No one would deny that we’ve reached a point in public healthcare finance where tough choices have to be made about what gets covered and what doesn’t. There is, however, one fairly easy choice, and that is to reconfigure the $3 copay for Medicaid members using the emergency room.

I would propose a replacement benefit of $0 for the first visit and $20 for each subsequent one, in a given calendar year. Not every state, but any state that reaches certain thresholds for physician access or urgent care availability may switch to this policy.

Here are the arguments in favor. First, each $3 visit costs the state and federal government about $500.  There are few discretionary or semi-discretionary patient decisions that cost so little to trigger so much taxpayer spending.  (Hospitalizations have that kind of ratio, but a patient can’t check himself into a hospital the way he can visit an ER.)

Second, one must consider the historical context. The $3 copay (“$3″ is a shorthand for $0 to $10 — I don’t think it is over $10 anywhere) is a vestige of the bad old days when it was very difficult to find physicians who accepted Medicaid patients. That is still the case in some locales; they would not be eligible for this waiver. The world has changed, but the copay hasn’t.

Third, ER utilization rates in the TANF population, which because of its average age is generally pretty healthy, far exceed that of the commercially insured population. This is despite the fact that TANF members in general cost much less than commercially insured people, a gap that widens still further once birth events are removed from the calculation. Clearly there is much excess utilization.

Fourth, while avid readers of this blog may recall that I am no fan of North Carolina Medicaid, my objections are confined solely to their consultant’s math — Milliman USA embarrassed themselves and their client by coming up with obviously impossible conclusions. See here. By contrast, I do think they (meaning Community Care of North Carolina) have done as good a job as possible under public-sector constraints to enhance access to care for Medicaid members, and my hat goes off to them for the tremendous efforts they’ve made.

However, what we’ve learned from that experiment is that the best-designed network in the world won’t attract Medicaid members if the ER is basically still free. Yogi Berra called this one right:  “If people don’t want to come to the ballpark, you can’t stop them.”  For this model or any other access models to be given a chance to work (and to be given a chance to pay for themselves), member economics have to support the access strategy.

Finally, this is not a take-away. The proposal would be $0 for the first visit — a cost savings. And obviously if someone shows up for a second visit without $20 and it’s a true emergency, that person wouldn’t be denied care.  (It also may not be easy to check eligibility for the $20, but most of the value of this policy is in people thinking that they might be charged $20, and deciding to go to their doctor instead.)

All the old objections need to be discarded or can be addressed. Yes, transportation may be hard to come by but most doctor offices are more accessible than most hospitals. Yes, after hours doctor offices aren’t an option.  That could be addressed by a call to a doctor to clear a visit to the ER.

I’m sure there will be objections — the THCB regulars are nothing if not opinionated — but please make sure to propose an alternate way to save a large chunk of money involving more savings and less of a take-away.

Al Lewis, president of the Disease Management Purchasing Consortium, is author of the critically acclaimed 2012 humorous look at the innumeracy of health plans, consultants and vendors, Why Nobody Believes the Numbers.

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62 Responses for “Is It Time To Charge Medicaid Members for ER Usage?”

  1. Dr. Mike says:

    Help me understand why the ER (i.e. hospital) would want to disincentives in place for Medicaid patients – as stated they stand to generate $500 in revenue for each visit.
    And Help me understand why most primary care docs would want to see more Medicaid patients in their office – they stand to lose money (or make very little) on each visit.

  2. Until we ensure that routine non-emergency care is available for Medicaid patients, and actively discourage non-emergency use of ERs, this problem will remain unsolved. Using financial disincentives may be part of this, but should not be all we do.

    For example, let’s encourage more PAs in 24×7 strip mall and drug store based clinics. They will be able to treat many problems and correct triage patients who may need to go to ERs.

  3. If we want to solve a problem, maybe we should figure out what causes the problem.
    Assuming that Medicaid members go to the ER more than other people, why do they do that? Certainly, it’s not because the ER is cheaper than a doctor’s office. In my State, the ER copay is indeed $3 and the physician copay is $1. One could say that the difference is not large enough to dissuade people from going to the ER, but that implies a preference for the ER. So why would folks with Medicaid insurance prefer the ER?

