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Last summer's Supreme Court ruling on the Affordable Care Act gave states the opportunity to turn town the expansion of Medicaid, and a handful of Republican governors and legislatures have decided that by punishing their citizens by keeping them uninsured is the way to go. The problem is, that isn't just punishing their uninsured, it's punishing health care providers and taxpayers, too. Hence, some big fights are brewing in those states.
So far, eight states have said they will turn down the expansion, while 13 states plus the District of Columbia have indicated they will accept it. The eight declining are Alabama, Georgia, Louisiana, Maine, Mississippi, Oklahoma, South Carolina, and Texas. Nearly 2.8 million people would remain uninsured in those states, according to Urban Institute estimates, with Texas alone accounting for close to half the total.

Hospitals aren't taking "no" for an answer in the states that have turned down the expansion. Although South Carolina's Republican Gov. Nikki Haley has had her say, the Legislature has yet to be heard from, said Thornton Kirby, president of the South Carolina Hospital Association. [...]

"Obamacare" was once assailed as a job killer by detractors, but on Wednesday in Missouri it was being promoted as the opposite. Missouri's hospital association in released a study estimating that the economic ripple effects of the Medicaid expansion would actually create 24,000 jobs in the state. The University of Missouri study found that about 160,000 state residents would gain coverage.

"This is not a political issue for us ... this is the real world," said Joe Pierle, head of the Missouri Primary Care Association, a doctors' group. "It makes no sense to send our hard-earned federal tax dollars to our neighbors in Illinois."

In the real world, hospitals and health care workers have to provide care to everybody who demands it, and often don't get paid for it. And quite frequently, the really sick people to whom they are providing care could have avoided getting sicker if they'd had access to affordable health care all along. In the real world, the status quo that these Republicans are fighting for has created a major crisis, and is draining state budgets. The pragmatic, smart policy thing for all states to do is to take the Medicaid money, and through it realize benefits like a healthier population, job creation and significant savings.

It's an absolute no-brainer, unless you're a crazy tea partier. And it's going to be the major fight for Republicans in those states that are resisting, because in most of these states there are fewer more powerful interest groups than the health care industry.

Originally posted to Joan McCarter on Mon Dec 03, 2012 at 03:28 PM PST.

Also republished by Daily Kos.

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Comment Preferences

  •  Howard Dean mentioned this (20+ / 0-)

    He says even Texas will knuckle under when the big hospitals gang up on the state legislature and Governor.

    "Work for something because it is good, not just because it stands a chance to succeed." -- Vaclav Havel

    by greendem on Mon Dec 03, 2012 at 03:33:10 PM PST

  •  My governor was a fool on rail (10+ / 0-)

    But I doubt that he will stand up to Big Health when it comes to medicaid. Walker may be a total fool, but there are other Republicans who want hospital and doctor support in the 2014 elections.

    The GOP is the party of mammon. They mock what Jesus taught.

    by freelunch on Mon Dec 03, 2012 at 03:59:28 PM PST

  •  You've (3+ / 0-)
    Recommended by:
    Neon Mama, Kansas Born, 207wickedgood

    Nailed it. The Hospital Industry is NOT a force to be toyed with.

    The Ghost of Tom Joad http://www.youtube.com/watch?v=8jVZHCUbS4U

    by Illinois IRV on Mon Dec 03, 2012 at 04:41:41 PM PST

  •  Medicaid expansion and taxes (5+ / 0-)

    States that, on principle,  refuse  federal funds for medicaid expansion will still have to pay taxes to support Medicaid expansion in New York, Massachusetts, California ,  Hawaii ... even as their own citizens suffer without health coverage and their own doctors and hospitals provide services for free.

    •  No such thing as free health services. (0+ / 0-)

      The taxpayers will pay through state taxes, local property taxes and/or higher insurance premiums.

      "In this world of sin and sorrow there is always something to be thankful for; as for me, I rejoice that I am not a Republican." - H. L. Mencken

      by SueDe on Tue Dec 04, 2012 at 05:46:09 PM PST

      [ Parent ]

  •  I work in a children's hospital with an ER that is (12+ / 0-)

    the busiest in the entire city, a city that is noted as being halfway recovered from the Bush recession.  This afternoon, we had a jam packed waiting room even before the evening rush. The ER is truly the 'safe haven' for everyone who can't find (and most have tried to do so) a family physician or pediatrician of their own.   We turn away noone, and we treat every child with the same kindness.  No child or family needing care turned away in 75 years.  How could one do it any differently?  But it sure as heck ain't free, because when it's your kid, everything better be done the right way. The yearly bill just for exam gloves is huge, and that's representative of only the small stuff.   The one more RN, physician, or PA, and the second respiratory therapist staffing the ER to get kids seen, treated, and back out the door costs money.  But that is what it really takes in the system we now have.   And the business case is that frontline care done right has the potential of saving multiple dollars, even if it is in the wrong place -- i.e., the ER.  If you can keep them from coming back next time, its still something of a win.

