Deal, listen to Georgia.

I do not claim to be an expert on the subject.  I haven’t even tried, but let’s face it…very few of us are.  I have decided I want to write my simplest thoughts about why I believe Georgia needs Medicaid expansion.  Some think that my Emory education has corrupted my once super conservative brain but I just believe that becoming a Nurse Practitioner has enlightened me.

When looking for jobs in the primary care setting, or even specialty offices like Infectious Disease or Cardiology it has become blatantly obvious that most doctors offices do not accept Medicaid.   I used to have it on my "non negotiable job list" that I would not work somewhere that does not accept Medicaid.  This has proven to be nearly impossible.

Why?  The easiest explanation is that Medicaid doesn’t pay.  A Physicians Assistant recently told me that he makes about $10 on a visit seeing one of his chronically ill HIV patients.  Medicaid reimburses physicians at about 59%of what Medicare pays them (some complicated policy has changed this temporarily in most states, thank God).  This is why it is fairly easy to find a physician seeing lots of old folks and zero poor folks. 

I had a renowned Infectious Disease doc sit with me in discussion recently and say, “Well, if Georgia was expanding Medicaid I’d have a job for you, but since Deal isn’t, I just don’t have the money or clientele” (because they don’t qualify for Medicaid they can’t come to his office). This doctor serves a huge number of low income HIV+ patients in Atlanta and if Medicaid was expanding many more of these AIDS patients would be funded through the (state+federal) government program and be able to see a primary care physician rather than an ER doc. I have yet to meet a physician in Atlanta that does not believe Medicaid should expand. 

So why should you care?  The arguments I hear are often are “why expand a broken system?” and “I don’t want my taxes to pay for them.”

Well, first of all the entire health care system is broken.  We can all agree to that, though none of us can agree on how to fix it. I believe expansion is a good step.

Secondly, let’s think of Calvin.  A 54 year old man who has lived on the street for most of his life, noticed that he has a large lump growing on his jaw.  He doesn’t think much about it because he doesn’t have insurance (or Medicaid…he doesn’t have an address).  He continues his life as the tumor grows.  He thinks about going to the doctor a few times but there are very few doctors in his area who would agree to see him even if he had Medicaid because the reimbursement rate is so low.  So the lump grows.

Eventually Calvin is in so much pain and discomfort from the now open, oozing tumor on his face he goes to the public hospital in the area that cannot turn patients away for lack of insurance.  By this time, two years later, he’s diagnosed with stage four cancer with metastasis to his brain.  The physician can’t live with himself doing nothing for Calvin so he is put through hundreds of thousands of dollars worth of chemo, radiation, ICU stays, intubation, life support and multiple physician consults to try to save what can no longer be saved. 

Who do we think is paying for this patient who now has a medical bill of at least six figures with no insurance to speak of? 

It is beyond the scope of this post for me to discuss how non-profit hospitals like this one survive and how your taxes pay for them to keep their doors open, but what I hope to help us remember is that all of this might have been prevented with primary care.

If Calvin had Medicaid, if primary care physicians in Atlanta took Medicaid as payment, and if he had been seen his first week rather than his second year he might still be alive. 

This is why movements such as Moral Monday make claims like, “If Georgia doesn't expand Medicaid 600 more Georgians will die this year.”

Our ER’s are overrun with patients like Calvin. Patients that come in during the last days of their lives because no one would accept them earlier.  Atlanta Magazine put an article out about a year ago about the story of a single mother who knew that she had breast cancer for nine years and came to Grady only when her breast had fallen off.  She couldn’t afford physician copays, couldn’t take time off work and feared the payment system as a whole. 

Hospital funding and politics is tricky.  I know very little.  But what I do know is that if primary care physicians don’t raise the bar and catch cancer and HIV and lung and heart disease early it becomes an astronomical hospital admission bill that the tax payers are left to settle.  It also becomes a lot of dead people that did not have to die.

Physicians must start accepting Medicaid and the only way that is going to happen is if it is expanded.  I used to be upset with physicians for not taking Medicaid, after all it is their choice, but now I realize that no one would choose to do something that will put her out of business. We have a frightening shortage of primary care physicians currently and this shortage is only expected to increase as other aspects of Obamacare go into affect this year. 

Why is there this shortage do you ask? Well clearly it’s because primary care physicians don’t want to pay taxes into a broken system either.