Medicaid Expansion is coming in Virginia....

Dear Friends, I have introduced three bills to address the growing disaster of Obamacare, as regards Medicaid expansion, Obamacare insurance salesmen sign-up organizers called Navigators, and keeping your previous insurance plan.  This alert discusses HB 39, to provide healthcare to the indigent without expanding Medicaid.

Medicaid Expansion Will Be Pushed in Virginia Democrat Governor-elect Terry McAuliffe wants to add 425,000 recipients to the already 1,000,000 recipients on Medicaid arguing that 30,000 jobs will be added to Virginia’s economy.  Medicine should be about improving health.

Some businessmen and “moderate” Republican State Senators want to expand Medicaid because they want the promised 100% of federal funding (first three years) and jobs (political patronage?).  Federal funding is not free money.  It comes from “We the Taxpayers” whose tax burden continues to escalate.  They also believe Virginia can exit out of Medicaid expansion if the feds do not pay the 100%.  They fail to cite any legal authority in the Obamacare law or published regulations for support to back out after expansion.< During the Governor’s race, Terry McAuliffe twice said he would not vote for a Budget unless Medicaid expansion was included.   It is unclear if the Republican Speaker of the House would risk what will be painted in the media as “stingy Republicans” shutting down Virginia’s government over Medicaid expansion, despite such a shutdown being Democrat Governor McAuliffe’s decision.

Recall it was Republican leaders who lead the efforts to impose the last three tax hikes on Virginians, including the 2013 road tax hike.  Add to that the incessant media drumbeat about Republicans refusing 30,000 jobs and rejecting health care for the poor, and I don’t think we can count on “Alamo-like” resistance to Medicaid expansion from Republican leaders in the House of Delegates and State Senate, unless the people make their voices heard.  That is why it is very important to pass my HB 39.

Alternative to Medicaid Expansion HB 39 will not cost a dime of tax money and will avoid Medicaid fraud because Medicaid is not used.  My measure would simply empower the Attorney General’s office to defend doctors who live in Virginia in any malpractice claims in their private practice as well as their charity care as long as they donate four hours a week of free primary care to Medicaid-eligible residents through a non-profit.

Non-profits, including churches, could enlist doctors to provide care to the indigent, either in the doctor’s office or free clinic.  Hospitals could set up similar primary care centers. No billing bureaucracy would be needed to administer the program.  Doctors would simply keep regular patient medical records.

Thirty years ago filing paperwork for insurance cost doctors 15-30% of their revenue.  Today doctors can pay 60%+.  Even more will be needed for Obamacare paperwork. (Business Insider, 5/29/13). Virginia already self-insures 3,400 physicians for care they provide in free clinics with no law suits pending.

Problems with Expanding Medicaid McAuliffe claims the Feds will cover 100% of Medicaid costs for three years and 90% thereafter.   But recall Obama and Mark Warner’s prior failed promises: “You can keep your own insurance,” and “you can keep your own doctor.”

To be viable, the Affordable Care Act (ACA) needs young people to sign up in rock concert droves.  They’re not.  Harvard’s Institute of Politics polled 2,089 young uninsured adults (18-29) in early November 2013 and found only 13% will definitely enroll and 16% will probably enroll.

Obamacare claims to be built on “savings” from other programs.  But the Congressional Budget Office told Speaker Nancy Pelosi (3/20/10) that savings “might be difficult to sustain.”  And Medicaid’s Actuary said the projected savings “may be unrealistic.” (4/22/10)

If Medicaid is expanded, Governor McAuliffe will need to find doctors to cover an additional 425,000 Medicaid patients when few doctors accept Medicaid currently.

Medicaid Eligibility and Access to Care The U.S. Centers for Disease Control found in their 2011 National Medical Care Survey that 31% of doctors would not take new Medicaid patients.  The 2012 Jackson Healthcare Physician Practice Trends Survey found that 36% of U.S. doctors will not take new Medicaid patients. A NEJM study (6/16/11) of Cook County, Illinois doctors found that “Overall, 66% of Medicaid-CHIP callers…were denied an appointment as compared with 11% of privately insured callers…” after women posing as mothers of pediatric patients with common health conditions made calls to identical clinic staff for appointments 30 days apart using the same script but identifying Medicaid or private insurance as payment.

So, a Medicaid card will not guarantee medical care for the poor.

Forces behind Medicaid Expansion Terry McAuliffe claims that “if we don’t accept [Medicaid] money it will simply flow to other states.”  This is not true.  Virginia’s “share” of Medicaid expansion money (our federal taxes) is based on a formula.  For 2016, Congress allocated $372 Billion for Medicaid for all 50 states, with $1.5 billion for Virginia.  If every other state rejected expansion, Virginia would not get the entire $372 Billion.