    Rejecting offhand the hypothesis that Medicaid members are somehow “different” than non-Medicaid patients, one possibility would be that the ER is providing them with better care, and the other possibility would be that the ER is more available.

    Considering the reluctance of many physicians to accept Medicaid insurance, and considering that those who do accept Medicaid are often overbooked and overextended to the hilt, and considering that some States have quick-access rules (at least for children) in the ER, then I would say that the ER is more accessible.
    For many Medicaid patients, lacking a personal physician, the ER may very well be the one place where they get to see a real doctor, and guess what? They can tell the difference….

    The solution sort of writes itself at this point, doesn’t it?

    To validate that this is indeed the right solution, go find some of those saintly doctors, usually pediatricians, who take lots of Medicaid and care for their patients equally well, no matter who their insurer is. Their patients don’t go to the ER.
    Since we cannot all be saints, just pay doctors a fair amount for Medicaid patients. Pay them more than private insurance.
    We experimented with stinginess for a very long time and it doesn’t work.

  4. BobbyG says:

    Abolish Medicaid.

    • Mandy says:

      Now there is a great idea!

      • tcoyote says:

        I’m sort of with Bobby. Give the chronic care part (and most of the federal match) and therefore the dual eligibles unambiguously to Medicare, and let the TANF’s get care directly (e.g. no billing) thru safety net providers like VA, FQHC’s and critical access hospitals via state capitation contracts.

        Medicaid WON’T pay physicians enough because they “make too much money”, and stand behind hospitals and nursing homes in the present Medicaid “slop line”. There is no practical way to reverse the disappearance of docs from Medicaid participation unless you force them to take the patients as a condition of licensure (like Massachusetts discussed).

        Present Medicaid program is unsustainable, and so is giving it to the managed care companies. They’ll be on way out with the payment cuts that happen in the next recession.

  5. Mandy says:

    In theory it sounds like a good idea to de-incentivize by charging higher co-pays for Medicaid patients, but in reality many of them are not worried about paying their co-pays if they cannot afford them, and of course I am generalizing. They will either a. make payments on a $20 co-pay or b. never pay it and the account either gets written off or sent to collections. Either way, they aren’t going to be turned away for non-payment. Good article. Nice idea, but too many things sound good in theory.

  6. MD as HELL says:

    In1979 Minnesota Medicaid required physicians at Hennepin County General Hospital to verify in each case that use of the ED and EMS was a true emergency. If it was not verified, then the hospital would not be paid.

    How useless waspatients ain that? Of coursse they were all true emergencies. they did their part and provided the service. Why should they get screwed?

    We first need to change the behavior of government. It really is Santaland. They are giving out that which is not theirs.

    Medicaid patients in the ED are like lottery winners, reckless and irresponsible. They have no tolerance for uncertainty. They have no capacity to manage their own healthcare. Broad generalization? Yes. But more true than not true. That is why the government treats them like pets with a vote.

  7. Peter1 says:

    “That is why the government treats them like pets with a vote.”

    MD, do you really believe the government would continue to treat Medicaid patients as second class citizens if they actually voted?

    Medicare recipients get unsustainable blue ribbon care because THEY do vote and are organized via AARP. For the most part the poor don’t vote – thank your lucky financial stars.

    I’m with BobbyG, abolish Medicaid.

  8. Al Lewis says:

    Margalit,

    the proposal is only for states that reach acceptable thresholds of access to primaries.

    To other (adult) comments:
    yes, not a total solution but part of one
    yes, some of the $20s will not be paid. written off etc. Not a panacea but should be part of an overall solution

  9. James says:

    “Rejecting offhand the hypothesis that Medicaid members are somehow “different” than non-Medicaid patients…”

    If your reject as off-hand that the patients themselves are different, then you have tossed out what may be the single largest factor. It will be a critical error in addressing the problem.

    Medicaid patients ARE different. For one thing, they are either very low income or disabled. They have lower levels of education and far lower medical literacy on top of it. They smoke in much larger numbers than the general population. They are more likely to be single (almost no married couples qualify). They may have a higher ethnic minority population than private insurance counterparts. They may be more likely to speak a language other than English as their primary one. They have a higher incidence of mental illness, chronic diseases, are often seen as difficult to manage, and have high”no show” rates for appointments.

