Category Archives: Medicaid

The next chapter in our unfinished novel


From: Mike KingMike King headshot 2

With the election of Donald J. Trump and Republicans firmly still in control of the House and Senate, we are, whether we like it or not, starting all over again on our tortured and very unfinished journey toward a health care system that is available and affordable for all our citizens.

This has been going on for more than 100 years. While other developed nations created more equitable and less costly (and, I would argue, equal in quality) health care systems we have steadfastly resisted the truth that our medical industrial complex works well for some, not at all for others, and costs way more than it reasonably should. So, after the Affordable Care Act’s noble effort to provide better access to care through a subsidized commercial insurance marketplace, we seem on the verge of blowing it up. I don’t think that will happen as quickly as promised. It’s a big, complicated law and it will take a complicated series of maneuvers to actually “repeal and replace” it. The new President doesn’t really have a replacement in mind. And his fellow Republicans in Congress have all sorts of proposals, most of them recycled free-market talking points about health insurance that have been tried – not all that successfully – at the state level. Expect to hear a lot more about those in the weeks to come.

Some of these ideas are worthy of consideration, if for no other reason, than we need to acknowledge we have tried a lot of things to bend the cost curve in recent years and they barely have budged it. (We got 20 million more Americans a health care plan, sure. But not enough has changed in terms of helping control costs. Perhaps nothing will. But we should be willing to consider all proposals.) You’ll be reading more about them on this blog in the weeks and months to come, if you are interested in exploring them further.

But it boils down to this (it always has): Are we capable of sustaining a thriving, for-profit commercial health insurance industry, a thriving for-profit pharmaceutical industry and a thriving health-care delivery system for a population that has equitable access to all three so that it too may thrive? All the proposals on the table, new ideas as well as the “good parts” of the ACA, should be considered.

One component that bears intense scrutiny and thoughtful reconsideration is Medicaid, the 50 year old program designed to get poor people access to health care. Medicaid, like it or not, has become a whipping boy that some states in recent years have purposely underfunded and undermined. This will be a major component of whatever comes next and it will — as it always has — be the key to the survival of our nation’s public, safety-net hospitals.

We should be open to a whole new approach on Medicaid. (Yes, even block grants, assuming – and this is a big assumption – that they aren’t being offered strictly for cost-saving reasons.) Perhaps there are some worthy experiments to conduct with the states along these lines. Among other things to consider: Why is Medicaid the payer for long-term care for the nation’s elderly and disabled? Shouldn’t there be a separate program for how to pay for nursing home care for those who can’t afford it? Why put these patients in competition for the same dollars with uninsured pregnant women and their children, or the day-laborer who can’t manage his diabetes and relies on the public hospital emergency room because the state says it can’t afford to put him on Medicaid?

Okay, everything back on the table. Except…..

There is one inviolable pact on which those of us who have pledged to equal access will not budge. We should muster all our energy and whatever political clout we have remaining to thwart, obstruct and litigate any plan at the federal or state level, where working people and their families living below the poverty level are purposely ignored and forced to go without the care they need.

That’s non-negotiable.

Better health, fewer deaths linked to Medicaid expansion


The theory guiding the Affordable Care Act’s call for expanding Medicaid to more low income and working-poor Americans is pretty simple: Getting them access to basic medical care will improve their lives and, in the long, run help control the overall cost of health care for millions of previously uninsured people.Mike King headshot 2

But measuring whether that theory works — beyond the anecdotal stories we’ve all heard — is exceedingly difficult, especially since the law is only a couple of years since being implemented.

The statistical evidence is beginning to come in, as illustrated here by this New York Times report about a study in the latest edition of JAMA Internal Medicine.

Looking at health surveys of people in neighboring states — one that expanded Medicaid and one that didn’t — researchers found that, in general, people who qualified for Medicaid in places where enrollment expanded reported better health than their demographically similar counterparts in states that have refused to expand the program. Moreover, those who got coverage reported two consecutive years of better health in follow up surveys.

Deeper dives into health care outcomes in years to come will be needed but this latest study is an indication that expanding Medicaid as the ACA envisioned it appears to be working. These same researchers using similar data points and surveys, two years ago calculated the predicted annual number of lives lost in states that refused to expand Medicaid.

In Georgia, that number is 1,170.

