed to provide that care available for the sick, there will be less.

10) Comment by InPVille - 14/12/2012

@DMJ: "The difference is WHERE the money is spent... on private health providers, insurers, pharmaceutical companies, rich people's tax breaks, etc? Or on health care for the poor and elderly? I know which way my conscience points me... " -[**]- I guess then, since the government has for the past decade been spending far and above what available revenue would allow, your conscience points you to creating a level of national debt which will cripple future generations of Americans all in the interest of feeling better about yourself in the near term. So much for the ethos of the past when people sacrificed and did without so their children could have the opportunity for a better life than they themselves had.

11) Comment by bourbon-soda - 13/12/2012

@Dawson - the now unfashionableHippocratic Oath includes " I will not give to a woman an abortive remedy."

12) Comment by bourbon-soda - 13/12/2012

The Church of Sociology will appropriate the old Catholic idea and decide what is a "just wage."

13) Comment by Dawson - 13/12/2012

@Twinkie..so how much does a doctor "need"? How about a plumber? How about a bus driver? Are you the one that decides how much time and effort someone wishes to spend on their livelihood to determine how much someone "needs"? Here is a plan, you take your skill set and maximize your earnings and I will take my skill set and maximize mine. You pay for your health care and I will pay for mine. Wouldn't that be a novel idea.

14) Comment by Dawson - 13/12/2012

DMJ..hate to break it to you but a tax "break" is not spending money. The government can't spend money it never collected. I know King Obama does it all of the time but that doesn't mean its real.

15) Comment by Dawson - 13/12/2012

Slave=a person who is property of or subject to another. Slavery is bad, right? But at the same time, a physician or health care provider is forced to care for a person for no compensation? If the government forces someone to do something for another (which is what Obamacare does) how can freedom loving people see this as a good thing? Government coercion is never a good thing.

16) Comment by NearBarbarian - 13/12/2012

What Mr. Lercher's letter is reminding us is this: healthcare is a matter of ethics, not just economics. To take it a step farther, ethics should be primary, economics secondary. And two words for "Doctor" Cassidy: Hippocratic Oath.

17) Comment by DMJ - 13/12/2012

The difference is WHERE the money is spent... on private health providers, insurers, pharmaceutical companies, rich people's tax breaks, etc? Or on health care for the poor and elderly? I know which way my conscience points me...

18) Comment by InPVille - 13/12/2012

@DMJ: "They're Republicans. It's all about money." -[**]- For Democrats it is all about money too. . . Spend, Spend, Spend. Unfortunately both parties have too many members with this mindset. Earmarks are a big problem. . . from the same report as below. "Eliminate all congressional earmarks. In FY 2010, Congress approved more than 9,000 earmarks costing taxpayers close to $16 billion. Earmarks are not competitively bid and are not subject to accountability mmetrics, making it difficult to measure effectiveness or conduct cost-benefit analysis."

19) Comment by InPVille - 13/12/2012

The report I just cited says this on "gaming the system": " On Page 40 of 66 "Medicaid Savings 3.3.8 Eliminate state gaming of Medicaid tax gimmick. (Saves $5 billion in 2015, $44 billion through 2020) Many states finance a portion of their Medicaid spending by imposing taxes on the very same health care providers who are paid by the Medicaid program, increasing payments to those providers by the same amount and then using that additional "spending" to increase their federal match. We recommend restricting and eventually eliminating this practice." -[**]- So it isn't something Rep Cassidy just made up.

