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When Rhetoric and Funding Collide...

Published April 18, 2012 1:31 PM by Tony DeWitt

By way of full disclosure I am a Democrat and I vote Democratic. I do not intend this to be a political post, but it will be read that way, and I don't want anyone to think I am refusing to acknowledge my biases. This post is about health care funding and Medicaid.  Nearly every SNF depends on Medicaid to meet its expenses and its payroll, and before long, Medicaid may cease to exist. That is something that is looming on the horizon, and the time to get involved for all health care workers is right now.

I want to ask an important question: How do you turn a Republican into a Democrat? 

Generally speaking, Republicans are often viewed as small business owners, substantially more wealthy than others. They have a strong interest in certain social issues (they are generally opposed to abortion, marriage equality, and social programs like Medicaid and Aid for Families with Dependent Children). They tend to be people who believe that the safety net programs are not necessary, and that all people need to do is work hard and they will succeed. Most have never experienced any outright form of discrimination and may in fact believe it does not exist. 

And importantly, these views are strongly held core beliefs. They are honest beliefs. Because of perceived religious or moral reasons these voters often tend to be "one issue" voters, meaning that they vote either against Abortion or for lower taxes, and those single issues are the only ones that matter to them. I understand them, and I do not belittle them. These folks believe what they believe because of the experiences they have had, and because of what they have been taught. But it does not make them right.

Democrats, on the other hand, tend to have a different view about social programs. They recognize that no matter how fair and equitable a society may be, there are still people who, for whatever reason, do not share in the economic fruits of our society. They recognize that without programs like Medicaid, there would be no way for children to get medical care. And, while it may be arguable that parents who do not work should not get special breaks on their children's health care, the fact is that without Medicaid many of those children would not get any health care. Improving access to children's healthcare was a fundamental premise of the Patient Protection and Affordable Care Act. Again, these beliefs are based on experience and the lessons learned in the trenches. They are firmly held honest beliefs. But again, that does not always make them right.

Aside from people who identify with one party or another there are folks who are either uncommitted to a set of ideals, or simply malleable with regard to what person or party gets their vote. These folks are sometimes called independents. Independents share a number of the same views of both parties, but tend to straddle the fence on other issues. They tend not to be one-issue voters. But they do tend to be economically-motivated voters. In other words, while an independent might not vote for a candidate because of his position on health care or defense spending, he will vote against a candidate if that candidate threatens action that ultimately costs him money or threatens his job or future.

So back to the question: how do you turn a Republican into a Democrat? The answer, of course, is to let your party's core beliefs and principles have a profound and negative impact on the economic well being of the voter. Across the country, those who want to "starve government" and radically rein in spending are attempting to effectively destroy the payment system for long-term health care.

Right now, playing out in Alabama, is a terrible game of chicken. The legislature is only in session for another 15 days, and Alabama has an $82 million budget shortfall in Medicaid. As a result pediatricians are not being paid for care delivered months ago. One of them I know has not taken a salary check in 12 weeks because he cannot get paid by the state for Medicaid patients he has already seen and treated. Today they went to the legislature to lobby their elected officials personally, and they were snubbed and rebuffed.  The Tea Party Mantra: no new taxes carried the day.

The pediatricians have advanced a proposal for a $1 tobacco user fee. Alabama tobacco prices are lower than the rest of the nation.  If the state imposed a $1 user fee to fund health care, the state's tobacco prices would still be below the national average.  What the doctors have proposed is a workable solution to a serious problem.

However, the Alabama governor has promised to veto any "new taxes" and as such the Republican majority in the legislature has refused to even put such a measure - which would generate over $200 million for health care in just the first year, completely obliterating the shortfall - on the legislative calendar.  The Speaker of the House recently told a group of pediatricians that he wasn't going to "waste his time." The translation: tough luck doctors!

Conventional wisdom says that physicians should favor the Republican party because they tend to be more affluent and would benefit from the tax policies offered by the Republicans. But pediatricians in particular are finding that voting Republican is like a chicken voting for Colonel Sanders. Republican Congressman Paul Ryan's budget proposal so restricts Medicaid and Medicare that it threatens the lifestyle and income of pediatricians more than almost any other physician's group. Pediatricians tend to see more uninsured, and hence Medicaid-paid patients than do other types of physicians. An internist or oncologist who did not accept Medicaid patients would still have plenty of business. But a pediatrician who does not accept Medicaid soon finds himself unable to pay the electric bill. And it is worth noting that if most SNF's failed to have Medicaid as a source of funding, they would not be able to remain open or care for most of their residents.

The net effect of the Alabama legislature's failure to pay for Medicaid and properly fund it may well be to drive doctors out of the state, and once they're gone, they won't be returning. I know one physician who moved to Alabama, built a nice new house, and planned her future with the belief that Medicaid would continue to fund children's healthcare. She now learns that Alabama's legislature doesn't consider this to be a problem. They refer to it as "her problem." By forcing her to choose between her practice as a pediatrician, and the economic viability of her home and family, they are forcing her to fund and advocate for candidates that have her values and will protect her economic interests. In essence they are turning hundreds of Repubicans into Democrats.

This is why health care policy that focuses on how health care is paid for and stratifies that by private payor (insurance) and public payors (Medicaid, Medicare) is doomed to fail. Health care costs continue to rocket upwards at an alarming pace as medicine makes leaps toward longer and healthier lives. But at some point rhetoric about improving access to health care and the funding of those programs collide with one another. When there is insufficient money in the budget to pay for children's health care, the decision not to pay for it clearly impacts those who provide the care more than those who seek the care. This is because the health care providers have an ethical duty to provide health care, and the legislature responds neither to ethics nor duty. And while Alabama has legislation that protects nursing home funding from cuts in Medicaid, most states do not. The battle that is playing out in Alabama over pediatric medical care could just as easily play out in your state over SNF funding.

Fifty percent of funding for Medicaid programs, and in some states more than fifty percent, comes from federal sources. A federal budget that drastically shrinks this money, or obliterates it altogether, will be an unmitigated disaster for those who provide health care. The time to organize and make your voice heard at the state house and in Congress is now.  If you do not, your industry may well be headed for extinction.

posted by Tony DeWitt

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    A.L. "Tony" DeWitt, RRT, CRT, JD, FAARC
    Occupation: Attorney
    Setting: Jefferson City, Mo.
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