    This is not to denigrate, but just the demographic and medical facts. If one is to solve a problem, one must know the factors — and client characteristics matter. What is effective to change behavior for one population/culture/group may fail in another. We know that from public health (and politics and just life in general)..

    Now, if one is to look at the problem, one must also split our the over-users. Most of Medicaid is moms and relatively healthy kids. Some go to the ER for non-emergent condition (baby feels warm, the kid has an earache) and some do it a lot for various reasons (sometimes reasonable, like no PCP available and sometimes not). Various states are reducing reimbursements for ERs for treating non-emergent conditions that could be done at a clinic level or PCP.

    However, it is in the SSI population where one sees the true super-fliers. These are where one finds the folks where you can have 100+ visits a year. Their general characteristics are chronic disease (often more than one), mental illness, and quite a bit of drug/alcohol abuse & addiction. Some of their visits are likely drug-seeking behavior (various pains and migraines) some are driven by mental illness, and a number of them are indeed emergencies rooted in their terrible health and rough lives (lots of open wounds, skin infections, etc.). You will see a surprising number of sickle cell crisis cases for the extreme fliers (the 100+ club).

    ER co-payments can have a role with some of the ER overuse. However, one must look at how Medicaid patients are different. One must also look at how even within Medicaid the patients are different depending on the type of Medicaid (moms/kids vs. SSI).

    Again, if one wants to help (and some of these cases are Book of Job tragic), one has to know ALL the factors driving the ER overuse.

    • It is possible that the disease burden and the socio-economics are different, but the people are just people, and a solution that works for the rest of the country should work for those who happen to have Medicaid.

      • Peter1 says:

        Exactly Margalit! To attempt to segregate this “population” of patients misses the point entirely. They are people who need health care in a system that creates uneven tiers of treatment based on where the subsidies come from. Employed, you get tax free employer subsidies. Got Medicare, you get subsidized care.

        There should be no “go to the back of the line” care anywhere.

        • Dude says:

          Again, patient characteristics matter and the attempts to inject polarizing racial terms like “segregation” and “go to the back of the line” appear an attempt to cut off discussion, not illuminate.

          Medicaid is a subsidized health care system, run by the same federal agency as Medicare and created in the same legislation.

          My point is that proposed fixes (from the left or the right, I add) that don’t take into account the reality of patient population characteristics within different insurance systems will fail.

          Even Medicaid itself is not a monolith, as there are several distinct subpopulations within it, even within the same state. Different regions of the same state may have client/physician medical cultures that vary widely.

          What works for one sub-population may flops for another, even within the same Medicaid program (and what works in State A may fail in State B). What works in the north part of a state may crach and burn in their south.

          One works with the reality of a population if the goal is to improve their health and outcomes. Part of the challenge is that big systems tend to use one-size-fits-all solutions that allow little flexibility to tailor mini-fixes or address specific circumstances.

          • Peter1 says:

            “Some would say that all populations overuse the ER (just like we overuse healthcare in general), so it’s always a question of degree.”

            “Again, patient characteristics matter and the attempts to inject polarizing racial terms like “segregation” and “go to the back of the line” appear an attempt to cut off discussion, not illuminate.”

            Then why are we only picking on Medicaid? Medicaid was created because southern whites didn’t want to be in the same waiting room as blacks – that’s segregation and its always meant we pick on Medicaid clients (the poorest of the poor) because they’re an easy target.

      • Dude says:

        No, it will fail for the same reason that a solution that works for a problem in the United States may fail miserably in the Middle East or China or Norway.

        This is true in public health, politics, economics, and it is true in health care.

        People are not just people. They are far more complicated than simple widgets stamped from a cookie-cutter. One has to look at the populations and tailer solutions to their particulars or one will fail.

  10. Al Lewis says:

    The point is, quasi-free ER access for Medicaid HAS failed. It means that the best-laid plans for Medicaid PCMH and other access-enhancing innovations are themselves doomed to fail because the “competition” from the ER, despite the expense to the system, is so heavily subsidized.

