Proceedings of the 22nd National Conference – Thought Provocateur #2 (Jonathan Weisbuch, MD): Repeal PPACA and Medicaid, but Expand Medicare

We gratefully acknowledge the sponsorship of the Cascades East Family Medicine Rresidency Program/Sky Lakes Medical Center/Oregeon Health Sciences University (Doctor Rob Ross, Program Director) for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

 

Mark Clasen, MD, Ph.D., Wright State University, Dayton, Ohio (Moderator): Our next Thought Provocateur is Doctor Jonathan Weisbuch, who will be discussing the idea of repealing both PPACA and Medicaid and replacing both with an expansion of Medicare. Welcome, Dr Weisbuch.

Jonathan Weisbuch, MD, MPH; Director, Maricopa (AZ) County Department of Public Health (retired)

Jonathan Weisbuch, MD, MPH, Phoenix, Arizona: Thanks. I feel humbled by this crowd because some of what I’m going to say Dr Geyman has said already. But I’m going to say it in a little different terms.

Dr Weisbuch’s Dedication of his Presentation to the Late Doctor David French

I’d like to start by dedicating this piece or this talk to a close and dear friend of mine who died just a week and a half ago, Doctor David Michael French. Some of you might have known Dr. French. He was one of the originators of the Medical Committee for Human Rights (MCHR) which brought together physicians, nurses and other providers of care to march with Martin Luther King during the civil rights efforts to care for the folks who were being attacked by the opposition if you will.

David went on to develop the Department of Community Medicine at Boston University, where I was very fortunate to have been hired by him to be the deputy director. We did what so many of you have done since  – that is, to create a community health plan or a community health system at the Roxbury Conference Health Center. It was David’s vision and thought that really put that together. It was the second community health center in Boston.

Many of you have known Dr Count Gibson, whom,  of course we followed. But Dr French went further than creating the Roxbury CHC, because after six years at Boston University (he continued to stay with BU), Dr French was able to acquire a major grant to try to provide healthcare to the indigent and to the uninsured and to those without services at all in the western 20 countries of Africa under an Agency for International Development (AID) grant, with the help of the World Health Organization.

Anybody who takes on the responsibility to bring a better quality healthcare for something in the order of 20 million people in that part of the world certainly deserves a moment of consideration. So I would like to dedicate this talk to someone who was a dear and close friend, with whom I worked for years, and, I can say, always had a vision of the future. He always asked, what can we do to improve the status of care and the status of people today, and tomorrow and the next day? It seems to me that is what we should be doing in thinking about this problem that we’re facing.

Dr French was a member of the Committee of the Hundred in the 1970s. He was very much in favor of the universal healthcare plan, and I think he would laud what we’re trying to do today – to improve the system that we’ve been given by the PPACA, that was passed just a year ago.

PPACA’s Problems

Now, let’s just think for a moment as primary care physicians what we would do if the PPACA was a patient were that came into your office and said “Hey doc, I don’t feel very well”? Of course, you would answer by saying, “Well really, what’s the problem?”

PPACA says: “I don’t know if I’m constitutional, or if the states create exchanges. I worry about the 50% of Americans who don’t think they like me very much. Half of the Democrats are against me and the Republicans hate me. Should everyone have to buy health insurance? Do we need “for profit” health insurance companies? And do we really want to continue to aid and abet and support Medicaid?”

PPACA’s Historical Antecedents: the Merchant Seamen’s Act

Let’s start the process by asking: what’s the history behind this law? Two years ago (at the 20th National Conference in Monterey), I spoke about John Adams.

I want to add the point that in 1798 not only did the United States pass a socialized medical system for the merchant seaman, run by the government, for the government, with government paid practitioners; but as a stipulation of that law being written, it said very clearly that every merchant seaman who is to be part of this system must pay for insurance to their employer that then would be transferred to United States government.

