This, and the video, are from The State:
COLUMBIA — Eleven protesters were arrested Tuesday for blocking the roadway leading into the State House garage, a Columbia Police Department spokeswoman said.
A group of about two dozen protesters gathered at the Pendleton Street entrance to the State House parking garage — and proceeded to block the roadway — in protest of the state’s rejection of Medicaid expansion under the federal Affordable Care Act, which they say will lead to unnecessary deaths.
They held signs that said “Expand Medicaid,” “Morality is not Partisan” and “SHAME.”…
You know, I can really identify with the frustration of these demonstrators. It is wrong, on multiple levels (not least of them common sense), for South Carolina to refuse to expand the Medicaid program, and the usual stuff — calm, polite debate in the State House — isn’t working.
At the same time, as y’all know, I have a problem with deliberate lawbreaking, even when it’s peaceful. From the Boston Tea Party to this, I don’t see street theater as the way to go.
And no, I don’t know what the answer is. I don’t know how we get from a position in which South Carolina is acting irrationally to one in which we’re acting like we have good sense. Because, as I said, the usual stuff isn’t even coming close to working…
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But…Obamacare Obamacare Obamacare
Nothing wrong with a little civil disobedience… especially in the name of a cause you feel strongly about.
This isn’t civil disobedience. It’s just wrong.
Michael, could you elaborate on your point? Maybe you can help me better articulate my own objections…
As I indicated in response to bud the activism should be doing something that should be legal and appropriate but isn’t because of the bad law. Also the action should be something you would encourage people to do; blocking the legislators from parking so that they can do the people’s business … no, that’s wrong.
I suppose that blocking the parking is the only way to ensure their presence is noted, in the hermetically sealed State House
@Michael
I’m sure the “people’s business” of recognizing a little league team or naming a bridge was not hurt by a little delay.
If you think I’m kidding, look at today’s schedule which includes honoring a high school football team, multiple readings of bills for different districts to deal with the snow days, changes to the regulations on the size of catfish in certain bodies of water, a bill to outlaw taking great white sharks, a bill to declare January 17th each year as “Eartha Kitt Day” (which has gone through four committee reviews since December), a bill to designate the second Sunday of August as “Spirit of 45” day, a bill to name a section of road in Dillon to “Bill Coward Highway”, a definition of the word “Bingo”.. and any number of tweaks to many other regulations… Oh, and a little issue buried at the end of the calendar that bans most abortions after 20 weeks.
So much wasted time, wasted money, and overall intrusion into people’s lives.
http://www.scstatehouse.gov/hcal/20140305.htm
Not exactly the Second Continental Congress, is it?
Can’t help but agree with most of that, Doug. Add to that a kazillion specialized auto tags, light bulbs, meddling in what should be county business…an endless list. And – They, like the US Congress, will still be working on the budget when it’s way past due.
Doug and I probably disagree on the Medicaid issue but I share his acceptance of peaceful civil disobedience. The best example is the lunch counter protests in the early 60s. They played a huge roll in ending Jim Crow laws.
Yes, absolutely. The law was that lunch counters were segregated. The law was immoral and unconstitutional. The civil disobedience demonstrators broke that law.
Ok, I’ll bite. Just for fun, I’ll give you a few reasons why SC shouldn’t expand Medicaid. Since it seems no one else in the commentaritat has articulated this, I guess it falls to me. So, without further ado, Bryan’s top 5 reasons why SC should not expand medicare. (No, I didn’t put The Beatles in a top 5 list. You can’t put The Beatles in a top 5 list.)
1. Expanding Medicaid means that those currently on Medicaid could face increased wait times for care. Remember, coverage does not equal care. The amount of medical providers is fixed. All the expansion does is add people to the same system with the same resources. Seems like wait times to get an appointment will have to go up. Who loses out? The people currently on Medicare (the poorest) are worse off at the expense of the less poor.