McAuliffe wants to reappoint Governor McDonnell’s Secretary of Health, Dr. Bill Hazel, who has been working to expand Medicaid since passage of Obamacare in 2009.   The Washington Post reported (12/18/13) McAuliffe announced his choice of Dr. Hazel at Virginia Commonwealth University School of Medicine in Richmond: “'I am confident that Secretary Hazel will be the best steward to help me carry my agenda forward and meet the challenges we face when it comes to health care in this commonwealth.”

The Obama Administration has cut from $500 million to $1 billion in reimbursements to VCU and UVA for hospital care for indigents.  The news of the VCU/UVA funding shortfall came from Health Secretary Hazel on the same day Terry McAuliffe announced he wanted Hazel to stay on as Health Secretary.  Terry McAuliffe would not be seeking to re-appoint Sec. Hazel if he were not also fighting for Medicaid expansion!

Nil Effects of Medicaid Expansion Medicaid expansion may not significantly improve health. In 2008, Oregon expanded Medicaid for low-income adults.  Two years later, The New England Journal of Medicine (NEJM) reported (5/2/13) “…Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services…”   Those words are from the authors of the article.  They are not mine.

And, a just published article in Science magazine [1/2/14] further analyzed Medicaid usage of patients enrolled in the 2008 Oregon Medicaid expansion.  The author’s summary reported on 25,000 Medicaid lottery participants over an 18 month period.  “We find that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40 percent relative to an average of 1.02 visits per person in the control group. We find increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings. ...  A back-of-the-envelope calculation, using $435 as the average cost of an emergency room visit suggests that Medicaid increases annual spending in the emergency department by about $120 per covered individual.”

In other words, because it is harder and harder for patients to receive primary medical care in private doctor’s offices, Medicaid eligible patients are going to hospital Emergency rooms for for primary care treatment at a rate of 40% higher than non-Medicaid participants.

Defensive Medicine  Because doctors fear lawsuits, many doctors practice “defensive” medicine which consists of ordering medical tests and treatments which shield a doctor from liability, but which may offer little or no benefit to the patient. This drives up general health care costs as well as tax-funded Medicaid and Medicare programs.

An AMA published survey, answered by 65% of 824 Pennsylvania doctors (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) found:  “... 93% reported practicing defensive medicine. ... such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%).  Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. ... Defensive practice correlated strongly with ... perceived burden of insurance premiums.”  JAMA. 2005 Jun 1;293(21):2609-17.

As more and more Doctors consider leaving the medical profession over Obamacare requirements, HB 39 can remove the burden of insurance claims for care provided by charity doctors, a significant factor increasing health care costs across the board. Relieved of that burden, doctors will be able to exercise their best clinical judgment, and not order tests to avoid litigation.  Doctors under HB 39 will have no incentive to encourage behavior that produces repeat pathologies, where voluntary behavior and not genetic history, social condition or accidents, is the major causative factor in illness or subpar health.

Doctors serving the poor through charity care will not waste time with Medicaid over users. Physicians who treat the poor without charge will have their reputations enhanced, which will attract additional paying patients. Non-profit groups or churches will be better able to direct only the truly needy to their affiliated clinic doctors resulting in true patient-centered care by physicians delivered in the local community.

The drawback for some politicians may be the absence of political payback votes.  In other words, instead of converting citizens into government dependents, the indigent will remain free men and women not beholden to anyone or expected to vote for a particular political benefactor.

HB 39 has the potential to take us back to a medical care delivery model that preceded Lyndon Johnson's so-called Great Society which bureaucratized Charity by creating government programs and agencies with employees who relied upon the indigent remaining so in order to keep their jobs.

Taking Action Since “Eternal Vigilance is the Price of Liberty,” I ask you to step up and alert your representatives in Richmond to support HB 39.  Please spread the word among your friends.

Go to  http://conview.state.va.us/whosmy.nsf/VGAMain?openform to learn who represents you and your friends in the House of Delegates and State Senate.  Please ask your representatives to co-patron HB 39 and vote for it in Committee and on the floor.

Unless you and your fellow citizens act, we will not only see an unnecessary expansion of Medicaid, and higher taxes, but a decidedly liberal shift in the active electorate as more and more citizens become dependent upon government programs.  I can only introduce the bill.  Without your help it will not pass.  Thanks for whatever you can do to improve medical care for the truly needy and resist expansion of Medicaid.

Sincerely,

Delegate Bob Marshall