Now that law was passed by our founders! The Constitution was written by half the people who were part of the Fifth Congress in 1798 and the law was signed by John Adams. It seems to me that PPACA has to be constitutional; because it’s doing the same thing that was signed by John Adams in 1798.

Dorothea Dix and Federally-funded Hospitals for the Mentally Ill

In 1854 another event took place which also defines the history behind where we are with this act. Dorothea Dix in 1852 (during the presidency of Millard Fillmore) was able to have passed through Congress a law that said the insane indigent should be treated in the District of Columbia in a mental health system which was then formulated by creating the Saint Elizabeth’s Hospital. Two years later, after a change of the administration to the presidency of Franklin Pierce, the same piece of legislation was passed in order to improve the health of the insane indigent, – using their terms “the mental health of those who were without funds” by giving federal grants of money and land to all the states to build hospitals and to support a national behavioral health system for that group of people.

But we don’t have such a national system today because President Pierce in his wisdom took the opposite position from what John Adams. If the government were going to provide care for this imminently needy group – the insane indigent – then what is to stop Congress in the next session, from simply providing care to all of the indigent.

That, President Pierce, in his veto message said that is not the role of government, nor is there anything that he read in the Constitution that said that care of the indigent was the responsibility of the federal government, rather than the states, or private charity. It was someone else’s problem.

Proposals for Health Care Reform: Theodore Roosevelt through Harry Truman

In 1912 this view changed again, when we had this happy looking individual, Teddy Roosevelt (left) who, in support of the platform of the Progressive Party in 1912, argued that, if elected, he would work for passage a universal coverage health system – “social insurance”, as he called it – for every working person in this country. It was not a bad plan, but, of course, he lost.

Then, of course, his cousin argued that the Social Security Acts of 1935, 1936, and 1937 should have healthcare for everybody. But better heads prevailed and FDR’s Secretary of Labor, Frances Perkins came to him and said we can’t do that President, Mr. President, but we can get Social Security if you drop healthcare from the Social Security Act. So he did and we got Social Security – in my opinion, probably the greatest piece of legislation coming out of his administration.

When Harry Truman ran for President in 1948, he said, that if he were elected, we would have health insurance.  Truman was elected, but we didn’t get health insurance. So they all failed. We know why Harry Truman failed. But in 1964, after President Johnson’s landslide election, we saw the passage of Medicare and Medicaid.

Johnson was the president; but I think, frankly, that Wilbur Cohen is the guy who did it. I think his picture deserves to be here, not just because he helped to pass Medicarem but he also passed Medicaid. For that I hold him responsible for its negative consequences, and we’ll find out why.

The ACA or PPACA is, in fact, just the most recent law in this long history of going back and forth between “we are our brother’s keeper” and “By God, government isn’t responsible for those folks”. That’s the dialogue that’s been going on in this country. We’ve had single-payer, we’ve had mandates to pay for insurance, we’ve had state and federal partnerships. We’ve had them all and I’m going to show you some more of them.

If we examine the PPACA, we find that it has has some pretty good stuff so far. It’s going to reduce the number of people without insurance – not 100% insured, but a good percentage. As we heard this morning, it’s certainly going to improve Medicare when it gets up and running. It’s going to tighten the rules of insurance – we’ve already seen that happening. It’s certainly going to expand Medicaid. The question we have to ask is, is it the right solution? Is expanding Medicaid the thing that we want to do?

The Beneficial Effects of Medicaid

Medicaid has been a great program, we all know that. I remember two years ago we talked about all of the benefits of Medicaid. It certainly provided a lot of care to millions of people. It’s serving 60 million today.

Its prenatal care has helped us to lower the infant mortality rate as we all know. EPSDT (Medicaid’s Early and Periodic Screening, Diagnosis and Treatment required benefit) has been great. Medicaid has benefited public hospitals. We’ve talked about that; and about its support for graduate medical education programs. It provides augmented medical care for elderly. And, certainly one of the great Medicaid benefits, it supports community health centers.