    Wouldn’t you agree that at least in some states the original rationale for $3 ER visits (meaning that doctors didn’t take Medicaid) has been obsoleted, and if the rationale is obsolete, perhaps so is the strategy? Perhaps it’s time to start encouraging Medicaid recipients to use more primary care now that it’s available?

    Or put another way: if you were designing a system from scratch, isn’t there a better use of $500 than extra ER visits when a doctor is available?

    • Peter1 says:

      Is ER misused by Medicare patients?

      • BobbyG says:

        Here in Vegas we have these fancy electronic billboards along our expressways where the various hospitals proudly tout their short wait times on digital minute clocks.

        I don’t get that.

        I know, I know, they’re fishing for high quality insureds.

        My UHC PPO plan has a $200 ER copay. I will not be going to one unless it’s truly and emergency.

  11. Al Lewis says:

    good question.

    Some would say that all populations overuse the ER (just like we overuse healthcare in general), so it’s always a question of degree. Medicare members run not much higher in ER visits/1000 as Medicaid (TANF and disabled combined, meaning mostly TANF), but are presumably quite a bit sicker given their much higher hospitalization and death rates.

    So just as over-medication is a Medicare issue much more than Medicaid or commercial, it would appear that overutilization is the reverse.

    • Peter1 says:

      If we rolled Medicaid into Medicare with same provider reimbursements would the Medicaid population get better access to primary care and reduce their ER use, if it’s possible to predict that?

  12. Al Lewis says:

    $200 would keep everyone of the ER. I’d rather bleed to death on the sidewalk.

    It’s a question of proportionality. You don’t want to set a price for Medicaid that keeps true emergencies away but you don’t want to make it free either. Now it’s basically free. I think $20 is the right number but I don’t know.

    The point is, it has to be something. Times have changed since the $3 copay was introduced and it’s time to change with the times.

  13. MD as HELL says:

    EMS also must charge and collect a co-pay for the ride. Medicaid needs to be the hammer, not just the sugar.

  14. Al, according to OECD data, the only thing we are overusing is imaging studies. The US is below average on everything else. I can’t find an ER specific indicator, but chances are that it is similar to our below average hospital use.
    Trying so hard to reduce utilization, is absurd, in my opinion, because that is not where the problem is.

    As to Medicaid patients, I will venture a wild guess here, that as soon as primary care “medical homes” or whatever they think of next, becomes truly available and accessible to all patients in equal amounts (and equal quality), their ER visits will level off after a period of learning and unlearning where one gets the best possible care at the shortest reasonable notice.

    But I’m with Peter here, what’s the point of having two separate public systems? I know why they were created that way, but enough is enough. If the system started treating people with respect, perhaps they will be more inclined to reciprocate the attitude.

  15. Al Lewis says:

    There is no way to make the argument that the US doesn’t overutilize a ton of stuff in healthcare. Our cardiac surgery rate is way higher than the EU.

    But what you say could be true for the US as a whole but still not be true for Medicaid, since the Medicaid rate is so far above the US average.

    Your guess on PCMH reducing ER visits is wrong, I’m afraid. There is an entire chapter in my bestselling book (well, it hit #2 today on Amazon in the health insurance category, so that’s close enough), Why Nobody Believes the Numbers, on the North Carolina Medicaid PCMH and ER visits have not come down one iota since they started tracking, vs. the rate in surrounding states. (They all went down a little, but NC not as much.)

    I used to teach economics at Harvard, but you don’t have to know much economics to know that if you charge $3 for something that costs $500, it will be overutilized.

  16. BobbyG says:

    “you don’t have to know much economics to know that if you charge $3 for something that costs $500, it will be overutilized.”
    __

    None of which is exactly news. See Elhauge, 1994 (Harvard btw) “Allocating Health Care Morally”

  17. Maybe I’m reading this wrong, Al, but the OECD database does not show that we do more cardiac surgery that other individual countries in Europe, some of which seem to be on a stenting rampage…
    http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#

    Regarding the $3 vs. $500, would you go to the ER for a headache (or whatever), if it was only $3, or even completely free? Would you go more often to the ER in that case? If your answer is no, then there must be a different reason for this behavior.

