Category Archives: Uncategorized

Baby steps toward Medicaid expansion in Georgia

By Mike King


It’s good to hear state Sen. Renee Unterman seems interested in pushing her General Assembly colleagues – finally – to cover more uninsured Georgians with Medicaid. That’s good news even if her fellow Republicans want to call it a “waiver” and not the dreaded Obamacare name for it “expansion.”


Some of us who have been advocating expansion under the Affordable Care Act are happy with any movement in that direction. Our only lament is that the state has taken so long and wasted so much time and money promoting the Republican Party’s “fake news” pledge to repeal and replace Obamacare once they gained complete control of Congress and the White House.


Still, it’s worth remembering, now that Unterman acknowledges that “the dollars are floating away,” how much the state has already been wasted by adopting the state Republican party line that Obamacare should be obstructed at every possible level.


In the first three years of its existence, when federal taxes were set aside to pay for Medicaid expansion, Georgia turned its back on about $10 billion (that’s billion with a “b”) that was appropriated for the state’s use. Taxpayers in Jersey, New York, California and elsewhere want to say thank you Georgia for helping with their state budgets.


By way of comparison, it’s also worth noting that Georgia has spent enormous amount of time lobbying the federal government – in both the Obama and Trump administrations – to make good on a one-time pledge to provide $640 million to dredge the Savannah River so the port of Savannah could be enlarged.


Take a moment and think about what that says about the state’s priorities: We beg for millions of as yet unbudgeted federal dollars for an economic development program like the port expansion so that the state can benefit from the jobs expansion creates. But we reject billions of federal dollars already appropriated to expand Medicaid for tens of thousands of Georgians, more than half of whom are working in low-wage jobs that do not come with insurance. And we know that lack of access to affordable care leads to increased disability and, when the safety net fails, death.


Keep in mind, as well, that this is money that could have gone to the state’s financially-strapped rural hospitals that take care of some of these very same uninsured Georgians, a crisis state government didn’t create, but clearly deepened by its political decisions. Moreover, that money could have gone to improved community mental health and substance abuse services for the at-risk Georgians who have died or are now addicted to pain-killing drugs, a public health epidemic like no other we have seen in recent years.


Unterman has correctly (even if belatedly) identified the need to assist rural hospitals and provide more services to opioid abusers as two of the reasons the state should now consider some limited expansion of Medicaid. Perhaps she will be able to persuade her colleagues that this little toe-in-the-water effort is worth the abuse they might take from the Georgia Republican party’s anti-Obamacare base. I sure hope so.


But she also worries that it might not be worth the effort if Democrats and health care advocates insist on full expansion. She thinks we are “obsessed” that Medicaid should be expanded the way it was envisioned in the 2010 law and the way some 31 other states have implemented it. (In those states that expanded, any individual earning less than 133 percent of the federal poverty level now qualifies for Medicaid.)


I can’t speak for all of those advocates, but let me just say you won’t get a demand for an all-or-nothing approach from this one. I’ve been waiting for a state Republican to break through the party’s obstructiveness on Medicaid expansion, or a waiver – to use your term – for years. Every little bit helps.


So, go for it, Sen. Unterman. It can’t hurt. Because what we aren’t doing now in Georgia is literally killing some of us.


Mike King is a health care journalist and author of the award-winning book, “A Spirit of Charity: Restoring the Bond Between America and Its Public Hospitals.”



By Arthur L. Caplan and Mike King

The first documented cases of local transmission of Zika infection in Florida illustrate the need for a coordinated and fully funded plan to deal with the public health threat Zika brings with it.

It’s one thing for the International Olympic Committee to ignore the clear and present danger of staging the Summer Games starting Friday in Rio. You can almost expect them to underplay the threat, given the financial investment of their member nations and the Brazilian government’s commitment to holding the games – Zika, raw sewage in the water, and bankruptcy be damned. But it is quite another for elected public officials in this country to walk away from their jobs with no funding and no real plan for what to do when – not if, but when – there is a Zika outbreak among pregnant women, threatening to deform and kill their babies.

It is too early for gloomy predictions of an epidemic in the mainland U.S. While Puerto Rico has been struck with a major outbreak it could be that other parts of the country will get lucky and dodge the Zika bullet.

But that’s the point. We already know enough about Zika to demand more action. We know that it can be spread by mosquitoes and is transmitted sexually by people who show no signs of illness or disease. We know it can get into the blood supply. We know that there is no vaccine or cure that mosquito control programs will help and that safe sex is a good idea. We know that all of us should take precautions while working or playing outdoors in areas where mosquitoes can breed.