    •  Not to mention spare capacity (2+ / 0-)
      Recommended by:
      Pluto, Amber6541

      - some ER's here in New York are so busy that emergency rooms get backed up, true emergencies can't be treated right away. If they are not imminent death emergencies, they have to wait in the ER lobby until space is available.

      There are no more exam rooms in the ER, and the ER is full of patients that were treated the previous evening, and have been admitted but who can't be moved into a room until patients discharged and those rooms are cleaned.  Patients who are going to be treated and released end up lying around on stretchers in the hallways of the ER.

      A real invitation for hospital acquired infections.

      •  Same thing in Bangladesh. (1+ / 0-)
        Recommended by:
        LilithGardener


        A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

        by Pluto on Tue Dec 04, 2012 at 05:47:12 PM PST

        [ Parent ]

        •  We lost St. Vincent's hospital, in Manhattan - (1+ / 0-)
          Recommended by:
          Pluto

          and it would have been very useful during Hurricane Sandy and the aftermath.

          NYU hospital had to evacuate the night of the storm after their back-up generator failed.

          Bellevue managed on back-up power for 2 days before they had to evacuate.

          There were many others who needed medical care, and there was very limited transportation for the first few days.  

          People couldn't just walk 50 - 80 blocks to the next nearest hospital.

    •  urgent care clinic? (1+ / 0-)
      Recommended by:
      Kansas Born

      I'm guessing a lot of the folks you see could be dealt with very competently by a nurse or nurse practitioner or PA -- they don't need the ER, they need a primary care provider who accepts Medicaid and is accepting new patients.

      Has your hospital considered opening a "school nurse"-type clinic adjacent to the ER, that is open evenings and weekends, but is lower-tech and staffed less expensively than the ER, to handle what are basically primary-care issues?

      It would seem like it would be cost-effective for the hospital.

      Or maybe they just triage those as they come in the door -- still seems inefficient.

      •  Yes, that is in the works, both for the onsite ER (0+ / 0-)

        and for a couple of satellite locations.  It has moved slowly due to a strong aversion to making an expensive and wrong guess without doing everything possible to maximize the efficiency of one central location.   Lots of things in flux in healthcare at the moment.  Lots of ways to make wrong moves.

  •  Can wait for the Hospitals and Dr's groups (5+ / 0-)

    to get a hold of our little "piss-ant" governor (Jindal) and "'splain" things to him. That is, if they can catch him in the state as he spends most of his time running for another office.

    "I'm totally pro-choice in the matter of abortion. But of course I'm also so radically pro-life that I think every person from birth onward must have full and affordable access to healthcare." - Gail Collins

    by gritsngumbo on Mon Dec 03, 2012 at 07:03:47 PM PST

    •  How can he not know this? (1+ / 0-)
      Recommended by:
      SueDe

      We have lost "government for the benefit of the people" entirely.  Much of the US is operating purely on partisan power fascism.


      A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

      by Pluto on Tue Dec 04, 2012 at 05:43:16 PM PST

      [ Parent ]

    •  Why haven't they already, is what I want to know? (0+ / 0-)

      We have known for weeks that the governors are going to deny the expansion...so why aren't they vocal about it?

       Seems to me, they need to get mad and start saying it...what are they waiting on?

  •  Provide Care (4+ / 0-)

    Many people in the real world are not provided only emergency care which can't treat most conditions that people have.  For example, if you have diabetes you need education and daily insulin.  You're not going to get that at an ER.  That's why it's estimated that 50,000 people die each year due to lack of health insurance.

  •  tea partiers are lacking in the brains (3+ / 0-)
    Recommended by:
    Amber6541, LilithGardener, skod

    department...

    It's an absolute no-brainer, unless you're a crazy tea partier. And it's going to be the major fight for Republicans in those states that are resisting, because in most of these states there are fewer more powerful interest groups than the health care industry.

    www.tapestryofbronze.com

    by chloris creator on Tue Dec 04, 2012 at 05:36:24 PM PST

  •  HEALTHCARE IS JOBS. (5+ / 0-)

    Medicaid means "jobs".

