Your state’s decision not to expand health coverage is creating two Americas: one where millions are benefiting from preventive care and covered treatments while local economies get stronger and healthier by the day; and another where patients continue to show up to emergency rooms without a way to pay and the local economies are falling further and further behind. 

Kay Hagan signs a letter to governors, including our own, from states that have not accepted Medicaid expansion. 

The letter is about Medicaid, but refers directly to the ACA. Hagan needs to hammer home the message that burgeoning healthcare coverage = ACA = Obamacare = no exclusion for pre-existing conditions etc. 

And she should emphasize the importance of personal stories and personal responsibility. As long as people are going to get healthcare in some way -- and they are, and they should -- they should have some way of paying for it. 

Related: "Ms. Marks had a hole in her tooth this winter, she said, and went to the emergency room. They gave her a painkiller and a bill for $600, which she has ignored. The tooth remains so damaged that she can chew on only one side of her mouth."

Our system -- and those of us with private insurance -- are paying for this kind of inadequate care already. Rationalizing payment and delivery is the smart and humane way to go.

Comments

[Jim Buie]

Thanks for the informative links, Ed.

[Spag]

Obamacare was supposed to fill the gap between those who could pay nothing and those who could pay something (while screwing over everyone else). Are you aware of the number of people in NC affected by non-expansion according to income level? You guys act like this is some huge crisis when in fact they could just sign up for Obamacare and pay a subsidized premium. Those who can't afford this still qualify more Medicaid expansion.

The real goal here is to expand Medicaid to eventually include everyone- the universal coverage that the Left has wanted for years.

[Andrew Brod]

Obamacare did fill the gap, which is between 100% and 138% of the federal poverty level. It did so by including Medicaid expansion as an integral part of the bill. Anyone in that gap can indeed sign up for insurance through the ACA and most qualify for premium subsidies. But if North Carolina had expanded Medicaid, those people could have gotten coverage for nothing. It's not an even trade-off for the affected low-income people.

As a result, some of them will be unable to afford even subsidized coverage and yet will earn too much to qualify for Medicaid. So let's not pretend that there are no costs of non-expansion.

The real goal of expanding Medicaid under the ACA was simpler than Spag's paranoid claim. The goal was to remove higher-risk people from the ACA exchanges and ensure a better-functioning risk pool. Therefore, another cost of North Carolina not expanding Medicaid (there are many) is higher premiums on the ACA exchange than there would have been with a less-risky pool of insureds.

[hartzman]

"if North Carolina had expanded Medicaid, those people could have gotten coverage for nothing."

Andrew Brod
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Nothing?

Your math is flawed Andrew, yet you continue to spew.

You misled city council and our community on this issue in public.

[Andrew Brod]

Not one bit, but thanks for chiming in.

[Spag]

"Therefore, another cost of North Carolina not expanding Medicaid (there are many) is higher premiums on the ACA exchange than there would have been with a less-risky pool of insureds."

Assumes these people who don't get Medicaid get coverage anyway and enter the risk pool.

Trying to have it both ways.

[Andrew Brod]

Actually not a terrible point. Mazel tov.

However, I didn't say "all of them" in two places. Some of them will enter the risk pool. Some of them won't be able to afford to.

[W.E. Heasley]

“if North Carolina had expanded Medicaid, those people could have gotten coverage for nothing." - Andrew Brod

Nothing?

Your math is flawed Andrew, yet you continue to spew.

You misled city council and our community on this issue in public. - Mr. Hartzman

Followed by:

“Not one bit, but thanks for chiming in.” - Mr. Brod

Upon further review, Mr. Hartzman is correct. A price and cost is associated with the expansion. Mr. Brod is exactly wrong as no free lunch exists as price and cost do not magically disappear.

However, if one wants to use political mathematics, also known as dupery and nitwitery, then Mr. Brod is exactly correct.

[Andrew Brod]

Hartzman isn't remotely correct, and neither are you. I didn't say there would be no social cost to providing health insurance via Medicaid, and only someone intent on missing the point would think I did. Obviously the ACA, including Medicaid expansion, comes with costs to society. The point I've made on various occasions, which Hartzman is apparently incapable of understanding, is that those costs are paid for in various ways.

