We have all read a great deal about health care- how it should be organized, paid for, eligibility, universal coverage, foreign comparisons. Paul Krugman has now written the single worst and most misleading article I have seen in 4 years of debate on this topic. Here it is-
Paul Krugman Medicaid Article
It really helps for commentators to actually understand what they are talking about. In this example that is clearly not the case. To put Krugman's article in perspective, her is a useful site for calculating inflation over any given time period-
Inflation Calculator
With this in mind, here is the skinny on Medicaid.
First, over the period covered by Krugman's chart inflation has been 29.7%. Let's use 30% as a round number. Therefore if spending on Medicaid has remained flat (the graph is not inflation adjusted) that means that real purchasing power of Mediciad has decreased by 30%. It also means that the outrageous costs of private insurers are slightly different when inflation is considered. There are a few other differences.
First, most medical spending (2/3) occurs in the last year of life. Medicaid doesn't cover this time, so its costs are much more predictable. Second, Medicaid pays horribly. Their reimbursement is 30-75% less than private insurers. While this does control costs it also means that very few doctors accept it. I accepted BlueCare, Tennessee's Blue Cross Medicaid HMO, in Knoxville. I was one of only TWO ObGyns who accepted it for gyn care in the entire 800,000 population metro area. Lots of doctors would accept it for OB, mainly because it is politically impossible to reduce OB payments as they have gyn payments.
Doctor choice is severely limited on Medicaid. Most physicians just won't deal with them, and I don't blame them. 100%, that's right, 100% of hysterectomies are denied by Tenncare. Routinely. There is no precertification- that leads to unhappy patients who complain to insurance commissioners. No, no, you can do any care you like, but if it does not meet their guidelines it gets denied. Except that 100% of cases are denied payment. The doctor then has to pay staff to fight with Mediciad to get paid for work done ethically and under their guidelines. Thus out of the already execrable payment must be taken the administrative costs of collecting it. You want a better example? Medicare is the easiest payor to work with. Submit a clean electronic claim and you are paid within 4 weeks. Medicaid not only pays badly but only with much hassle and very late.
Therapeutic options are just as limited as doctors under Medicaid. For a pregnant woman with nausea Zofran is more effective than Phenergan and causes no drowsiness, so she can work and drive. Medicaid doesn't cover Zofran. Medicaid doesn't cover some ultrasounds, doesn't cover most oral contraceptives, doesn't pay for better antibiotics. Oh they save money alright. If is always inexpensive to not buy things.
Eligibility for Medicaid is also severely limited. Each state sets its own level, but beyond that there is eligibility for certain services. You can get coverage for a pregnancy even if you are an illegal alien but you cannot get coverage for a hysterectomy even if you need transfusions to correct anemia from excess menstruation. Physical therapy, nursing home stays and other parts of recovery from major surgeries like a comminuted leg fracture may not be covered, or are covered only at extra cost the enrollee cannot possibly pay. And if you die, or are injured in a car, Medicaid will collect from your estate or from your car insurance all the medical costs for your care. If you win a judgment against another person for your injuries Medicaid will reimburse itself by collecting from your judgment all its expenses. You get nothing. The money goes from the defendant's insurance to Medicaid.
THIS is what Paul Krugman thinks is the future? We should all be scared and outraged over an article like that. Medicaid gives the government a fig leaf to hide behind, claiming it provides comprehensive medical coverage to the poor. Nonsense. The government provides a minimal coverage that cuts the poor off from the best treatments, the best doctors and the best care. And please don't go and blame this on Republicans. Medicaid funding has been a favorite football for both parties, who in the name of efficiency and reducing payments to 'fat cat doctors' have done nothing except prevent care for the very constituency they purport to care for and serve.
Krugman is either a liar or a fool, and the politicians are manipulative liars without honor or decency. For those commentators and politicians who actually want to know as opposed to bloviate, come down to any office or clinic, and we'll show you what you have done. Better yet, why don't you put your families on the program you like to tout so much? That goes for you too, Krugman.
Ted
Paul Krugman Medicaid Article
It really helps for commentators to actually understand what they are talking about. In this example that is clearly not the case. To put Krugman's article in perspective, her is a useful site for calculating inflation over any given time period-
Inflation Calculator
With this in mind, here is the skinny on Medicaid.