20) Comment by InPVille - 13/12/2012

http://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/TheMomentofTruth12_1_2010.pdf Report of White House National Commission On Fiscal Responsibility And Reform Preamble "Throughout our nation’s history, Americans have found the courage to do right by our children’s future. Deep down, every American knows we face a moment of truth once again. We cannot play games or put off hard choices any longer. Without regard to party, we have a patriotic duty to keep the promise of America to give our children and grandchildren a better life. Our challenge is clear and inescapable: America cannot be great if we go broke. Our businesses will not be able to grow and create jobs, and our workers will not be able to compete successfully for the jobs of the future without a plan to get this crushing debt burden off our backs." . . . "Economic recovery will improve the deficit situation in the short run because revenues will rise as people go back to work, and money spent on the social safety net will decline as fewer people are forced to rely on it. But even after the economy recovers, federal spending is projected to increase faster than revenues, so the government will have to continue borrowing money to spend. The Congressional Budget Office (CBO) projects if we continue on our current course, deficits will remain high throughout the rest of this decade and beyond, and debt will spiral ever higher, reaching 90 percent of GDP in 2020. Over the long run, as the baby boomers retire and health care costs continue to grow, the situation will become far worse. By 2025 revenue will be able to finance only interest payments, Medicare, Medicaid, and Social Security. Every other federal government activity – from national defense and homeland security to transportation and energy – will have to be paid for with borrowed money. Debt held by the public will outstrip the entire American economy, growing to as much as 185 percent of GDP by 2035. Interest on the debt could rise to nearly $1 trillion by 2020. These mandatory payments – which buy absolutely no goods or services – will squeeze out funding for all other priorities."

21) Comment by twinkie1cat - 13/12/2012

Medicaid and Medicare would not cost so much if doctors and drug companies did not practically try to make a year's salary off of each patient. Why do they need more than $250,000? Why does any CEO type or state Department leader need more than that?

22) Comment by twinkie1cat - 13/12/2012

And what do you really expect from a Republican? They are greedy, selfish people who like to put on a show of their generosity, like the Bible story of the rich people putting money in the offering box. Cassidy should especially be held to task because he is a doctor. I do not see how a doctor could ever be one of those. That is even worse than a teacher being one. His attitude is hurting people and, just like Jindal, he needs to go.

23) Comment by 8point6 - 13/12/2012

@agagent: My "progressive" friends won't ever "get it", no matter how many facts you throw at them.

24) Comment by agagent - 13/12/2012

Here is data from Medicare: "When Medicare Part A was enacted in 1965, costs were projected to rise to $9 billion by 1990, but actual costs reached $67 billion by 1990.12 Or consider that when the Medicaid special hospitals subsidy was added in 1987 annual costs were projected to be $100 million. By1992 costs had risen to $11 billion annually."--Cato Institute

25) Comment by agagent - 13/12/2012

Maybe Medicare cost 7 times its projected cost . . . typical of programs designed in Washington.

26) Comment by agagent - 13/12/2012

The federal government has no money for Medicaid expansion. States cannot afford it either, and Medicaid does not provide proper care for its participants. Obamacare is even more onerous. The federal government could have given free health insurance to all the uninsured, and it would have cost a lot less than the cost of Obamacare. We do not know Obamacare’s true cost as it now appears to cost almost twice what was first estimated. Didn’t Medicare cost about 9 times its estimated cost through its first 10 years?

27) Comment by agagent - 13/12/2012

Getting out of government run schools makes you more dependent on government? Many parents who accept vouchers must pay additional money to educate their children. Also the voucher cost the taxpayers less than educating a child in public schools.

28) Comment by swinham - 13/12/2012

Most people attacking Mr. Lercher take the usual approach of demagoguing and regurgitating the same tired and selfish philosophies. They totally ignore his last sentence and main point ["But if health-care reform is going to work, this will require the cooperation of both doctors and patients, and that is not done just by making a law."]. Of course, human nature and greed being what they are, this would seem idealistic - but no less right.

29) Comment by DMJ - 13/12/2012

I'll say it again... Republicans, such as Cassidy, have no interest in covering everyone. This would keep costs down, which means Cassidy and his colleagues would make less money. They're Republicans. It's all about money. Do they have to come right out and say it for people to recognize??

30) Comment by gary - 13/12/2012

@scrooge: beat me to it - it is the who's ox is gittin' gourd. Vouchers is an excellent example - talkin' bout guverment messin' with us. What do they call it - hypocrital or something like that.