Let that sink in.

More than a thousand Georgians die every year because they don’t have insurance and can’t afford health care. If they lived in Ohio, or New Jersey or another state where Medicaid is available, they would be alive. Why is this not a public health priority?

By way of comparison, the Governor’s Office of Highway Safety wants Georgia to continue the note worthy trend of reducing the state’s annual death toll from traffic fatalities. The target for 2016 is 1,130. That’s a big challenge, given how crowded Georgia’s interstates and highways are.

It would be nice if we could get the number of Georgians who die because of lack of access to Medicaid down as well. That’s not so big a challenge. It’s pretty simple, actually.

Expand Medicaid. Save lives. Improve health.

Mike King is the Author of A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals,” available through and the Seattle Book Co.

Read The New York Times review of the book:


The Coming Cave-In on Medicaid


Mike King headshot 2This blog is hosted by the author of “A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals,” available on Amazon. com and Seattle Books.

From Mike King

If you want to handicap what kind of Medicaid expansion Georgia and other Southern states that have thus far obstructed Obamacare’s efforts to reach more of the poor and uninsured will eventually embrace, Kentucky is a good place to watch.

The Bluegrass state was, until this year, the very model of how Obamacare and the Medicaid expansion contained within it has significantly reduced the number of people without insurance. Yet last November, voters elected  new Republican governor who campaigned to end the expansion and the state’s highly successful health insurance exchange. Not surprisingly, upon taking office, he began to reconsider both promises, realizing the amount of money the state would lose.  Moreover, it could have dawned on him that his promise put 400,000 or so Kentuckians back into the ranks of the uninsured, jeopardizing their health and turning their care over almost exclusively to the state’s public hospitals who will have no recourse other than to try to recoup their losses by raising local taxes or their charges to privately-insured patients.

So the new governor, Matt Bevin, has spent the first six months in office trying to fashion an alternative to the Medicaid plan now in place in Kentucky. He wants to seek a waiver from the federal government that creates a new set of rules for who qualifies for Medicaid and what is expected of them. Those new provisions are straight out of the Medicaid-is-a-Welfare-Program playbook, popular among Republican office holders in the South. It would, among other things, require new Medicaid enrollees to work, or be seeking jobs, or volunteer opportunities in order to qualify for coverage. It would also charge them premiums and deny coverage for six months, and require re-enrollment, if they fell behind on their premium payments.

Sound familiar? Republicans in the South have over the years conditioned many social welfare programs — from unemployment to food stamps to temporary assistance for needy families — on such moral hazard principles. It’s not a new thing. It goes back decades. As A Spirit of Charity details, in the post-New Deal era, Southern politicians looking to roll back some of FDR’s most successful programs, lobbied long and hard for allowing the states to set the rules for who gets government assistance and when. In those days, race played a significant role in the decision making. (A good argument could be made that it still does in some places.) But the basic premise — that able bodied Americans should work and save money and provide for themselves and not be dependent on the government — still holds for many political leaders in the South. When Medicaid was created as a health care program for the poor in 1965, the states were given considerable leeway in deciding who qualified for it and how much they would pay doctors and hospitals who provided care to them. The 2012 Supreme Court decision that made Obamacare’s Medicaid expansion an option for the states reinforced that when it comes to care for the poor the states still have a lot of say.

But the prospect of losing billions of dollars in federal funding for Medicaid expansion is simply too much to ignore, especially now as the Obama administration draws to a close and the political value of mindless bashing of anything connected to Obamacare is fading fast. Even in Georgia, where obstruction of Obamacare has been an organization principle of Republican politics, the tide is turning.

So be on the lookout for workfare/healthcare demands on new enrollees if Georgia and other southern states start creating new Medicaid expansion plans. Look, as well, for premium-sharing plans so that the poor will have to pay something to get coverage. (And yes, it’s not a stretch in this region of the country for our political leaders to demand drug testing for adult Medicaid enrollees.)

The question then becomes, will these requirements pass muster with the Obama administration, or a Democrat in the Oval Office in January of 2017?

The answer, more than likely, is hell-to-the-no.