2. State pending will Increase. Yes, the Feds will match 100% for three years. Yes, I know that. Doesn’t matter. (Keep reading) First of all, where do you think federal money comes from? Anyway, after three years, SC has to start paying a bigger tab, because the feds back out. WIth more people in the program, it’s going to cost more money. Currently, Medicare is roughly 25% of SC’s budget. That number will have to go up after three years, crowding out funds for education, transportation, public safety, etc. If you think this is only temporary, and we can blithely opt-out, you’re wrong on a practical and legal level. Practically, once a government program is enacted, it doesn’t contract. For the legal, see the following point.
3. The Decision is Permanent. Once a state approves the expansion, the expanded program immediately becomes the old program for the purposes of the law and then states can’t leave. So you’re stuck with the three years of federal government money, and then the SC is left holding the bag. The law doesn’t allow an opt-out at a state’s whim.
If you don’t believe me, go back and read NFIB vs. Sebelius. The Court’s opinion merely held that the feds cannot threaten to take away current funding. The Court didn’t say that the feds cannot make it a permanent deal. States cannot opt-in and then opt back out. So you must choose, but choose wisely.
4. It’s Not a Zero Sum Game. Refusing to expand doesn’t mean other states get the money. The expansion is an entitlement; if SC doesn’t expand, the money stays in the federal coffers (well, it actually reduces the amount Washington must borrow). The money doesn’t go to other states.
5. Because Incentives Matter. Medicaid imposes a huge disincentive on the poor to find work because they fall out of the program once they start earning better incomes.
If you made it all the way to the end, your head has probably exploded.
Here’s something to cleanse the palate: Barry Jive and the UpTown Five
Thank you, Bryan, for your cogent, well-reasoned and lawyerly response. It certainly beats the objections we’re used to hearing (“Obamacare, Obamacare, Obamacare!”)
Barry would not be able to mock your list. Especially since you didn’t put the Beatles in it. Or Beethoven…
The response to Bryan’s reasoned objections will likely be “Yes, but it’s for the children!”
Supporters only want to focus on the easy parts – “Take the money” versus the tough stuff – “Where does the money come from and why can’t the government balance the spending with cuts in other areas?”
Doug, while we disagree on whether SC should expand Medicaid, I think we’re in agreement that there are some other places (albeit well-concealed) where spending could be cut in other areas to offset the expansion. Bryan makes some good points; but a workable alternative solution would be welcome.
But by raising the eligible income levels through expansion, the disincentive to earn more is removed!
Not removed. I would concede that the disincentive is shifted upwards in terms of income and perhaps lessened, but it’s not entirely removed.
You could only remove the disincentive by eliminating all means-testing.
Or one could say that the disincentive to earn is broadly repealed under these changes – and still be accurate with one’s language. “Perhaps” is inaccurate in this instance.
Shifted upwards and diminished in importance.
Right…that’s what I said.
Concede, Dude. You’re busted.
Huh?
Bryan I’m agreeing with Mark that it’s not “perhaps” but “de facto.”
Well said, Bryan.
The issue isn’t whether Bryan’s arguments are wrong, which they are. The issue is that they exist and that our governor believes them and an insufficient number of our state legislators don’t (not enough to override her veto).
The people we elected made a decision. It’s the wrong decision, very much the wrong decision, and people will die and our economy will be harmed because of this bad decision. Gov. Christie made the right decision expanding Medicaid for NJ.
Getting arrested does nothing to change Gov Haley’s mind and does nothing to change our state legislators’ minds. Getting arrested blocking our elected officials from doing their jobs, regardless of how consequential their schedule is, because you believe, even rightly, that the elected officials are wrong about something, even something this important, is wrong.
1. Any expansion of access to care increases demand. You skip over the part where more demand (not need, but money) increases the amount of compensated care (as opposed to cost shifted) and diminishes the future need for more expensive care because of lack of treatment. Everybody from Walmart to Eckerds is looking to opening fast-care practitioner-manned clinics for non-critical, but needed care.