What I said upthread was that the low-income people who would receive health coverage under Medicaid expansion would see it as free. You may not like them receiving free health coverage, but it doesn't make it any less free from their perspective.

[hartzman]

"those costs are paid for in various ways."

Andrew Brod
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The way much of the costs are supposed to be paid for have been delayed/altered/put off indefinitely.

The age and quality of sign ups were inaccurately projected to the downside of what we were told would happen.

100% subsidized Medicaid sign ups spiked.

That's why the CBO can't calculate what you take as fact.

How is it that Andrew Brod can say it's all paid for if the CBO can't?

[Andrew Brod]

The CBO is no longer calculating deficit projections for the entire ACA; that's true enough. But if one reads their documents, it's apparent that they still believe that the ACA will reduce deficits. I'd rather have numbers, but we have what we have.

It was 2012 when the CBO made its last projection of the overall deficit effect of the ACA. It would be a gross mischaracterization to claim that the CBO now believes that the deficit implications have turned upside-down in only 2 years.

But forgive me for stepping on your toes: gross mischaracterization is what you do. Have at it!

[Andrew Brod]

Moreover, the 2012 projection included a calculation for the second 10 years of the ACA, not just the first. My understanding is that the CBO asked that it not be required to do that, because such projections are understandably less reliable. A 10-year projection is iffy enough!

But with the caveat that these are just projections (albeit the best non-partisan ones we have), it's worth noting that while the 2012 document projected a very small reduction in the federal deficit over the first decade of the ACA, it projected a pretty large one in the second decade. If that second projection was even somewhere in the ballpark of reality, it would appear that the various delays mentioned by Hartzman will delay the bigger deficit-reducing effects of the ACA. That's not good, but it's not catastrophic.

[Andrew Brod]

As for such concerns as the age/risk mix of the insured pool, the CBO continues to make numerical projections of the cost of the insurance-coverage provisions of the ACA. Its most recent projections have factored in the most recent information, and guess what?

Its projections of future costs are falling.

The April 2014 projection is lower than the February 2014 projection, which is lower than the 2013 projection, which is lower than the 2012 projection.

[hartzman]

"An important feature of the Affordable Care Act (ACA) is the penalty tax imposed on people who do not have health insurance. But newly updated report from the Congressional Budget Office projects that just under 4 million people will pay the penalty in 2016, less than 15 percent of the estimated 30 million people who won’t have coverage that year."

Forbes, 6/12/2014
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Meanwhile, Andrew and Ed's healthcare industry friends continue to raid the Treasury via debt allocated to our kids for overpriced care.

Outright theft by an industry that has been sucking the life out of our economy.

[Andrew Brod]

If they're my friends, I wish they'd give me a cut.

[hartzman]

As I recall, you already got a cut for a "study" or something, no?

[Andrew Brod]

I knew you'd say that.

Yes, over a 10-year span, I worked on a couple of studies for the Moses Cone Etc. Etc. Health Foundation and Cone Health itself, and UNCG got paid for both of them.

[W.E. Heasley]

“Hartzman isn't remotely correct, and neither are you.” - Mr. Brod

Ah, a notional statement held forth as fact with no supporting evidence. How very nice indeed!

“You may not like them receiving free health coverage, but it doesn't make it any less free from their perspective.” - Mr. Brod

Ah, vilify opponents in order to deny opponents legitimacy. An old and worn out debate stratagem [Yawn].

“Obviously the ACA, including Medicaid expansion, comes with costs to society.” - Mr. Brod

And to that: ‘ “Society”….. - a makeshift phrase people resort to when they do not quite know what they are talking about.’ - F.A. Hayek, The Fatal Conceit, paperback edition, page 113.

“The point I've made on various occasions, which Hartzman is apparently incapable of understanding, is that those costs are paid for in various ways.” - Mr. Brod

No, price is paid, not costs. Cost(s) is/are always the forgone alternative(s).

[Andrew Brod]

Yes, I've read a few economics textbooks as well. Unlike you, I understood them. You're misusing the definition of opportunity cost.

[NitWitCharmer]

Brod:

Yes, I've read a few economics textbooks as well. Unlike you, I understood them. You're misusing the definition of opportunity cost.