Medicaid is not a welfare program. Placing work and earnings requirements on enrollees destroys the purpose for its existence. Decades of trying to do just that have demonstrably resulted in millions of Americans unable to afford health care access. There is no science to show that demanding such requirements will succeed in moving the poor from Medicaid to private insurance. Recent history has proven quite the opposite. As more and more employers ditch coverage, especially to part-time workers like those who make too much now for Medicaid, the need to be covered by a government plan has become more acute, not less.

This is not to say that a take-it-or-leave-it approach to Medicaid as we know it now is good public policy either. The program has its flaws and needs serious reconsideration. States that want to seek waivers trying to find better systems of health care delivery — the use of medical homes, telemedicine, nurse practitioners, physician assistants and other allied health professionals where there are shortages of primary care doctors — should (and have been) encouraged. Put those ideas and others in a waiver application and they will get a fair hearing.

No one disagrees that there is a huge need to make Medicaid a better, more effective program. Doing so will bring this country closer to the goal of joining the rest of the economically developed world when it comes to guaranteeing health care for all its citizens. But if your state’s waiver plan is premised on the notion that the poor are the problem and they should be paying more for their care, then you are about 50 years too late to the debate. You’ll need a better plan than that.



The insurance market, Georgia style



By Mike King, author of A Spirit of Charity


So, another session of the Georgia General Assembly has drawn, gloriously, to an end. We should all breathe a sigh of relief. The inmates are finally out of the asylum again. (Okay, I know that’s counterintuitive, but if you’ve ever spent any time around the Georgia legislature, you know what I mean.)


For public health advocates, there was little to cheer in this session. But then again with this bunch of solons,  just keeping stupid stuff from happening can be counted as progress.


Case in point: While other states are re-examining their knee-jerk opposition to expanding Medicaid under Obamacare, Georgia remains consistently obstinate – to the point of turning away about $9 million a day in federal funding that would allow hundreds of thousands of the state’s low-income adults and families to qualify for coverage.


At least this year there was no effort to claw back any more provisions of the law that would make it easier for people to sign up on the Obamacare exchanges. It wasn’t that long ago that the Legislature and Insurance Commissioner  threatened state employees (at UGA, in public health departments and other state government agencies) with repercussions if they agreed to become unpaid, volunteer navigators that the new health law encouraged in order to help people understand their rights and benefits.


But  this year something even more ironic happened. Had it not been for the vigilance of The Atlanta Journal-Constitution in shining a spotlight on the usual shenanigans at the Gold Dome in the last weeks of the session, the state’s poor, put-upon insurance brokers would have had a guaranteed commission for any policies they sold on the Obamacare marketplace.

Yes, you read that correctly. The Legislature seriously considered a law that would have guaranteed insurance brokers a minimum commission.

These free-market-loving legislators were complaining, bitterly it turns out, that the health insurance companies were hosing their friends in the brokerage business. They contended the insurance firms were shortchanging the agents because the big companies were only being allowed to get a 20 percent return on premiums under Obamacare rules governing  profits, marketing and administrative expenses of the companies selling plans on the exchanges. That’s just plain unfair, or so the legislators – many of whom sell insurance in their day jobs – seemed to think. The dirty little secret, of course, is that individuals don’t need an agent to go on the exchange to help them find a policy – no more than you need an airline reservation clerk to book you a ticket, or a paid advisor to help you sign up for natural gas service or digital television. Perhaps an agent would be helpful in finding group policies for small businesses, but compensation for that role is usually negotiated between the agent and the company he or she is touting. If they don’t like the deal, the brokers could walk away. But, no, they wanted the Legislature to guarantee them a piece of the action.

In the end this heaping helping of special-interest guano was too much for the legislative leadership to swallow, especially once the newspaper was on the story, so the insurance-broker-full-employment-bill died a much-deserved death.


Meanwhile, as Andy Miller at Georgia Health News reports, the impact of the state’s resistance to Medicaid expansion can now be quantified in an area where Georgia has a pretty shameful history to begin with.

The hits just keep coming.

I suspect the guaranteed commission bill will be back next year, as will the advocates of hundreds of thousands of Georgians who just want a little help finding affordable insurance. It is, and always has been, a matter of priority.


Mike King headshot 2

Spirit Cover

Why we don’t let people “die in the streets”

Spirit CoverA Spirit of Charity: Restoring the Bond Between America and  Its Public Hospitals will be available in print from Secant Publishing in May 2016. This column is drawn from the author’s research.