2. The leveraged nature of the spending even after the “free three” make it foolish as well as uncompassionate to refuse to expand a program whose admin costs fall multiples below private insurance (even after forced down to 20% by the ACA).
3. The 3 years/left holding the bag comment is just deceptive by ignoring the 90% and 80% match following. You also ignore 3 years of uncompensated care with the costs shifted to the rest of us and the horror of those in the “expansion gap” not getting subsidized coverage under the act despite being working poor people. (They are people.)
4. The money will, indeed not be spent in South Carolina. It will not cycle through our economy. If you think it will be used to reduce deficits, you’ve never watched the lobbyists in action.
5. This provision does nothing for the out-of-work poor, but helps the already working who don’t have my opportunities to find high-paying work. It also will pressure hospitals to close or hike fees on everybody else. This, and other “disincentive” arguments, simply take desires to justify harsh, greed-based feelings with no regard to the facts about job supply/demand many folks choose to ignore.
How is it that with every new social program, we don’t see any change in the poverty levels in the country? Why didn’t the creation of Medicare and Medicaid raise people up before? Why don’t food stamps move people up and out of poverty?
No, really, THIS TIME it will work! This is the program that solves poverty!
Doug, there are always going to be poor people and poverty. But did you miss the significant drops in infant mortality, increase in life expectancy, etc. since 1950?
Poor is a relative label, but also an absolute one. Poor today is still a far better place to be than poor in 1938… So, yeah, I think we as a society have made significant strides against poverty.
I am still confused why people do not see the huge need to restructure the healthcare delivery model in America. Why is this the only sector of the economy/society that is hobbled by such fearful reactionaryism? It’s a new century; we need progress on our biggest societal mess. That means finding more efficient and more effective means of delivering healthcare. Creative destruction means change – with an eye to a better future.
I’m fine with restructuring the healthcare model… but not with handing that task over to the government.
Medicare is a perfect example of what NOT to do.
Mark: 58% of the government budget goes to Medicare / Health and Social Security/Unemployment. 17% goes to the military. Would you accept cuts in the military to increase spending on healthcare and the poor?
Our current spending exceeds revenues and has for years. How much more debt should the government take on to fund programs that have yet to prove to be efficient in dealing with poverty?
And if you want “creative destruction”, why not start with things like tort reform, allowing insurance to be sold across state lines, loosening up drug patent laws, allowing for humane assisted suicides…
There are so many ways the government could get out of the way in order to let progress happen.
Not true. Poverty when all income is taken into account has certainly declined over the past few decades. People really are much better off today because of the various safety net programs. The problem today is that we have far too much corporate welfare which is taking away money from the vast majority of Americans at a time of rising productivity.
Where is all that the money going bud? To people who pay the majority of the federal taxes. Here’s some facts to consider:
“The Top 50 Percent of All Taxpayers Paid 97 Percent of All Income Taxes; the Top 5 Percent Paid 57 Percent of All Income Taxes; and the Top 1 Percent Paid 35 Percent of All Income Taxes in 2011”
So the majority of whatever is being passed on as part of the Federal budget to low income people is already coming directly from just 5% of the population.
FIrst a preface: (Let’s dispense with the argument that I don’t care about these people, and that you’re somehow more compassionate that I am. First of all,I call bullsh*& on that. Compassion is not measured by your willingness to spend other people’s money. To the extent you’re making this argument you’re doing only one thing:. you’re alienating me from possibly being open to your argument by insulting me. That’s a lesson I’ve learned in litigation.)
To address the points in order:
1. Your position appears to be that in increase in the amount of people covered under Medicare will cause an increase in the amount of physicians. I don’t think that’s correct, and here’s why:
In 2011, nearly one-third of physicians nationwide did not accept new Medicaid patients. This is mostly because Medicaid generally pays far less than private insurers. Nationally, for every $1.00 that is paid by someone with employer-sponsored insurance, Medicaid only paid 52 cents. So what do doctors do?