  18. Al Lewis says:

    Of course I would and so would most other people — it’s simple economics. Last summer I stepped on an oyster shell. It didnt’ realyl require an ER visit but I thought given the location of the cut it would be better to have a pro clean it out,. I was on the fence so I called the insurer to check my co-pay and called the ER to see if they were busy. The copay was “only” $50 and the ER had no wait at that point, so I went.

    Now make the copay $3 and add those billboards about waiting times and watch economics at work.

    • I wouldn’t have gone, but OK, let’s assume that for the incidental minor cut and bruise people would go.
      Regulators are requiring all sorts of things to be in place in a hospital, why can’t they require that every major ER has attached to it (not across the street or three blocks down) a simple urgent care facility, and patients are triaged accordingly (all patients, not just the poor ones) when they come in?

      • MD as HELL says:

        Typical solution: Someone else gets to sort out the chaff from the wheat. Who pays for the sorting? Do you think that will be free?

        Most patients do not need the ED. Not just Medicaid patients. In fact most people do not need all this healthcare at all.

        We need to stop turning healthcare into a religion.

        • Yes, it is a typical solution, because I don’t think we need any radical solutions for this, and no, it’s not free, but it should be significantly cheaper for all involved.
          The question, of course is whether “all involved” have any interest in making anything cheaper, as opposed to making things inaccessible for those who can’t pay exorbitant and unnecessary prices.

          And I agree with you that most people don’t need any of this stuff, so maybe “all involved” quit spending billions on advertising, construction and lobbying instead of spending it on what it was originally billed out for – medical care for those who need it.

    • BobbyG says:

      “simple economics” are replete with totemic anecdotes, long on confirmation bias laden theory, and short on science, Al.

  19. Douglas Dame says:

    This article and discussion is excellent. I think part of a satisfactory solution would involve:

    * Medicaid paying a ED “(facility) triage fee” for the EMTALA screening, even if done by an RN/ARNP/resident rather than an MD. If nothing is paid, then the financial incentives are for the ED to upcode to “real emergency” to get paid. Let’s not encourage that, and let’s not encourage cost-shifting the burden of EMTALA screenings onto the other patients.

    * clarification that if a reasonably diligent EMTALA screening for a true “emergency” is done, the hospital can and should refuse treatment, without liability. (I think there was a EMTALA lawsuit recently related to this issue, and the patient lost.) There may be a need for the Feds to develop more Safe Harbor guidelines on this.

    * No payment to hosp or ED docs for non-emergency ED care, other than for the triage service.

    * many Medicaid patients go to the ED because they get faster access than to a primary care physician. Or pediatrician. If we change that to “if you seek non-emergent care at the ED, you’ll wait a long time, and at the end you’ll leave after x hours without getting any care*,” then people will learn to change their behaviors. What used to work for the Medicaid patients, won’t work any more. (* They do get a confirmation from a medical professional that their problem, or their kid’s problem, is seemingly not an acute problem with life-threatening implications. That’s an outcome of some value, of course.)

    Two additional observations:
    * If there is a facility EMTALA payment, AND patients who are not deemed to be emergencies are 100% turned away (unless they want to pay cash, in lieu of going to an urgent care provider), then the amount of any co-pay becomes moot in terms of modifying behaviors …. going to the ED for a non-ED problem simply wastes your own time, with no result.
    * The works for all payors, not just Medicaid. Unnecessary ED utilization is expensive to society, regardless of what payor source.

  20. MikeQ says:

    There is a pony in this pile of proposals and comments, especially the last one. Anyone who doesn’t think that ED overuse in Medicaid isn’t a problem is simply wrong, and yes, being “free” and billboard signs and habit and perceived (and sometimes actual) lack of access all contribute.

    And in this thread are elements of an elegant solution.

    I might add two more things:
    (1) Reimburse at the urgent care rate for non-emergencies, like they do in Illinois
    (2) Track the hospitals against one another and investigate all “outlier” hospitals. Like with RAC audits, miscoding would be penalized.

    • MD as HELL says:

      Another m***n wanting to short the hosppital for doing it’s job.

      Mcaid and the beneficiary need to do their job! Stay out of the ED with your whiny crap!!

      • d.d. says:

        hey, MD as HELL, it seems your goal of “stay out of the ED” is the same as the goal of @Al’s post and the other comments on this blog … would you mind enlightening us with a little more detail on exactly why you think these policy recommendations would not work?