You’re forgiven if you can’t quite make out the Republican front runner’s health care reform policy positions. Donald Trump is not one for articulating details. Yes, he brings up the usual talking points his party’s leaders have offered over the years — Medicaid block grants to the states, more tax breaks for health savings accounts. You’ve heard those many times. But his overall vision of what the post-Obamacare-Donald Trump policy would look life can be summed up with this oft-repeated assurance:

“I will not let people die in the streets.”

Why doesn’t make you feel better?

Well, for starters this country decided a long, long time ago (during Colonial times) that not letting people die in the streets was a worthy goal. In fact, this is why large public hospitals like Bellevue in New York City and Charity in New Orleans were created in 1736. It’s also why places like Grady Memorial in Atlanta and County Hospital in Chicago opened a century or so later while European nations embarked on a path toward tax-supported health care for their populations. In our country the Bellevues, the Gradys and the Countys  and a few dozen others like them are more than safety net hospitals, they are the safety valves for a $3.2 trillion health care system that still hasn’t figured out how to care for the poor and uninsured.


When you really examine it, it’s more that a little embarrassing that of all the other comparable nations in the developed world, the U.S system remains so profoundly warped. Only here do we seem satisfied that when poor people develop chronic, treatable medical conditions they can at least get rescued by a public hospital when they finally get sick enough to need one.

Even now, even after the Affordable Care Act — the law Trump and his Republican colleagues want to repeal and replace (with what, no one seems to know for sure) — the continued existence of large, urban, public hospitals with charity missions make the unfinished business of health care reform so much easier to put off by voicing such platitudes that we won’t let people die in the streets.

You may have heard other versions of Trump’s not-to-worry health care position before. President George W. Bush, in justification of his veto of expansion of the Children’s Health Insurance Program for low-income families that Democrats tried to foist upon him in 2007, famously declared that it wasn’t needed because Americans already have access to health care, regardless of their ability to pay. They need only go to a hospital emergency room, Bush said.

True, that. But also truly inadequate. Then and now.

Indeed, the law that requires most American hospital ERs to take in people without ability to pay stems from evidence compiled by the medical residency staff at Chicago’s Cook County Hospital in the 1980s. County physicians documented that competing private hospitals were routinely turning away indigent patients — including pregnant women about to deliver — and sending them instead to County. When they published their findings in a prestigious medical journal, public hospital physicians around the country reported the same thing was happening in their communities.

The resulting 1986 law, known as EMTALA (Emergency Medical Treatment and Active Labor Act), forbids the practice that became known as “patient dumping.” It’s a good law and it has no doubt stopped some of the worst abuses. But the reality is that it only applies to patients deemed to be presenting with an “emergency medical condition.” If they aren’t considered in danger of death, the hospital can legally turn them away.

Still, most American hospitals are pretty good about treating indigent patients who show up in a emergency room with a chronic conditions like  diabetes, hypertension, even cancer. They write off millions of dollars of ER charges every year. But their responsibility ends once the patient is out the door — with or without a prescription or a follow-up appointment with a physician to manage the condition that sent him or her there in the first place.

This helps explain why life expectancy among Americans remains below 80 years and lags badly behind Japan, Italy, France, Canada, the United Kingdom, and 43 other nations. And why, as well, that we spend on average nearly $8,000 per year per person on health care while France spends, on average, half of that

Life expectancy by race within our own country raises even more troubling questions. Consider that there is an astounding 25-year difference between the life expectancy of Asian-American women and African-American men living in the United States. The former can expect to live, on average, 86.7 years, while the latter live just 61.7.

This is where public hospitals must shoulder the burden of a health care system that has no real program to assist the millions of Americans who remain uninsured. Yet the mission of the nation’s largest public hospitals over the years has expanded to go beyond the emergency room and attempt — often without the public financing they need — to provide primary care services to the poor and uninsured to keep them well and out of the hospital.

Public hospitals in urban areas, like Grady Memorial in Atlanta and others with large African-American populations suffering from hypertension, offer some of the best stroke and stroke recovery care in the nation. But they often go beyond just being there for stroke victims. They have vigorous outpatient and in-the-community programs aimed at preventing and controlling hypertension in populations at-risk for stroke. Cook County Hospital  has a highly coordinated program with Chicago’s federally-funded primary health care clinics to manage the chronic conditions of the city’s large Medicaid enrollees so that they can stay well. By doing so they not only keep the patients healthier, they help control Medicaid’s costs.