31) Comment by Scrooge - 13/12/2012

You are right agagent, don't vouchers do the same thing by making "them dependent on government' and "invite waste, fraud, and abuse"?

32) Comment by agagent - 13/12/2012

Expanding Medicaid to those making 138% of the poverty level puts many with median incomes, who had paid for their own health insurance, in government-run health care, and make them dependent on government. In fact 138% of the poverty level would include millions more in an already unsustainable Medicaid system.

33) Comment by agagent - 13/12/2012

Medicaid has created an entire legal industry: lawyers working to make people cash poor to enable them to collect Medicaid. It is not illegal. It is just an example of the way cumbersome laws, such as Medicaid, invite waste, fraud, and abuse.

34) Comment by agagent - 13/12/2012

The Advocate reported that 75% of all births in the state where paid for by Medicaid. That should give you a hint that people are abusing Medicaid since the poverty rate is about 20%. A recent report cited the federal government “misdirecting” over $100 billion a year: payments to the wrong party, the wrong amount, to dead people, and sometimes they do not know where the money went. Sometimes the fraud is caught and we see it announced in the papers, but that could be the tip of the iceberg. And then there is the inefficiency of paying for the federal bureaucracy and funding ineffective programs. Even Obama said he could save $900 billion from Medicaid and Medicare through “improved efficiencies” when he was looking for ways to fund Obamacare.

35) Comment by jdk944 - 13/12/2012

Mr. Lercher, the policies of your old state, New York, have put them on the brink of bankruptcy and thousands of wealthy New Yorkers are now in other states. Those of your mindset still DON'T GET IT. This country is all but bankrupt as well, by your kind of thinking and yet, your solution is to just continue providing more benefits and pushing this issue down the road. Yea, right!!

36) Comment by postscript56 - 13/12/2012

Republicans had twenty years from the defeat of "Hillarycare" to the passsage of the ACA to address health care issues in this country. They did nothing except mumble about the virtue of the free market and watch the situation grow worse. So every last one of 'em needs to sit down and ***** while the grownups try to address this issue. Perhaps the costs would be lower had the issue been addressed earlier and surely the cost will be greater if we do nothing now. Is the ACA a perfect answer? No, but it is an answer - an attempt to address the problem. In that regard Republicans are way too late to the dance and have arrived without a partner. Republicans made the election into a national referendum on health care - and they lost. Not because the ACA is perfect, but because they had nothing to offer as an alternative.

37) Comment by Wallop - 13/12/2012

Mr. Lercher, several times you mention "people" and "getting them the care they need." That's why you're bemused by Cassidy's ideas. He, like agagent below, thinks only of his ideology. Agagent, when making your remarks about the waste of medicaid, please provide objective data.

38) Comment by Bighug - 13/12/2012

Costs could be lowered in many ways. It would help if suppliers were prevented from offering cash and other incentives to doctors for using their goods. I would prefer that my doctor prescribe what will help me get well, rather than what would give him points toward a vacation trip.

39) Comment by agagent - 12/12/2012

Government run health care is full of waste fraud and abuse. Instead of reforming a system needing reform, Obamacare just expands a very flawed system.

40) Comment by agagent - 12/12/2012

The federal exchanges plan to collect a 3.5% administrative fee on the federal exchanges, so that gives us an ideas of the cost of exchanges to the states. States are already covering billions of dollars for uncompensated care because of low federal reimbursement rate. Obamacare will increase the reimbursement rate for primary care physicians to Medicare levels, but then it turns that added cost over to the states after 2 years.

41) Comment by agagent - 12/12/2012

Obamacare assumed federal authority to force states to expand Medicaid beyond the poverty level and to implement costly insurance exchanges. The Supreme Court said that the federal government did not have that authority. States well pay the cost of their exchanges and would eventually pay their share of increased cost of expanding Medicaid. States are already going bankrupt with their current Medicaid program. This year Louisiana is closing state facilities to pay for a huge Medicaid deficit.