The Negative Aspects of Medicaid: its administration as a “welfare” program

But Medicaid has some negative aspects as well. We realize that Medicare was initially an orphan, as we all know. Originally, the legislation’s proponents wanted to put it in the health side of the then Department of Health, Education and Welfare. But Surgeon General Luther B. Terry said: “Oh no, it’s a welfare program. I don’t want it under the Health Department. So Medicaid was put in the welfare department.

Medicaid has had this long history of being administered as part of welfare services, but the state welfare agencies were not particularly attuned to providing healthcare services. They really didn’t understand reimbursement. For example, it took Massachusetts three years to get up and running, whereas the Medicare program was immediately given over to Blue Cross, which had a perfectly helpful system of paying for doctors and hospitals and was up and running within a year.

So Medicaid had that problem. I don’t think most of the Medicaid agencies understood how to use health data, certainly not the quality and prevention or the EPSDT data. All that stuff was foreign territory for most of the Medicaid agencies.

The bottom line is that, because it was thought of as a welfare program, Medicaid employed “means-testing” right from the very beginning and that immediately created the problem. Some of the major issues that we have today are due to the notion that this is a welfare program. I’m going to discuss that in a minute.

But there are even more problems with it. Every single state has a different definition of what “medically indigent” – the term used in the law – means.  New York and California initially decided it was four times the poverty rate, until they realized they couldn’t pay for it if that remained the definition. Alabama still defines “medically indigent” as at 33% of the poverty level, I believe.  You are not eligible for Medicaid if you are at the 34 level percent of poverty in Alabama, but f you’re at 33% you can get services, whatever they might be.

The implementation of Medicaid clearly was influenced by a variety of prejudices that relate to our welfare system. One of the big problems I see today is that something like 33% of the people who are eligible for Medicaid show up in the emergency rooms sick and it is there that they realize they qualify for the program. We used to make our homeless people in Arizona eligible for Medicare, but by the time they were homeless, and sick and drug-addicted and alcoholic, their health problems had become very expensive. Certainly, preventive health services were neglected as a result.

Medicaid Eligibility Varies Dramatically Between States

It gets worse, I don’t know of a state where the reimbursement rates or program rules are the same as in any other state. In every state, the federal-state ratio is different for a variety of reasons that change depending on the economy of the state. Arizona, for example, today would get either $4 or $3 for every recipient, and for some states its less.

The biggest problem is that the funds that are allocated to Medicaid are allocated from the general tax revenue. Because we have a Medicare trust fund, Medicare is a little less subject to the ebbs and the flows of the economy. The trust fund’s revenues goes in, and expenditures come out, but it’s not subject to the kind of day to day variations in state or national economics. We’ve seen what happens in the economic situation today with regard to Medicare, Medicaid and the states.

The problem that I think is really terrible is that you can cease to be eligible for Medicaid without becoming eligible for any form of health insurance simply because you happen to earn $1 more than whatever the state has determined was your base. That strikes me as being illogical, unconscionable, and reprehensible.

Two Problems: Providers Who Won’t Participate in and Providers Who Game Medicaid

But the system has other faults as well. There’s no requirement that all health care providers have to accept Medicaid patients. Providers can opt in and out,  and when they opt out that reduces health care access. On the other hand, we have had people opt in realizing that they can cheat the system. It’s not as common today, but certainly was at the beginning of the program when the welfare agencies were not as astute at determining who was eligible and what were legitimate health needs. Then, we had a fair amount of fraud. I’m sure that this is continuing today.

Non-profit hospitals dumping patients on county systems

But we’ve also found that hospitals know how to play the system, especially the concept of a non-profit hospital, I think we all recognize the idea that such hospitals are not for profit is probably not 100% accurate. What has disturbed me the most, however, is that the system allows for patients to be dumped. Once they have to care for them and stabilize the patient in the emergency room, then they can move the patient as they do in places that I’ve worked – Los Angeles, Boston and now in Arizona. They just simply move them over to the public hospital and say now it’s your problem; now you take care of it, we’re out of here.

