Monday, February 10, 2014

Gov. Rick Perry, Obamacare and The Morality of Rejecting Medicaid Expansion

by Nomad

Texas Governor Rick Perry's decision not to expand Medicaid, a provision of Obamacare that each state can accept or reject, will have serious consequences for the uninsured and the poor of that state. 

Here's a moral question for you:
Suppose you found that you possessed the power to save the lives of three thousand strangers, without doing anything except changing your mind, would you do it? Would you do it even if it required you to reverse a strong personal viewpoint or a core philosophy? Could any one of your personal beliefs really be so strong that you would allow the deaths of thousands and the suffering of many more? 

Those are the questions that the citizens of Texas should be asking their governor, Rick Perry.

The Cost of Perry's Resistance
In a recent article for the Dallas Observer, Eric Nicholson points out:
Governor Rick Perry's decision to opt out of Obamacare's Medicaid expansion has been well-documented. Billions in federal funds are off the table. More than a million poor adults won't have access to health coverage. Texas businesses will wind up paying an estimated $400 million in tax penalties.
Useful numbers, but none really captures the human toll of Perry's decision. A better figure for that purpose is 3,035, as in the number of people who will die as a result of Texas' refusal to expand Medicaid.
Nicholson cites a study by researchers at Harvard Medical School and CUNY School of Public Health. Admittedly this is a worst case scenario but even the best case scenario puts the number of people who will die at 1,840. That's not all.
Even for those who don't die, the outcome won't be good. The researchers predict that 184,192 Texans suffering from depression will go undiagnosed, 109,307 diabetics won't get medication, 40,562 women won't get mammograms and 62,610 uninsured individuals will have catastrophic medical expenditures.
Critics of the study say the study cannot be taken to prove a causal relationship between Medicaid expansion and lower mortality rates.

When the ACA was passed back in 2010, a requirement in the law required states to expand Medicaid for all households whose incomes fell below a certain level. A fairly generous level too. However in June 2012, the Supreme Court decided that states should be given an option to decide whether they wish to expand the Medicaid rolls. It could not be forced on the states by the federal government.

The Lone Star legislators in their wisdom then decided that expanding Medicaid was in the the great state of Texas was simply not going to happen. No way, Jose.

After legislation was passed that rejected $7 billion of federal funds for Medicaid, Perry said earlier last year that his state will not be "held hostage by the Obama administration’s attempt to force us into this fool’s errand of adding more than a million Texans to a broken system.”
And Perry is nobody's fool, that's obvious.

Urged on by the conservative think-tanks like Texas Public Policy Foundation, Perry and his fellow conservatives have objected to the expansion. They argue that it will cost the state too much. And, Perry suggests, Texas will be in a financial crisis if the government should ever pull the plug on reimbursement in the future. The healthcare system is on the verge of collapse, Perry reasons, and he has compared expanding Medicaid to adding a thousand more passengers to the Titanic.

Using the old state's rights argument again. Perry has called the ACA a “brazen intrusion into the sovereignty of our state.” 
It's a rather strange point of view. Does the sovereignity of any state offer a good excuse just to let people die?

Perry's Bright Idea
So Perry must have a pretty good alternative if he is prepared to throw away a cool seven billion, right? I mean, RIGHT?

"Everything's fine in Texas" is the only thing Perry seems to be offerring. He has argued that uninsured Texans can get their healthcare... from emergency rooms. This little dodge is pretty popular and has been sung like a pop ditty by the likes of Republicans such as Tex Cruz and Haley Barbour and Romney. They've all proudly said- nearly word for word- the same thing.

It's a kind of "let them eat cake" idea because while he may (or may not) be correct that anybody can get treated in emergency rooms, Houston, we have a problem with this idea. For the patient in need of healthcare, it's expensive. Really expensive. 