Self fellation is not an argument. But when one is limber enough to rationalize incorrect statements I suppose it can pass for self soothing.

...not that you troubled yourself with rationalizing your misuse of opportunity cost before that self soothing.

[NitWitCharmer]

Ed:

The letter is about Medicaid, but refers directly to the ACA. Hagan needs to hammer home the message that burgeoning healthcare coverage = ACA = Obamacare = no exclusion for pre-existing conditions etc.

One wonders when prohibition was on the road to repeal if there was a similar cadre of dead-enders.

Hammer away.

[Andrew Brod]

It's certainly amusing to have clueless non-economists (most non-economists aren't clueless) accuse me of not understanding opportunity cost.

It's like non-scientists claiming that climate scientists don't understand climate change.

Oh, right. Never mind.

[NitWitCharmer]

Just as nature has not met the predictions of climate scientists, the state of healthcare under the ACA has not met the rosy predictions of ACA supporters. Each of you have been wrong.

By contrast, realists in the TeaParty predicted both correctly. The TeaParty was especially correct in regard to the ACA. From keeping your doctor and plan to saving $2500/year the TeaParty was right. You were wrong.

You predicted that ER visits would drop under the ACA. They have risen.

You predicted that America would save money under the ACA. It has not.

You predicted that more people would have under the ACA... and there are, but only because so much of the ACA has been delayed. You were right! But so very wrong.

A realist would conclude that if the only time your predictions are correct is when the ACA is delayed then we are better off without the ACA. A realist you are not. Like climate scientists you cling to your credentials and your statistics while denying nature itself.

Reality has spoken not only to climate scientists, but to you; your educations have failed each of you. Perhaps a round of self education is in order.

[hartzman]

I agree with nitwit charmer except for the climate stuff.

tbs, I think what ever we did to the planet's human occupied atmosphere is too late to reverse.

Earth is a self flushing system, and we appear to be fecal relatively.

[Andrew Brod]

It's a village of straw men!

I did not predict that ER visits would drop. Frankly, it makes sense that they would rise in the short run, and it's not a bad thing. It's also not where the high cost of care is (something I learned from one of the studies noted above).

I did not predict that healthcare spending would drop in absolute terms. No one did.

And I don't know what "more people would have under the ACA" means. More would have insurance? That prediction has been borne out by most of the data we've seen so far.

[NitWitCharmer]

Yes, insurance.
My fault.

[NitWitCharmer]

Brod:

More would have insurance? That prediction has been borne out by most of the data we've seen so far.

'...but only because so much of the ACA has been delayed. You were right! But so very wrong.'

And I don't recall you arguing that the ACA would raise costs in absolute terms, nor do I recall you arguing that the ACA would increase ER visits in absolute terms.

Your position regarding the ACA appears to have changed.

[hartzman]

Revisionism is a popular in the "actual" economics profession.

Especially within the political sphere in which andrew operates.

truth is tertiary

[hartzman]

"One of the crucial areas where the Affordable Care Act, better known as Obamacare, has driven profitability for insurers has been through the expansion of Medicaid, which the majority of states have implemented. Those millions of new people on the company rolls have helped drive revenue across the industry. And more may be yet to come.

...we think of Medicaid as a government program, but when we increase funding for it, we’re really increasing pass-through to private contractor.

Insurers Molina Healthcare (NYSE: MOH ) , UnitedHealth (NYSE: UNH ) , and Aetna’s (NYSE: AET ) Coventry Health may all see sales growth tied to the Affordable Care Act’s Medicaid expansion this year as California digests a big backlog of enrollees and Michigan’s newly launched expansion kicks in.

Molina is a major provider of Medicaid services in California, and all three companies provide private Medicaid insurance in Michigan, where the enrollment expansion began on April 1.

...In the 12 months ended April 30, health-care stocks in the S&P 500 index gained 22.7%, beating the overall index’s 17.93% return. Health-care stocks made up 13.2% of the S&P 500 index’s market capitalization as of April 30.

...The key point to remember in all discussions of ObamaCare is that neither it, nor indeed the entire private health insurance “industry,” should exist. They are rent-seeking parasites, economic tapeworms. One does not improve a tapeworm; one removes it.