But public hospitals often fight these public health battles without the help they need from local, state and federal officials who look for marketplace miracles to minimize public spending on health care instead of examining how to do it better. The ACA has gone a long way toward extending health insurance to millions of Americans who couldn’t afford it before the law was enacted. But there are still about 30 million without it — many of them in states where political opposition to the law’s Medicaid expansion trumps (forgive the pun) the wisdom of receiving billions in federal financing. This desperately needed money that is being sent back to the federal treasury would go a long way toward insuring more low-income workers and their families, not to mention help public hospitals keep them healthy.

No matter who moves into the White House in January 2017, we still have a lot of work to do when it comes to health care reform. Perhaps the first place to start is to challenge the role of the states in setting Medicaid enrollment and reimbursement policies. There is a reason that Texas, Florida and Georgia have the most uninsured residents in the country after Obamacare was fully implemented. By refusing to expand Medicaid those states and about 15 others have purposely left millions of working poor people behind in the arrogant confidence that public hospitals won’t let people die in the streets.

Because of a dysfunctional health care system many of these Americans will die instead inside a hospital. Isn’t it time to find a way to take care of them before they need to go there?

Mike King headshot 2





The author, a former editor, writer and columnist at The Courier-Journal in Louisville, Ky. and The Atlanta Journal-Constituton, blogs about health policy issues.

Back in the game with some interesting reading

Been gone a while. But now that the dust is settling on the Obamacare rollout — we’re still a long way from being able to talk about cost control and whether access to affordable plans has been greatly expanded (or just good enough to be happy about year one) — I thought you might be interested in a couple of good reads I saw recently on

This first one deals with why Republicans always choke on a viable alternative to Obamacare. (Hint: It was because it was THEIR plan to begin with.

Speaking of a plan that many thoughtful people long ago concluded is the only way to truly get universal access and have a real shot at controlling costs, Sara Kliff of Vox offers this lengthy explanation of what’s going on in Vermont.

And lastly, my favorite website since the first of the year is this one. It shows how we Georgia taxpayers, since the first of the year, have been sending our hard-earned federal taxes to New Jersey, Kentucky, California and other states to help subsidize their expansion of Medicaid enrollment for the working poor while we sit here listening to our elected state leaders say they are proud to give up those dollars and let our working poor fend for themselves. Consider, for a moment, whether they would be willing to give up federal highway funds? Or public safety funds? Wouldn’t it be great if we had one of those billboards — like the one on Peachtree that used to roll out the ever increasing Atlanta population — that showed how much money (about $100 per second, by my count) Georgia’s hog-tied and Tea Party bound GOP leadership is purposefully throwing away for our state. Within the next few days, this number will reach $1 billion (billion, with a “b”) since the first of the year.

A helpful look at Georgia’s priorities

My friend, and former AJC reporter/editor Tom Baxter has a great column discussing the difference in how Georgia’s political leaders think about spending money on a project like deepening the Port of Savannah versus expanding the Medicaid program to cover an additional 650,000 uninsured Georgians. It’s on the Saporta Report website. The standard brush off line that the governor’s office gives to reporters asking about why Georgia won’t take advantage of Obamacare’s offer to pay the full cost of the expansion for the first three years and at least 90 percent of the costs after that is “the state can’t afford it.” Georgia has a $20 billion annual budget. The “cost” to the state to expand Medicaid would run about $200 million a year. Do the math. It ain’t much. But can we afford a lot more than that to expand the port? Sure we can. An expanded port provides jobs, right? (Well, hopefully, although the promised benefit is pretty much a best, most optimistic guess.) Whereas the Medicaid expansion results in more Georgians being covered, a revitalized health care sector and, more than likely saved lives that might actually help the state improve its dismal health rankings. We could probably afford to do both. But you won’t hear that from the state’s leaders. It’s a matter of priority. What Nathan Deal and Ralph Hudgens mean to say about the Medicaid expansion is not that “the state can’t afford it,” it’s that we don’t think its worth spending any more money on poor people. They ought to at least be honest about that.

Here’s the link to Tom’s column.