And we also know this: That we need a sizeable infusion of federal and state dollars to carry all this out. Unfortunately, when Washington and the states can’t agree on how to engage a potential epidemic, history shows that that the burden of dealing with infectious disease outbreaks falls heavily on public hospitals, public health departments and local safety-net providers as it did 30 years ago with HIV/AIDS. Many of these providers are already overwhelmed dealing with poor and uninsured people with chronic conditions, like cancer, hypertension, heart disease and diabetes. Will the funding for programs these people depend on be set aside to deal with the more imminent threat of Zika? Should it be?

Florida officials have now confirmed more than a dozen cases of local transmission are located just north of downtown Miami. But weeks before that public health departments in South Florida had to scramble epidemiologists to investigate hundreds of potential cases, set up testing protocols to make sure no one is missed and gone door-to-door asking for urine samples. They have stepped up efforts at mosquito control in the region’s wetland-rich breeding vectors. Those efforts will be more important than ever – and more costly – now that it appears Zika-carrying mosquitoes have made their way into Florida’s tropical climate.

And if a locally widespread outbreak happens it will be South Florida’s largest public hospital, financially stressed Jackson Memorial in Miami, which will once again have to muster the expertise and financing to deal with a major public health threat.

Lest we calm our fears by wishful thinking that perhaps the transmissions will be contained to Miami, remember how wrong we were to think in the early 1980s that the first widespread cases of HIV among Haitian immigrants was mostly a South Florida problem. Keep in mind too that Miami is one of the biggest ports of entry into the U.S. from South American countries where Zika is widely circulating already. This includes returning visitors from Rio de Janeiro, which is expecting a half million tourists for the summer games. Brazilian health authorities have acknowledged more than 30,000 cases of Zika in the region around Rio.

The IOC ignored a plea by scientists and public health experts to postpone or move the games with what amounted to a claim that the event was too big to fail. But Congress lacks even that flimsy excuse for its failure to take timely action in this country. Despite President Barack Obama’s request for $1.9 billion in funding for Zika prevention and detection programs, Congress adjourned in July for seven weeks with no plan for how much the federal government is willing to spend.

Once again Republicans in Congress balked at more public funding for a public health emergency, preferring that the total appropriation be much less than what Obama sought. They insisted that whatever money was to be approved be offset by reductions elsewhere in the budget. This line of reasoning about zero-sum budgeting has gained popularity in recent years among the most zealous conservatives in Congress, even extending to special disaster assistance money going the Federal Emergency Management Agency after natural disasters. This crowd wants to hold the public health response from the Centers for Disease Control and Prevention and other federal health agencies to the same standard despite the fact that in outbreaks like Zika ands Ebola, speed matters and delays cost lives.

Even worse, when it appeared that a compromise on the funding level might be reached, conservative House Republicans attached deal-breakers to the measure – inserting language abolishing public funds for Planned Parenthood and some Obamacare programs – which Democrats correctly would not tolerate.

Unfortunately, holding important public health initiatives like Zika prevention hostage has become a standard tactic in a Congress that places a higher priority on ideological obstruction and zero-sum budgeting for anything but military spending. Zika unfortunately does not care about politics. Your children and grandchildren will pay the price for inaction.



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Arthur L. Caplan is director of the division of medical ethics at the NYU Langone Medical Center. Mike King is a journalist and author of the recently released book, A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals.


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.



Blowing up the system

One of the most interesting aspects of the 2016 Presidential race thus far is that the discussion over the Affordable Care Act — what little discussion there is — has involved, essentially, blowing up the system and starting over.

Democratic candidate Sen. Bernie Sanders has gained significant traction with his call of “Medicare for all” — another way of talking about a single-payer system like the one in Canada (which is actually called “medicare”). The buzz stirred by Sanders and his supporters for a single-payer plan, with the government being the player, can be directly traced to the complicated and not-so-consumer friendly Affordable Care Act. The 2010 law has gone a long way toward getting millions of Americans coverage, but falls short of being all that affordable for too many and is still out of reach — thanks to backwards-thinking states like Georgia — for millions of low income people who should be, but aren’t covered by Medicaid. Why not simplify it? Enact payroll and income taxes to support it and make health insurance available to everyone — young, old, affluent and poor — the way Medicare is available to everyone over the age of 65.

The discussion on the Republican side has had a less-than-lofty tone, with presumptive nominee Donald Trump promising to repeal Obamacare and replace it with something or another that someone or another will present him when he becomes the greatest president of all time. Trump has also declared that he wouldn’t let people die in the streets, which has been — for more than a century now — the default health care policy of the United States since public hospitals, like Atlanta’s Grady Memorial, serve everyone regardless of ability to pay. (In this way, America doesn’t let our poor die on the streets. They can get sick on the streets, but they die in public hospitals because we don’t have a mechanism to ensure their health to keep them out of the hospital.)

On a more serious note, Republicans in Congress, including Georgia’s Tom Price, have offered boilerplate GOP proposals for repealing Obamacare and making insurance more affordable by instituting high-risk health pools, selling cheap policies across state lines, enacting more limits on malpractice lawsuits and other fixes that have demonstrably failed in the past at controlling costs or getting more Americans coverage. Interestingly, none of the talked-about plans have had a serious airing in the Republican-controlled House or Senate.