    Medicare means "jobs".

    Cut healthcare, cut jobs - been there and seen it many times.

    Repubes hate employed Americans, they hate sick Americans who try to get well, and they really hate unemployed Americans who want to get jobs.

    And man...jobs in preventative healthcare.....repubes gotta lay awake at night hating those......

    The path of the righteous man is beset on all sides by the inequities of the selfish and the tyranny of evil men.

    by xxdr zombiexx on Tue Dec 04, 2012 at 05:37:05 PM PST

    •  And when unemployed people are sick it is (2+ / 0-)
      Recommended by:
      xxdr zombiexx, Pluto

      really hard to get a job.

      •  yes, yes, yes (1+ / 0-)
        Recommended by:
        LilithGardener

        This is a big argument for having Medicaid cover dental as well -- people with decent teeth have an easier time getting jobs. People whose diabetes is under control have an easier time getting and keeping jobs. Etc. etc. etc.

        People without access to medical care are more likely to become disabled, and to apply for SSI-Disability because they have trouble working AND SSDI comes with a Medicare card.

        I am hoping the ACA helps eliminate some of the incredible distortion throughout our whole economy due to the way we've been doing health insurance the past 60 years.

  •  "The pragmatic, smart policy thing..." (1+ / 0-)
    Recommended by:
    Pluto

    Uh huh...
    Rick Perry.

    If I ran this circus, things would be DIFFERENT!

    by CwV on Tue Dec 04, 2012 at 05:37:40 PM PST

    •  I believe he is a farm animal. (0+ / 0-)

      It's asking a lot of him to comprehend the world of humans.


      A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

      by Pluto on Tue Dec 04, 2012 at 05:44:54 PM PST

      [ Parent ]

      •  Perry knows a lot about humans, (1+ / 0-)
        Recommended by:
        Pluto

        particularly whether they have a lot of money they would be willing to spend on him, his political campaigns or those of his fellow Republican officeholders.

        "In this world of sin and sorrow there is always something to be thankful for; as for me, I rejoice that I am not a Republican." - H. L. Mencken

        by SueDe on Tue Dec 04, 2012 at 05:56:29 PM PST

        [ Parent ]

        •  Okay, a "gifted" farm animal. (0+ / 0-)

          There was a chicken in Chinatown that always beat me at tic tac toe -- so I know some of them can be gifted. But it would never occur to me to vote for the chicken to run the state.


          A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

          by Pluto on Tue Dec 04, 2012 at 06:08:36 PM PST

          [ Parent ]

  •  Maybe I'm confused about this (5+ / 0-)

    But my understanding was that the bulk of the Medicaid expansion (gov funding to the states) was to help hospitals with their massive losses from uninsured patients.

    (Much more so that expanding Medicaid rolls directly.)

    Hospitals say that without the funding, they'll have to close (or move to states that have accepted the funding). That is certainly the prevailing investment strategy on Wall Street regarding hospitals.

    Thus, states that reject the funding are closing hospitals to everyone. No?


    A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

    by Pluto on Tue Dec 04, 2012 at 05:39:47 PM PST

    •  Ditto - I had the same understanding (2+ / 0-)
      Recommended by:
      Pluto, jm214

      - by making more people eligible for medicaid, more people can be seen at clinics and by physicians who take medicaid, and when those same eligible people show up in the ER, the hospital can refer them to a clinic if it's not a life threatening emergency, and receive gov reimbursement when they do provide stabilization and treatment.

      One example:

      Elderly person, living independently, breaks hip but is otherwise in good health for their age. Before medicaid expansion, they might be stabilized in the hospital and released with a bill. No support for their follow-up care.

      With medicaid expansion, they can be treated in hospital, hooked up with home health care nursing organization or rehab, (and other social services) while they are in the hospital or when they are discharged.  

      The patient's chance of a full recovery at home is much higher than if they can't manage on their own, and then need a second trip to the ER.

      •  Okay. Makes sense with the clinics. (1+ / 0-)
        Recommended by:
        LilithGardener

        (Are they funded separately or through Medicaid?)

        In the big picture -- I believe this expanded Medicaid was one of the very few cost controls in the ACA. Which then puts a sinister spin on the rejection.

        Republicans should remember:  It's pillage first, then burn.


        A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

        by Pluto on Tue Dec 04, 2012 at 06:13:44 PM PST

        [ Parent ]

        •  Depends on the state (1+ / 0-)
          Recommended by:
          Pluto

          In New York state it's both.