        Charm alone will not carry this argument.

  21. d.d. says:

    My suggestion was to:

    (1) pay the provider (a fair rate) for providing an EMTALA screen, even if performed by a non-MD
    (2) allow them to not provide ED care if not warranted
    (3) strengthen legal and safe harbor protections for not providing care

    …. how does that “penalize the hospital” ? (Especially compared to the situation today.)

    In terms of changing patient behavior, my version of the scheme allows EDs to not provide care beyond an EMTALA screen, if that screen shows that no “emergency” exists. And strengthens protections against denial of care allegations.

    Someone not needing emergency care can sit in the ED for 12, 24, or 72 hours, but they’re not going to get care from our most expensive resources unless they have a genuine need. To get access to the care they want, they will have to go to their PCP, or a community clinic, or an urgent care center.

    Would you keep going to an ED where you’re not going to get care, or after a few long, pointless waits would you decide you just might ought to go the PCP/community clinic/urgent care center in the first place ?

    • MD as HELL says:

      Sorry. I just replid to an automated esponse in my email. your proposals also will not work.

      #1. Care will retrospectively be determined to have not been needed.
      #2. Denying treatment again will be retrospectively be determined to have been appropriate.
      #3. When patients complain to CMS or DFS (in NC) there will be time-consuming investigations into those decisions.
      #4. It still does no change the behavior of the culprits.

      • d.d. says:

        @Md as HELL:

        I disagree on #4 that behaviors won’t change, but I can see where there could be a concern on your first three points. You have a very valuable point there, that I did not think about.

        Those all relate to “compliance responses” that have been developed in response to real or perceived abuses under the current system of reimbursement and access. If policy makers significantly change the ED system in the ways suggested, then hopefully there would be a recognition that the old compliance mechanisms also need to be reviewed and modified, to make them appropriate for the new rules.

        • Peter1 says:

          d.d., if you haven’t been on this blog for long then you fail to see that “MD as Hell” is a health care Scrooge who would like to see a Dicksonian health care system where children still worked in factories to pay for their health care and debtor’s prison is where we held those on Medicaid.

          • d.d. says:

            Coming to agreement on system changes often requires acknowledging and addressing the substance of objections raised by affected parties, even if they come in a prickly wrapper.

  22. Al Lewis says:

    Doug, of course that’s what you said. This board is not moderated so there is no requirement that comments have to reflect adulthood in order to be posted. When I send this thread to my West Wing contacts, I’ll be deleting half of these comments.

  23. Al Lewis says:

    Yes. I personally have programmed my computer so that his comments don’t show up.

    btw I think there are only three of us left in this thread so I vote that we all declare victory and get out.

  24. Medicaid patients can’t afford to pay more. That’s why they’re on Medicaid. And many times they can’t find a doctor who will treat them in an office because reimbursement rates for Medicaid patients are so low. One solution is to increase payments for providers who understand how lifestyle changes can prevent, reverse, or slow chronic illness. Advanced chronic illnesses are expensive.

  25. Al Lewis says:

    Agreed

    the original article (way up at the top of this thread) says you’d only do this in states that reach certain thresholds for physician access.

    Doctors can preach all they want, but even commercially insured members rarely make the lifestyle changes they need to make. That’s why obesity hasn’t declined and smoking is declining only at a very slow rate.

    Hence I think you’d have to set the standard for access more objectively than you are suggesting, unfortunately.

  26. MD as HELL says:

    MD as HELL is a 30 year physician in the same ED providing care to all who present themselves believing they have an emergency.

    Originally we screened out nonemergency complaints and sent them to an on-call physician who was oblidged to see them once without demanding payment. It worked until the feds passed EMTALA. The medical staff became less interested in playing ball and courts decided that anything short of treatment was not “stabilized”.

    In 1982 in a county of 100k population we had 18000 ED visits plus 6000 nonemergency screenins referred out.

    In 2012 we have 60,000 annual visits in a county of about 130k population.

    Today the ED remains the destination for people who have no capacity to deal with acute minor illnesses that require no physician, much less a rescue squad and an ED.

    We are the second opinion specialists. See the Pediatrician in the daytime and go to the ED at night when the kid still has a fever. No barriers when you are on Medicaid.