As one authoritative source explains:
Lacking a medical home, uninsured people tend to look for health care in the emergency room, the most expensive setting they could possibly choose....
Using Medicaid payment rates and data on Medicaid patients' unnecessary emergency room visits, the Legislative Budget Board estimates that a condition that could be treated in a doctor's office for $56.21 (including lab and x-ray) costs $193.92 in the emergency room. National studies back up that data, finding, for example, that the charge for treating an ear infection in the emergency room is $170 versus $55 in a family physician's office.
Emergency care is for emergencies. That's not so difficult to understand. First problem with the solution is basic: Every non-emergency case takes resources away for actual emergencies.

Secondly, when the uninsured and the poor cannot pay those emergency room rates, the effect is passed on to the rest of us, one way or another. Taxpayers, Texans with insurance, and employers who offer health benefits also pay extra for caring for the uninsured. 

Emergency Care for the Poor is No Answer
And there's yet another problem with relying only emergency care. When a health problem becomes an emergency, the problem is already more expensive to treat, if treatable at all. Mother Jones cites a study from Harvard Medical School, which reports that someone dies as a consequence of not having health insurance about once every 12 minutes in the United States. Why? Because they aren't able to seek basic primary care treatment that can prevent more serious problems. Heart and blood pressure problems, diabetes, many kinds of cancers, HIV infections (to name but a few) all can be successfully managed if caught in time. However, this requires something more than emergency care.

And besides, as Melissa del Bosque writing for the Texas Observer notes, it is simply not true that everybody has access:
And not everyone in Texas has access to health care. People with chronic conditions—especially those with cancer—face a bleak future without health insurance. They are among the thousands of Texans whose lives could be saved by Medicaid expansion.
She adds:
The job of providing a health-care safety net has increasingly fallen on hospitals, counties and local taxpayers. To patch together a system of care, large metropolitan counties like Bexar have taxed themselves to create health districts and to fund public hospitals. Rural counties, with their limited pools of property taxpayers, don’t have that option, and provide fewer services to residents.
Perry in Denial
When confronted with the sad state of healthcare in Texas by no less than a Fox News interviewer, Jenna Lee, Perry's response was just plain odd and a little bit frightening.

“According to a new federal government report—I know you’ve seen this—Texas has ranked last when it comes to health services provided by the state. The facts are one out of four Texans is without health insurance. One out of four Texans is on Medicare or Medicaid. The health crisis, the big crisis for the country and for your state, what is one solution you are offering to the citizens of Texas?”

It seemed to have caught Perry off-guard. This was, after all, Fox News, the friendliest darn news network in the world for Republicans. Perry said. “The idea that this federal government, which doesn’t like Texas to begin with, to pick and choose and come up with some data and say somehow, Texas has, you know, the worst health-care system in the world is just fake and false on its face."
Lies, I tell you, it's all lies!

More than 6.3 million Texans - including 1.2 million children - lack health insurance. Texas' un-insurance rates, 1.5 to 2 times the national average, create significant problems in the financing and delivery of health care to all Texans. Those who lack insurance coverage typically enjoy far-worse health status than their insured counterparts.
(Take a look at this link. It's not a pretty picture.)

Cicero's Advice
To return to my original question then, it seems obvious that all of us have a moral duty -if one has the power and the foreknowledge- to stop the unnecessary suffering and deaths of our neighbors. Is it even possible to argue otherwise? Can there ever be a political principle more important than that? 

For some moral guidance, the Roman philosopher and statesman (through some turbulent times) offers these words of wisdom for Rick Perry and his conservative cohorts:

“The welfare of the people is the highest law.”

Cicero also discusses those who habitually weigh the right course against what they regard as advantageous. Unlike good men, he says, they judge everything by profits and gains which seem to them as valuable. Preferring advantages to doing the right thing is not only a crime, he states, it is also sinful to attempt a comparison between the two things. Even to hesitate between them.

But then Cicero perhaps had a more personal message for the Governor of Texas.

“Any man can make mistakes, but only an idiot persists in his error”