They stop accepting medicare patients.
Because most doctors want to make money – not lose money.
As a result, patients, often have trouble finding consistent care. When they can’t get consistent access to care, their cancers go undiagnosed and their heart conditions go unmanaged. Receiving care from a specialist or surgeon can be particularly challenging. Talk to some of your friends who are specialists. They likely don’t take medicare patients. My friends who are doctors mostly cite a poor reimbursement rates as reasons they won’t accept any (or any more) patients from the program. Doctors are wonderful people. They all got into medicine to help people in pain. But they also did it to get paid.
2. I’m not sure what you mean by “leveraged nature”. If your point is that Medicare is cheaper than private insurance, I guess I agree. — it pays less. As far as administrative costs are concerned, maybe you’re right – economies of scale and all. But have you considered the administrative costs on the health providers in complying with Medicare? That’s going to be higher than with private insurance. So maybe it’s a wash.
3. (As an aside, I don’t think I was deceptive on any point as you allege here — at least not intentionally.) I think your point on this issue is that the people who would qualify under the new rules would experience bad outcomes if the program isn’t expanded to cover them. Well, I guess that’s true to an extent. However, I’m looking at what’s best for everyone, not just a few. When you means test an entitlement, there’s always going to be a cutoff, and the people just beyond the cutoff are going to be the ones who get the short end of the stick. All we’re really talking about here is extending the cutoff. However, my point on this main issue was to impress upon people the fact that states cannot simply jump in and out of Medicaid like a puddle. I have heard plenty of people say that “We should just take the money for three years, and then opt back out.” I was trying to inform people that this idea of opting out is likely not viable.
4. I think your point here is two-fold. One is that the SC economy will not be boosted by the medical spending, and also, we’ll waste the money anyway. To the extent we’re borrowing money to finance this spending I’ll take not spending the money and try to fight the battles on not wasting it when they come up. Saying that we’ll spend it on something anyway isn’t convincing to me.
5. The disincentive argument is real. In my practice I have many clients who tell me that they have Medicare and that they are happy to keep it, but they are actively not looking to improve their income because they’ll lose that benefit. As for the out of work poor, they’re already on Medicare since they earn zero. But they’ll be hurt by higher earners in your “expansion gap”.
I know you think you got me outnumbered and cornered, but we got something in this territory that we call a Missouri Boat Ride.
You mean Medicaid?
Lawyer’s clients who are Medicaid recipients are not a random cross-section.
Yeah. My brain keeps mixing up the two words. I’ve been doing that for awhile. I’m subconsciously stupid with those two words. I’m not sure why.
And you’re right, the part about my clients was anecdotal.
Bryan you’re making this too complicated and in the process missing the point. Without the Medicaid money the same amount of medical care, actually much more, will be needed. It’s how the care is ultimately paid for that is the issue. With the Medicaid money the taxpayers pick up the tab directly and the ultimate goal is to provide more people with cheaper, preventive care. Without the Medicaid money folks will still either be (1) provided preventive care somehow, perhaps through a free clinic. Which of course is free only to the patient. Someone must pay. Or, more likely, (2) the preventive care will be skipped and people will get sick and die. Or the most likely (3) the preventive care will be skipped and these low income folks will get treated for a very expensive, and preventable illness with the costs born by a number of sources.
Bottom line. The Medicaid money is an enormous benefit to not just the low income folks but to all of us who won’t be footing the bill for expensive and preventable treatments. Since conservatives/libertarians seem only interested in money the state, hospitals, the Medicaid recipients AND the insured ALL benefit. It’s not a zero sum game but rather a win-win-win-win.
Bryan, I appreciate your willingness to engage openly. Let me reply to a few of your rebuttal points.