          There are a variety of clinics where the capital to build the clinic was provided by the state or a Federal program, and the treatment of patients is funded through medicaid.

          (Are they funded separately or through Medicaid?)
          There are also private and non-profit clinics of various kinds, that charge on a sliding scale depending on income.

          Some hospitals run medical clinics for low income people on the same campus as the hospital. Those programs are regulated and funded through the state. Some are financed under the medicaid, and some are not.

          But here in New York, expansion of Medicaid eligibility opens up a whole host of other services for those people, such as housing assistance, employment assistance, even some child care programs (e.g. for a parent who is training for a job).

      •  Inconsistent with the Red Command: "Sick? DIE!" (0+ / 0-)

        "Is that all there is?" Peggy Lee.

        by jm214 on Tue Dec 04, 2012 at 06:25:14 PM PST

        [ Parent ]

  •  I'm waiting for the Republican voters (4+ / 0-)

    in those states that refuse Medicaid expansion to finally figure out why their property taxes are going up dramatically, particularly the percentage represented by the local hospital authority.  A lot of those voters won't ever figure it out, but enough of them may finally understand that their state Republican government has done them no favors whatsoever by refusing federal money, because "freedom."

    "In this world of sin and sorrow there is always something to be thankful for; as for me, I rejoice that I am not a Republican." - H. L. Mencken

    by SueDe on Tue Dec 04, 2012 at 05:43:04 PM PST

  •  I heard a commercial today on WABC Radio, (1+ / 0-)
    Recommended by:
    Pluto

    home of Rush Limbaugh and the other dregs of humanity here in NY.
    The commercial stated that the cost to taxpayers for the Medicaid exchange would exceed 100 million dollars per state.
    These people should be locked up.

    "Beer is living proof that God loves us and wants us to be happy." -Benjamin Franklin

    by hotdamn on Tue Dec 04, 2012 at 05:46:02 PM PST

    •  Democracy is impossible in (1+ / 0-)
      Recommended by:
      hotdamn

      ...in a nation where it is constitutional to lie to the people about political matters over the public-owned airwaves.

      I don't know of a developed nation that allows that.


      A child of five would understand this. Send someone to fetch a child of five. -- Groucho Marx

      by Pluto on Tue Dec 04, 2012 at 06:23:38 PM PST

      [ Parent ]

  •  These rebellious Governor's and state legislatures (1+ / 0-)
    Recommended by:
    jm214

    are going to provide an ironic benefit to the nation, as they show the true cost of screwing over their most vulnerable residents, and a critical industry.

    There will be easy comparisons in metrics for those states who implement the ACA right away, and those that refuse to set up their exchanges on time, and those that refuse to accept the medicaid expansion.

    These asshats are going to unwittingly become compelling negative controls!

  •  I wonder when AHIP will realize (2+ / 0-)

    that Republicans aren't really their friends at all?  Do they have to learn the way GM did?

    Early to rise and early to bed Makes a man healthy, wealthy, and dead. --Not Benjamin Franklin

    by Boundegar on Tue Dec 04, 2012 at 05:48:10 PM PST

  •  State republicans won't turn down the money. (0+ / 0-)

    For the same reason the Supreme Court upheld the Obamacare mandate ($$$$$ from the healthcare industry), which I correctly predicted against the collective wisdom of the site; state republicans (in all but maybe 1 or 2 states) will accept the federal Medicaid expansion money (i.e. $$$$$ from the healthcare industry). Mark it down (i.e. big money calls the shots).

  •  Republican Politicians are Amazing (4+ / 0-)
    Recommended by:
    Pluto, meralda, Dewstino, Illinois IRV

    The policy makes both fiscal and ethical sense and yet they oppose it purely for political reasons. They don't care at at about the citizens who elected them. They only care about scoring political points against the Democrats and consolidating their party's power. Worse, yet the people who voted for them are too ignorant to understand that these official couldn't care less about what is best for their state.

  •  What's the motivation? (0+ / 0-)

    RE: The eight declining are Alabama, Georgia, Louisiana, Maine, Mississippi, Oklahoma, South Carolina, and Texas.

    Note that, AL, GA, LA, MS, SC, and TX have minority populations that exceed 25% of the total population. The refusal of benefits will disproportionately affect low-income minority residents.

    Now, I wouldn't say that the decision by the states in question was racially motivated. Also, I wouldn't say that this is a case of Republican leaders in those states who are ignoring the needs of people who don't vote them, or a case of those leaders who are using policy decisions to somehow hurt or penalize members of the electorate who don't for them.