In Arizona and Florida it’s even worse. If you happen to be an individual from another country without adequate insurance – even though you may be legitimately working in the United States or in Arizona – and you are comatose in the Saint Elizabeth or the Saint Frances Hospital or any other hospital in Arizona and you’re going to be expensive and you’re a Mexican or Guatemalan or Honduran, you can be transferred by ambulance to a hospital in that county, whether or not that hospital can care for you. That’s done because our Medicaid system does not support those individuals.

That’s not good public policy. Charity has been lost. We don’t provide charity in our systems anymore. I think that  this welfare system which Medicaid has created has resulted in “them” and an “us” thinking. You see that talked about all the time. I see that in our legislature in Arizona. I’m sure most of you see it in yours and it’s certainly coming through in Congressman Ryan’s budget at the present time. Basically the system is loused up. We’ve said that there’s got to be a better option.

Our little patient comes back and we can let her know that PPACA depends to too great an extent on the current Medicaid system. While the Affordable Care Act has a lot of good things going for it, I feel Medicaid is not one of them.

Nor would I would support the insurance companies either, both of which should be high on our problem list for this particular patient.

Do we have other options? We do have other options in this country. In fact, we’ve got many of them. We probably have more healthcare systems in this country thatn the rest of the world combined. There’s the Indian Heatlh Service, the Veterans Health Care System, and the Department of Defense’s health services for active military and Tri-Care for military dependents. There’s the federal workers’ health care systems and retirement plans, as well as similar public and private retirement plans.

There are community health centers and rural health centers. There are several large hospital systems, such as in Los Angeles, Chicago and Boston. There are large non-profit health maintenance organizations, such as Kaiser-Permanente, HIP and Puget Sound Health Plan. Some states, such as those in Massachusetts and Vermont operate health plans, as did Tennessee before its Ten-Care went defunct. Vermont’s newly enacted single payer system, Green Mountain Care, may prove to be the future of health care in this country.

There are union health plans associated with the United Auto Workers, the Service Employees International Union, and the United Mine Workers, as well as over 1500 private insurance plans. There are a myriad of health plans.

There is another health system, the biggest plan that serves the most people, that we never talk about. We might call it the “Hospital Emergency Room Care Plan.” You become part that plan when you don’t have health insurance and get sick and go to the public emergency room. Then someone else will take care of your cost, because you won’t be able to pay. That seems to me an inappropiate way of providing healthcare.

Medicare For All

Once it is understood that the problem of PPACA is its reliance on the existing Medicaid system, the best solution to transform PPACA so as to move people from Medicaid to Medicare. This will not be easy politically, as Dr Geyman observed in his previous presentation. It will require a committed president and the election of a Congress that is in agreement.

What should be done is what the stimulus package tried to do – to transfer federal dollars now spent through the Medicaid mechanism to Medicare, by transferring, in stages, current Medicaid recipients to Medicare.

The impact of this would be to move $200 billion dollars out of the state budgets in to the federal budget system. This can be done in a way that would not result in a net tax increase – but instead, a transfer of current obligations from the state tax systems to the federal. It would nationally reduce the state cost by $600 a person.

Under this proposal, beginning in 2014 and then every year thereafter over the next six years, another group presently on Medicaid would be shifted to Medicare – first 13.5 uninsured mothers and children.

Then in 2014, the 50 to 65 year olds, followed in 2016 by the 35 t0 50 year olds.

By 2018, the 20 t0 35 year olds would be added for a total cost of 1.8 trillion, not a small amount, but possible with the right kind of leadership and a Congress that understands the advantages.

My personal preference would be through some mechanism like a 50 per cent per share tax on stock trading, that could generate close to 600 billion a year, and gradual increases in the present 3.3% Medicare payroll tax up to something like 10 to 13%. This combination of revenue increases would probably yield enough to cover the need.

Thank you.

Dr Clasen (moderator): Thank you, John. We’re running a bit late, and won’t have questions here, but we’ll catch up in the next session.