So, profits there may be. They have at best no social utility; they do not serve public purpose. It’s as if we were diagnosing the health of a body by measuring he length of a tapeworm within it.

...1.7 million applicants in limbo + 2 million accounts with “discrepancies” = 3.7 million, and 3.2 million / 8 million = 46% of 2014′s ObamaCare surge have screwed up Medicaid accounts. Of course, the Republicans can’t hold hearings on this, let alone run a Dukakis-style “competence” campaign because (a) even they couldn’t handle the hypocrisy of denying Medicaid to their own citizens while exposing how poorly the administration handled expanding it..,"

Naked Capitalism

[Andrew Brod]

As usual, you provide no URL, just a block of text. But if this is Yves Smith, it sounds like she's arguing for single payer. That's an argument to which I'm sympathetic. But Frog's head just exploded.

[Andrew Brod]

Bad attribution, Hartzman. Some of that text is from the Motley Fool. There may be other sources in there, but I gotta run.

[NitWitCharmer]

But if this is Yves Smith, it sounds like she's arguing for single payer. That's an argument to which I'm sympathetic.

Call it what it is ... monopsony.

[hartzman]

Our current system is a rip off which lines the pockets of the healthcare industry bigs and many doctors, who line the pockets of the politicians on both sides who keep it that way for them with borrowed money.

It's broken and needs fixed.

Andrew and Ed seem to be bent on leaving it like it is, with some cosmetic adjustments to calm the masses but not actually do anything about the blatant corruption.

Par for course.

[Andrew Brod]

You've changed the subject, which of course is par for the course.

If what you're saying now is that you'd prefer more significant reform than is delivered by the ACA, I doubt that the corporate lackeys known as "Andrew and Ed" (actually, that sounds like a bad morning radio show) would disagree.

[hartzman]

Cool how you can change colors so easily.

Does your tail fall off when you get scared?

[hartzman]

I apologize for name calling.

What would you and Ed most likely agree about regarding lowering healthcare costs for the American population?

[Ed Cone]

George, are you now advocating for a single-payer system? If so, how would it be funded? And what incremental steps would you take to move the massive system-of-systems that is healthcare toward this objective?

One example re my last question: It's easy to say we should return the practice of medicine to the highly-respected and well-compensated -- but not fortune-making -- profession it used to be, and still is in much of the world (a goal I advocate, fwiw). But how do we address the med-school cost and debt docs face today if their lifetime income is greatly reduced?

[hartzman]

Possible answers;

Eliminate the healthcare insurance industry, which would eliminate the tax deduct-ability of premiums.

Have the healthcare industry post what everything costs.

Provide x amount each year to medicare recipients and let them provide or not provide themselves with care with what they get.

Stop the government from providing anything but hospice for terminally ill patients. If they have the money to blow for a couple more months, they should be welcome to spend their own money.

Eliminate Medicare prescription and other subsidized pharma/drug coverage and impose the VA's prices at least.

I among many would have another $20,000 a year in my pocket if the above were imposed.

I'll think of some more, but you get the idea.

I know of a doctor who lives in Texas but practices in the USA and Mexico. He charges a small fraction of what he gets in America.

Enforce patent expiration instead of the crony capitalistic current buying off generic manufacturers to not bring less costly drugs to the market.

Total price transparency and physician rating systems.

Break up the hospital/doctor practice monopolies.

Open up the medical education industry to less costly alternatives.

[hartzman]

Quid Pro Quo Clarice;

What would Andrew and Ed suggest regarding lowering healthcare costs for the American population?

[Andrew Brod]

As usual, it's a thicket one has to crawl through.

But let's focus on two points. By advocating the elimination of the private health insurance industry and barring government from providing health care (other than hospice care), it would seem that you want publicly provided health insurance and privately provided health care. In other words, you want single payer. Is that accurate?

[hartzman]

I don't think the government should provide hospice care.

We are obligated to provide VA care.

I don't know the final answer, but what seems appropriate to me is along the lines of everyone for themselves, and the system would adapt to a new, transparent, non-skimming, non-crooked new reality.