Now comes two more Republicans, Rep. Pete Session of California and Sen. Bill Cassidy of Louisiana — states with some of the highest rates of uninsured Americans — to offer another GOP plan. They want to change the tax code so as to provide every American adult with $2,500 to purchase coverage. They would do away with the tax credits provided to American employers for covering their workers on the job and essentially throw open the health insurance market to buy health insurance the way we now buy auto or home insurance.

Not gonna happen.

Just like Bernie’s single-payer plan, to do either of these things would require the current health insurance system to be torched and rebuilt from the ashes. For better or worse, the employer-based system we have now has been in effect for seven or so decades. It’s not going away, not very easily anyway.

It is no surprise that neither plan outlines in any detail how we get from here to there — from the current system of Medicare, Medicaid, private commercial insurance purchased on the Obamacare exchanges or elsewhere, or insurance provided and paid for by employers and their employees. How, under what time frame, do we go from this to a single payer, or a $2,500 stipend for everyone to go buy a plan on their own?

These are important questions that need be answered. Vox has a good piece up today about what would be needed to get to what Bernie is taking about.

My own best guess is that the Sessions-Cassidy plan is mostly just election year talk, whereas the single-payer option will continue to have resonance if a Democrat retains the White House in November. But we are still a long way from either. Meanwhile, we have Obamacare and in all likelihood we’ll tinker with that first. Incrementally, and with no small amount of blood, sweat, tears and another round of misrepresentation and outright lies about the impact — we’ll eventually adopt a universal plan that, in the end, looks a lot like Medicare-for-all.

Mike King headshot 2


Mike King is the author of “A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals,” on sale now through Amazon.com


Doomsday for Obamacare: Again?



IMG_1864News that UnitedHealth Group, the nation’s largest commercial insurer, is withdrawing from the Affordable Care Act’s state exchanges because it can’t make enough money on them, has set off the latest round of gloom-and-doom predictions for Obamacare. Predictably, this rendering of failure, like all the others, is coming from opponents of the 2010 law that has made health insurance available to millions of Americans who otherwise may never have had an opportunity to purchase it.

This was the message in the Washington Post Tuesday from a fellow at the American Enterprise Institute.

It’s worth noting that the big insurance firm’s decision to get out of the ACA marketplace is not good news for Americans living in rural areas who rely on the insurance exchanges to get individual coverage. Indeed, in those sparsely populated areas of the South and West UH’s withdrawal will likely lead to fewer choices for many residents who can only afford what’s available on the government-subsidized exchanges.

But a little perspective about the company’s decision is needed as well. And when examined more closely, the Obamacare-is-destined-to-fail scenario of opponents is once again shown to be wishful-but-unhelpful thinking.

Here’s one of the better analyses I’ve seen of it — offered by a columnist and blogger for The Los Angeles Times.

Digging deeper into these developments as Obamacare evolves is extremely important because most Americans have little understanding how the health insurance marketplace works. As such they can be easily misled — and, as recently shown, lied to — about what’s happening and why.

I’m certain that many readers reacted with alarm when they heard the news last week that UnitedHealth was going to ditch its ACA exchange plans,. I’m willing to bet that most didn’t know that the company’s decisions does not impact the plans it offers to consumers through coverage they get on the job, or through an employee retirement plan or its large and profitable Medicare Advantage plans. Nor were critics quick to point this out because in their world any tremor in the health insurance force is ALWAYS a direct result of Obamacare, even when it isn’t.

In reality, the decision is limited to those plans the company was offering through the individual market exchanges, an arena UnitedHealth reluctantly joined in the first place, And even then, it declined to create low-cost premium/high deductible coverage plans in many markets. That one decision clearly put the company in competitive disadvantage with companies that were more than willing to jump into that part of the individual market, which we know now is the most popular with consumers. (Whether that tier of coverage is a good thing — it may be affordable, but is it really helpful? — is a much different topic and remains one of the most important policy questions remaining to be answered in the first years of the ACA.)

Indeed, the evolution of the insurance market after the ACA seems to be shaking out pretty much as the experts who promoted it in 2010 said it would. Millions of Americans who were screened out of the market before the ACA because of pre-existing medical conditions can now get insurance. Others, thanks to the individual mandate and subsidies, can afford coverage for the first time. And yes, some who had individual coverage in the past that they paid out of their own pockets have had to purchase new policies on the exchanges, a disruptive process that critics unconvincingly exploited as the beginning of the end of Obamacare. In reality, many of these consumers also qualify for subsidies now to help them afford better plans than they had in the first place.