    I would say that GOP leaders in those states might be a little out of touch with the needy citizens of their states... at the least.

  •  They don't *want* healthier poor people (1+ / 0-)
    Recommended by:
    Pluto

    Poor people are supposed to get sick and die.

    I know that sounds like fascism, but the GOP is not fascist: they would never spend public money on gas chambers while we have perfectly good streets for the poor to die on.

  •  Would the Republicans be so decent (1+ / 0-)
    Recommended by:
    Pluto

    as to offer us euthanasiums -- a place to go so the people so desperatedly ill as to need medicaid can die in comfort and not be a disgrace dying on the street?  

  •  How it looks, in real life: Rick Scott kills for (2+ / 0-)
    Recommended by:
    Pluto, EarthTone

    privatized profit. Please, read the whole article, and look at the picture?

    Disabled daughter dies just hours after state takes her from mom

    Even after Marie Freyre died alone in a nursing home 250 miles from the family in North Tampa that loved her, Marie's mother had to fight to bring her home.

    In March 2011, state child protection investigators took 14-year-old Marie from her mother, Doris Freyre, claiming Doris' own disabilities made it almost impossible for her to care for Marie, who suffered from seizures and severe cerebral palsy. But a Tampa judge signed an order that Marie be returned to her mother, with in-home nursing care around the clock.

    Florida health care administrators refused to pay for it, although in-home care can be demonstrably cheaper than care in an institution. Child welfare workers ignored the order completely.

    Two months later, Marie was strapped into an ambulance for a five-hour trip to a Miami Gardens nursing home, as her mother begged futilely to go with her.

    Marie died 12 hours after she arrived.

    "Since the state of Florida took custody of my daughter, I would like the state of Florida to bring me back my daughter," Freyre, 59, said at a May 9 court hearing, 12 days after her daughter died.

    http://www.tampabay.com/...

    I know a woman who works full time and then cares for a daughter that is in similar circumstances to the kidnap victim in this story. She has had to go to war with the state, which first wanted her daughter to "get a job" to justify cutting the puny benefit she does get (a day nurse to let her mom be productive and taxpaying, as a nurse in her own right). Then they tried to force her into a "nursing home," which would also have been a death sentence for HER. All to make some of Skeletor Scott's buddies a little richer.

    It's almost always far cheaper, and always kinder, to leave people needing this kind of care in the homes where they are loved and looked after, rather than to the "mercies" of for-profit institution owners and the sad people who have to work for them and lose their lovingkindness in the thrust for "productivity" and profit. (And yes, there are exceptional situations where 'nursing homes' with rats and fire ants and roaches biting the inmates, and abusive staff, and shitty food and bedsores and the rest, are better than a biological parent with a lit cigarette and a warped mind. A very few exceptions, from what I know, and "the state" is piss-poor at distinguishing them, especially when ordered from on high to dump 'em in the "facilities for abuse and profit.")

    What the fuck is the matter with these people? Wait, don't answer that -- I know all too well. They are just too much of a set of prime examples of the REAL nature of most humans, at least the ones that are drawn to the "conservative" darkness. I despair of any likelihood that the mix of personalities in our maybe-we-already-killed-ourselves-with-overconsumption-of-everything species' population will ever shift toward a preponderance of Golden Rule-ers...

    "Is that all there is?" Peggy Lee.

    by jm214 on Tue Dec 04, 2012 at 06:23:18 PM PST

  •  Just a word on this line: (1+ / 0-)
    Recommended by:
    Portlandia
    In the real world, hospitals and health care workers have to provide care to everybody who demands it, and often don't get paid for it.
    Only true up to a point - hospitals have to provide emergency care sufficient to stabilize the patient.  And that can be quite a lot of care in some circumstances.  If you show up in the midst of a heart attack, I've seen that emergency care extend all the way to bypass surgery.  But, if your condition is "stable" - like high blood pressure, or  diabetes or a painful arthritic condition or a suspicious lump or many other things, there is no such obligation.  We don't want to propagate the Republican lie that people can get all the care they need in the ER

    "Wouldn't you rather vote for what you want and not get it than vote for what you don't want - and get it?" Eugene Debs. "Le courage, c'est de chercher la verite et de la dire" Jean Jaures

    by Chico David RN on Tue Dec 04, 2012 at 06:34:42 PM PST

  •  The eight declining are Alabama, Georgia, Louisian (0+ / 0-)
    "The eight declining are Alabama, Georgia, Louisiana, Maine, Mississippi, Oklahoma, South Carolina, and Texas. "
    A roll call of the benighted and stupid states.

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