1. Not all providers are physicians. The mix of practitioners is changing to include lower-cost options such as PA’s and Nurse Practitioners with much lower overhead than top-heavy practices. Many are specialists, and make $40-75 per hour as salaried employees without huge startup costs. Medicaid fee scales are generally higher than Medicare, and usually state-dependent. Non-profit clinics can also generally accept Medicare and Medicaid payments.
2. By “leveraged'” I mean after the first three free, we phase up to spending 10% (in 2020) and get 90% federally paid, thereafter.
Medicare is the cheapest and easiest third-party payer program for providers. Code, click, get paid. It’s the myriad of different forms, fee schedules, and denied claims from private insurers that fills the doctor’s office with payment clerks – as well as creating fantasyland billing amounts designed to leave no money on the table.
3. Here you make a good argument for a single-payer system, which Obama (and I) wanted, but didn’t protect the interests of the insurance industry. Most neutral-sponsored studies confirm what you guess is true. Outcomes and later costs are better for those who have good access to care. People who suggest taking the 3 year full-funding and then backing out aren’t very fair-minded, are they? And, I would wonder about their commitment to any degree of fairness in our state.
4. I meant that the money left on the table by not expanding will not be spent here. Money brought in through expansion will, indeed be spent here – with providers, and drug suppliers, and likely will be recycled to main-street businesses on many kinds. There will be another boost by more money in the hands of the minority of expansion-eligible families who now send money to private insurers and can’t buy much else.
5. I’m assuming you mean Medicaid, because Medicare isn’t means tested. The “not looking to improve” comment has been addressed by other posters other than to say that some of your clients need some better information and basic understanding of math or may be chronic slackers. They can have all the Medicaid they want, and still won’t have a dime in their own pockets unless they team-up with fraudulent providers and lawyers. In that case, they need to be prosecuted, which has been done at a greatly accelerated rate since 2009.
Amidst all the baseball hoopla, did anyone else notice that council had extended the deadline for the developer to close on the Palmetto Compress Warehouse until November? Apparently the developer asked for an additional six months. I wonder if the deal isn’t going to fall through? How will the additional delay affect the city’s “profit” on the deal? I wonder what the monthly carrying costs on $5.6 million are? If you figured the city’s cost of capital, the cost of staff time spent on the project and transaction costs, is there really a profit at all? I’m pretty cynical about this deal.
I have information from the purchaser that I cannot reveal, but the deal is proceeding apace. Of course, it ain’t over ’til the fat lady sings, but this one is well capable of doing so.
Does your information include a $100K “profit” for the city? or is that diminished by ongoing costs?
And, frankly, why should YOU be aware of information related to the purchase that is not available to all citizens?
I get suspicious when the length of the extension is longer than the length of the original contract period… that suggests something big. Like maybe the inspection uncovered issues that the city will be on the hook for…
Because I know the buyer and she shared this information with me.
Is it information that the council is aware of? and, if so, why aren’t they sharing it?
I have no idea. In transactions, it is not uncommon for each side not to be totally forthcoming with the other. I would imagine council was told enough to make a decision based in reason?
Huh.. that’d be a first.
Yes, it does.
I’m beyond cynical about this. The city was foolish, plain and simple.
Six months won’t make a difference; this wasn’t ever going to turn a profit, or even only accrue a small loss.
If you want to get that far off-topic, please request another thread.
Here are the videos to watch: from the SCHA. The hospitals know that expanding Medicaid helps them provide the care that they want to provide.
Regarding Bryan’s point about incentives and means-testing, etc., the thing to read is Krugman’s “The Real Poverty Trap”
“[W]hen such programs [Medicaid and Food stamps] are absent or inadequate, the poor find themselves in a trap they often can’t escape, not because they lack the incentive, but because they lack the resources.”
Conservatives and liberals alike decry the poverty trap of inadequacy. Rejecting Medicaid expansion solves the problem of health care inadequacy by replacing it with the problem of absence. Absence sounds cheaper while adequacy sounds expensive, but in reality it’s the other way around.