And lastly, the American-revered concept of for-profit, commercial health insurance survives, even as the government plays an important role in helping make insurance more affordable and comprehensive. UnitedHealth is still a hugely profitable enterprise. It still offers employers and retirees and others in large-group markets a range of coverage options. It has simply decided to get out of the individual market because it wasn’t making enough money in it.

Too bad for them. Buh-bye.


Mike King headshot 2

Mike King is the author of “A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals.” Advance ebook sales are available online through Amazon. The book will be available for full release May 31, 2016

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.


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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?

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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.

“Spirit of Charity”

The book I have been working on for several years about Grady Hospital and hospitals like it around the country has a new title.

Atlanta's Grady Memorial Hospital
Atlanta’s Grady Memorial Hospital

“A Spirit of Charity”: Restoring the Bond Between America and Its Public Hospitals.

 The title is based on one of my favorite FDR quotes; “Better the occasional faults of a government that lives in a spirit of charity than the consistent omissions of a government frozen in the ice of its own indifference.”

I’m going to keep the Failure to Thrive blog theme here. Originally that was going to be the title of the book too, but there are already too many books out there with that name or something like it. Still,  I like it for the blog, mostly because of my strong feeling that our nation still hasn’t created a health care system that allows the poor the same kind of access to needed care that the rest of us have. You need only look to Georgia and neighboring southern states to see how we have left millions of working poor people and their families behind to fend for themselves. It is impossible for these folks to thrive in the face of such icy indifference. And public hospitals like Grady shoulder the burden of this fundamental failure. That’s what I’ll be talking about in the book.

Last weekend The New York Times and Enroll America provided a revealing map of the counties around the country where the highest concentrations of people without health insurance live. You can look at it here.

Meanwhile, watch this space. “Spirit of Charity” will be coming soon to a bookstore near you, or  to the digital device that you may now be holding in your hand.

Coming Soon: The Unfinished Business of Health Care Reform

Failure to Thrive: Hope and Reality at Grady Memorial and America’s Great Public Hospitals

Expected publication: Early 2016

Henry W. Grady Memorial Hospital is a fixture in Atlanta, built and chartered by the city in 1892 to provide care to anyone who needs it. Over the years Georgia’s largest public hospital has earned a reputation as one of the nation’s best teaching hospitals. But it also was a place so rife with political mismanagement that it nearly had to close its doors in 2007.

Many of Grady’s counterparts around the country – iconic places we know by their first names like County in Chicago, Parkland in Dallas, Jackson in Miami – have been through similar turning points and survived. Yet how these hospitals operate, who pays for them and how they fit into the nation’s $3 trillion-a-year health care system, is a mystery to most of us.

Through the prism of Grady, Failure to Thrive explains the unique history of America’s large public hospitals, as well as their continuing challenge. More importantly, it is story about how the poor are cared for in the United States.

In a country that has yet to determine whether access to basic medical care is a right or an earned privilege, these hospitals bear the burden of that indecision. Indeed, their very existence makes it easy to avoid the discussion altogether.

That’s because the people who show up in the emergency rooms and clinics of America’s public hospitals represent the gaping holes, the ill-conceived compromises and the unintended consequences resulting from decades of attempts to reform health care in our country.

Even now. Even after the Affordable Care Act, the latest contentious effort to make health insurance more available to Americans without it. The 2010 law – subject to so much litigation at the federal level and ideological obstruction at the state level – still leaves millions of Americans behind when it comes to getting the health care they need, especially among residents of the South, where state leaders have a history of eschewing federal programs aimed at helping the poor. These patients will continue to turn to Grady and Parkland and County and Jackson and dozens of other beleaguered last-resort providers for the care they need and deserve.

Failure to Thrive makes the case that these hospitals represent more than a frayed safety net for the poor; they have become a safety valve for the nation’s highly profitable health industrial complex.

They exist, not just to take care of the poor but to relieve others from the challenge to profits that poor people represent. And because they exist – indeed, many, like Grady, have been around for more than a century – we seem content to take them, and the essential services they provide, for granted.

Public indifference toward large public hospitals can be understandable for nearly all of them have had years where they failed badly in their mission. Many, like Grady, have had to overcome financial improprieties and political interference. Others have been scandalized by horrific treatment of the very patients they were chartered to help.

But know this too – America’s public hospitals are remarkable at survival. Some of the best and brightest minds in medicine, public health and administration are committed to the cause of caring for the poor. And, despite the financial constraints under which they are forced to function, many of them are providing state-of-the-art services for indigent and paying patients alike.

These hospitals are sentinels to the future of health care in America and, ultimately, how our country treats the poor. Knowing more about them will improve the ongoing discussion of health care reform as we move forward.


Mike King, the author, is a retired health policy reporter, editor and columnist for The Atlanta Journal-Constitution.

Secant Publishing, Salisbury MD, expects “Failure to Thrive” to be available in early 2016.






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.