First, over the period covered by Krugman's chart inflation has been 29.7%. Let's use 30% as a round number. Therefore if spending on Medicaid has remained flat (the graph is not inflation adjusted) that means that real purchasing power of Mediciad has decreased by 30%. It also means that the outrageous costs of private insurers are slightly different when inflation is considered. There are a few other differences.
First, most medical spending (2/3) occurs in the last year of life. Medicaid doesn't cover this time, so its costs are much more predictable. Second, Medicaid pays horribly. Their reimbursement is 30-75% less than private insurers. While this does control costs it also means that very few doctors accept it. I accepted BlueCare, Tennessee's Blue Cross Medicaid HMO, in Knoxville. I was one of only TWO ObGyns who accepted it for gyn care in the entire 800,000 population metro area. Lots of doctors would accept it for OB, mainly because it is politically impossible to reduce OB payments as they have gyn payments.
Doctor choice is severely limited on Medicaid. Most physicians just won't deal with them, and I don't blame them. 100%, that's right, 100% of hysterectomies are denied by Tenncare. Routinely. There is no precertification- that leads to unhappy patients who complain to insurance commissioners. No, no, you can do any care you like, but if it does not meet their guidelines it gets denied. Except that 100% of cases are denied payment. The doctor then has to pay staff to fight with Mediciad to get paid for work done ethically and under their guidelines. Thus out of the already execrable payment must be taken the administrative costs of collecting it. You want a better example? Medicare is the easiest payor to work with. Submit a clean electronic claim and you are paid within 4 weeks. Medicaid not only pays badly but only with much hassle and very late.
Therapeutic options are just as limited as doctors under Medicaid. For a pregnant woman with nausea Zofran is more effective than Phenergan and causes no drowsiness, so she can work and drive. Medicaid doesn't cover Zofran. Medicaid doesn't cover some ultrasounds, doesn't cover most oral contraceptives, doesn't pay for better antibiotics. Oh they save money alright. If is always inexpensive to not buy things.
Eligibility for Medicaid is also severely limited. Each state sets its own level, but beyond that there is eligibility for certain services. You can get coverage for a pregnancy even if you are an illegal alien but you cannot get coverage for a hysterectomy even if you need transfusions to correct anemia from excess menstruation. Physical therapy, nursing home stays and other parts of recovery from major surgeries like a comminuted leg fracture may not be covered, or are covered only at extra cost the enrollee cannot possibly pay. And if you die, or are injured in a car, Medicaid will collect from your estate or from your car insurance all the medical costs for your care. If you win a judgment against another person for your injuries Medicaid will reimburse itself by collecting from your judgment all its expenses. You get nothing. The money goes from the defendant's insurance to Medicaid.
THIS is what Paul Krugman thinks is the future? We should all be scared and outraged over an article like that. Medicaid gives the government a fig leaf to hide behind, claiming it provides comprehensive medical coverage to the poor. Nonsense. The government provides a minimal coverage that cuts the poor off from the best treatments, the best doctors and the best care. And please don't go and blame this on Republicans. Medicaid funding has been a favorite football for both parties, who in the name of efficiency and reducing payments to 'fat cat doctors' have done nothing except prevent care for the very constituency they purport to care for and serve.
Krugman is either a liar or a fool, and the politicians are manipulative liars without honor or decency. For those commentators and politicians who actually want to know as opposed to bloviate, come down to any office or clinic, and we'll show you what you have done. Better yet, why don't you put your families on the program you like to tout so much? That goes for you too, Krugman.
Ted
I read Krugman's original article, then looked up his bio on Wikipedia. It is hard to believe that someone who is so clueless about the economics of health care could have won a Nobel Prize. But then again, it is easy to sound authoritative while living in an ivory tower as an academic and all you write about are generalities of one aspect of a complex problem, as opposed to people actually working in the health care system who must deal with the detailed, concrete realities of billing and payments.
ReplyDeleteI love the line "It is always inexpensive to not buy things." And, of course, the challenge for Krugman to put himself on Medicaid is appropriate - it shows the hypocrisy of his position.
-D-