Costs would drop dramatically.

Tear it down and let it re-evolve without all the cronyism, political and industry wide.

There is no way to pay for the boomers medicaid costs, so let's not.

Let's stop screwing our kids.

I still haven't heard any ideas Andrew and Ed, or do you like everything like it is?

It's going to disintegrate anyway, so why not try to limit the damage?

In my view, once the Ponzi/Fed economy blows, the healthcare industry is going to take it on the chin anyway.

As more info comes out on how our physician crowd walked with so much from so many borrowed from other generations, I fear what could be/will probably be a violent backlash.

It will probably start with a revolt against education costs and debt for degrees that didn't pay.

Our generation will have reaped what we sowed, or let happen via apathy.

[Andrew Brod]

I'm sorry. I tried to start a conversation, and you're just parroting your usual nonsense. My bad.

As for me, of course I don't like everything as it is. But the ACA is a good start. When it comes to policy, I don't want the perfect to be the enemy of the good.

[hartzman]

Can't come up with anything you would fix if you could?

What's nonsense Andrew?

What don't you like as it is?

Please don't make denigrating generalizations after I get specific.

Quite the lame response for a "PhD".

"you're just parroting your usual nonsense" which I believe I am going to be right about, and have been right about before a couple of times.

If you can't point out what "nonsense" is that you speak of and why it is so, you have forfeited the debate in my view.

Living with blinders on is no way to play economist.

Sad really, to be publicly quoted as much as you are to not be able to defend your economic philosophy/outlook while at the same time put down the forecasts of others who have proven track records without specific reply.

When you taught, did you teach your students those tactics?

[NitWitCharmer]

"...the ACA is a good start."

While the ACA has helped a select few, it has harmed the whole of America.

The ACA is a Bad start ... a dead end from which to turn. Ask a vet.

[Ed Cone]

"Eliminate the healthcare insurance industry..."

and

"Stop the government from providing anything but hospice for terminally ill patients."

So you would get rid of private and public insurance?

This does not seem remotely realistic to me, George, in either political or practical terms.

My stated preference (and these conversations would be easier if you acknowledged previous threads, including comments made directly to you) would be for some version of a German-style multi-payer system. In the meantime, I think ACA is a reasonable if flawed step toward requiring everyone who is likely to use the healthcare system (i.e., everyone) to find some way to pay for their use of the system.

[hartzman]

For all the good hospice does, I hear it also is one of the biggest money makers for private industry paid for by taxpayers.

What ever system that ends up happening, it's going to be about less sponging off of everyone else to line pockets.

What it comes down to is doctors, hospitals, pharma and device makers need to make a lot less money. These folks have massively abused a taxpayer funded gravy train.

"U.S. health-care expenses are bankrupting our country. And there is no way to control these expenses without limiting physician pay."

Forbes
.
.
Can Ed or Andrew admit it?

[Andrew Brod]

Hartzman: "Stop the government from providing anything but hospice for terminally ill patients."

Hartzman: "I don't think the government should provide hospice care. We are obligated to provide VA care."

He's unintelligible, and that's only one example.

[hartzman]

No an idea between you.

not an answer to doc pay between you.

acts of rhetorical cowardice gentlemen.

[hartzman]

"He's unintelligible, and that's only one example."

Andrew Brod
.
.
I offer to debate these issues with you and Ed anytime, anywhere, with a third of the time allotted to me Andrew.

If this were a debate class, you would have received a F Andrew.
.
.
"you're just parroting your usual nonsense."

Andrew Brod
.
.
With Andrew, it's like debating a middle school student.

It would be fun to watch you make an ass of yourself live.

Not up for it professor?

Happy father's day.

[Ed Cone]

George, in all fairness, you don't seem to be reading what's actually written in response to your own remarks here.

For example, when you challenge me to "admit" that doctor pay is a big issue, you're ignoring that I said the same thing a few comments upthread -- complete with some detail on the complexity of fixing the problem.

Also, you don't seem to be debating policy -- you throw out things that seem unrealistic (get rid of private and government insurance) and then move on, while not responding at all to policy points actually raised by others.

So it's hard (for me, at least, and perhaps the problem lies with me) to have real conversation with you.