    After 15 years my company has more money in collections than we have actually received in the last 15 years. From 4 docs in 1982 to 10 docs and 10 PAs in 2012 my personal purchasing power after taxes is lower now than it was in the 1980′s.

    I see the same patients over and over. i see the same Mcaid and Mcare enabled irresponsible behavior over and over.

    I am no Scrooge. I give more than I get. This country is going down due to these runaway entitlement programs fueling citizen greed and sloth. All the nice people on this blog are goodhearted and want to do the right thing. I promise you no one dies if they cannot go to the ER ;like they do now.

    This country is addicted to healthcare. Why break the bank feeding the addiction when people can live better and happier without it?

    • Peter1 says:

      “I am no Scrooge.”

      Then come up with a more elegant solution instead of taking your bitterness out on Medicaid recipients.

      • MD as HELL says:

        In fact I am not. They are treated like pets. They have no accountability for their expenditures. They have no budget. They have no constraints.

        The soluton is to give them x dollars a year. What they do not spend they keep. the left howls that they will forgo needed healthcare and keep the money. That means they are treated like pets; incapable of determining what care they need on their own. Hence the disconnect between me and the left.

        You must treat them like equals and let them fail if they so choose. There children are theirs. Let the evolution begin.

        • Peter1 says:

          “They have no accountability for their expenditures.”

          What expenditures, they’re the poorest of the poor.

          “You must treat them like equals and let them fail if they so choose.”

          They’ve already failed, that’s why they’re on Medicaid.

          If you’re no Scrooge then stop thinking and speaking like one. Bring back debtor’s prisons eh MD, that’ll teach’em.

          • MD as HELL says:

            OK. Then let them have consequences instead of rewards. I do not believe they have failed. I believe they are smarter than the blogger who thinks they need all this help. The bleeding heart do-gooder who is blind to the scam.

  27. MD as HELL says:

    I am declaring victory.

  28. Finger pointing says:

    Why do Medicaid ED visits attract anger and controversy disproportionate to the amount we spend on them? The highest users of healthcare dollars have frequent hospitalizations (they may go thru the ED but the point is that they are very sick and require admission) and/or require total long term care at home or in a nursing facility. There is a lot of reason to believe that we can reduce the huge expenditures on the very sick by addressing their needs (for example, search for Gawande’s article on hot spotters on the net). Spending on a single diabetic patient who requires multiple ICU admissions this year due to failure to address mental health barriers to keeping blood sugar levels in reasonable control blows the unnecessary ED visits of hundreds of families out of the water.
    Further, it is convenient to point fingers at the very poor who go to the ED for primary care needs but the really big dollar abuse of the system may in fact be middle class families who evacuate elders’ assets to get their nursing home care paid for by Medicaid to the tune of a great deal of public spending on the behalf of middle class families.

  29. Al Lewis says:

    I think you are referring to some of the more recent comments, and may recall from the actual article 59 comments ago that I myself did not point fingers but rather (1) proposed a $0 copay for the first visit, which is $3 better than now and (2) suggested that only states meeting primary care access standards could qualify for that.

    I would certainly concur in your comments about reducing utilization for other large users by addressing their needs, but it shouldn’t be an either-or. You may be able to use savings from unnecessary ER visits for the worried well to finance your suggestion.

  30. It’s a pity you don’t have a donate button!
    I’d definitely donate to this outstanding blog! I guess for now i’ll settle for bookmarking and adding your RSS feed to my Google account.
    I look forward to fresh updates and will share this website with my Facebook group.

    Chat soon!

  31. phillip says:

    I think all of you need to go the ER with only Medicaid. See how you are treated. I have had always had good insurance through my employer. I have a fiance’ who is on medicaid. She started having bad tremors which was a side effect of an anti-depressant. She couldn’t walk she was shaking so bad. They checked her vitals and everything looked ok. The Dr. walked in and told her she was faking. Oh and this was at Baylor medical center in Dallas. The little nurse said she didn’t think this was an emergency. Well if she was at home and couldn’t get up to walk to the bathroom ; I wonder if that would be an emergency. It was because she was on medicaid. I never been treated the she way she was.

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