30 Governors Open Health Care Ghettos: October 1, 2013: Full Text

The governors from over half of the 50 states have or are considering refusing to establish Health Care Exchanges and participate in Medicaid as provided for by the Affordable Care Act, (ACA) cynically known as “Obamacare.”  My assessment is that the consequences of this decision by Chief Elected Officer of these states is going to in actuality create a third-tier, low quality health care environment.  Simply put, those states that offer to their residents full participation in the rights and privileges provided by the ACA, which is the law of the land, will develop in a few short years, into first-tier, high quality health care systems.  The states that don’t, however, will within a similar number of years see their health care, both private and public, degenerate into a ghetto of medical inferiority.

Continuing from the Post Page…

I call it…The Gubernatorial Wall of Shame.

The states on The Gubernatorial Wall of Shame within a matter of years will face a series of negative consequences through denying their residents high quality public health programs, effective infection control programs through vaccinations from infants all the way to adults, and access to the very best medical care–either because the public will not be able to afford the cost–or–the best medical talent will refuse to practice medicine in the opt-out states because the pay is so poor.

On top of that, the opt-out states will find that they will have trouble recruiting new businesses that have a commitment to providing their employees high-quality health benefits.  If the ACA doesn’t fully exist in that state, entrepreneurs won’t begin new businesses, let alone move, their operations there.  And why should they?  Only the most hard-core right-wing cynical ideologues would want to subject their employees to living in the medical equivalent of a third-world nation.

Thousands of their citizens will not be insured, not able to afford insurance offered by the so-called “free-market,” health care industry, which is undoubtedly salivating at the prospects of committing crimes against humanity they could only dream about under the disastrous pre-ACA health care system we have had here in the United States.  Not only will the premiums skyrocket, but the health insurance, pharmaceutical, and medical equipment industries will find ways to exploit every possible loop-hole in its laws and regulations, knowing that they merely have to whisper the term “free-market” into the ear of any elected official and they will get no resistance from either the governor’s office or the state’s legislature.

The governors and legislators that refuse to accept the ACA will condemn their citizenry to the lowest possible practice of health care, especially affecting the poor, children, women and the medically most fragile to a tortured existence, all in the name of sustaining a failed health care system that is the laughing-stock of the Free World by those nations who long have made a commitment to their citizens that health care is an inalienable right.  The states on the list may balance their budgets on the backs of their dwindling middle class, but with such inferior health care available (except for the wealthy who can afford to go to other states participating in the ACA for superior care), the residents overall health will be too compromised to “enjoy” the fruits of their government’s austere approach to fiscal conservatism.

Here is the Gubernatorial Wall of Shame, the list of those Governors who have elevated ideology to idiocy (in my humble opinion) above the health and well-being of the very citizens they are sworn to protect (in no particular order).

The Gubernatorial Wall of Shame

  • Gov. Mary Fallin, Oklahoma, Republican
  • Gov. Scott Walker, Wisconsin, Republican,
  • Gov. Paul LaPage, Maine, Republican
  • Gov. Rick Perry, Texas, Republican
  • Gov. Bobby Jindal, Louisiana, Republican
  • Gov. John Kasich, Ohio, Republican
  • Gov. Robert Bentley, Alabama, Republican
  • Gov. John Heineman, Nebraska, Republican
  • Gov. Sean Parnell, Alaska, Republican
  • Gov. Phil Bryant, Mississippi, Republican
  • Gov.. Nathan Deal, Georgia, Republican
  • Gov Nikki Haley, South Carolina, Republican

Governors reportedly still making up their minds (a euphemism for what’s politically most expedient or advantageous to my next campaign):

  • Gov. C.L. “Butch” Otter, Idaho, Republican
  • Gov. Rick Scott, Florida, Republican
  • Gov. Chris Christie, New Jersey, Republican
  • Gov. Jan Brewer, Arizona, Republican

“Uncommitted” governors, but leaning toward opting out (perhaps polling their base for the odds of being recalled if they opt in):

  • Gov. John Hickenlooper, Colorado, Democrat
  • Gov. Mitch Daniels, Indiana, Republican
  • Gov. Sam Brownback, Kansas, Republican
  • Gov. Rick Snyder, Michigan, Republican
  • Gov. Jay Nixon, Missouri, Democrat
  • Gov. Brian Schweizter, Montana, Democrat
  • Gov. Beverly Purdue, North Carolina, Democrat
  • Gov. Jack Dalrymple, North Dakota, Republican
  • Gov.Tom Corbett, Pennsylvania, Republican
  • Gov. Dennis Daugaard, South Dakota, Republican
  • Gov. Bill Haslam,Tennessee, Republican
  • Gov. Gary Herbert, Utah, Republican
  • Gov. Earl Ray Tomblin, West Virginia, Republicam
  • Gov. Matt Mead, Wyoming, Republican

Of the thirty governors listed here (and this number will change over time, so consider this list a snapshot as of this writing), 26 are Republicans.  It may be instructive to note that of those 26, eight of them were Blue states in the presidential election (CO, FL, ME, MI, NJ, OH, PA WI) plus the border states (TX and AZ). Very possibly their political fates may be influenced by the Rising American Electorate (RAE) that is the wave of the next generation who tend to be much more liberal and progressive on issues such as health care, as well as other key social issues that Red State elected officials have, as former presidential candidate Mitt Romney rather indelicately termed political “gifts”.  The increasingly blue-politics of the RAE is likely to have a major impact in the next two elections, possibly eclipsing the Tea Party by their sheer numbers.  Governors that place their stats on the health care Wall of Shame may find themselves out of a job and having no prospects for electability in any position above county commissioner in a shrinking number of “red” counties in their states.

The Affordable Care Act, as it is fixed and improved in the next decade, is the United States’ best option for a significantly healthier nation.  On the off chance that some governor or aide reads this post, I would point you to the great incoming tide of the Rising American Electorate.  They overwhelmingly support the ACA and it’s role in the coming generation of America.  I urge you to look to the future of your state offered through the transformation of health care through the ACA; the failures of the past can no longer be sustained.

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10 thoughts on “30 Governors Open Health Care Ghettos: October 1, 2013: Full Text

  1. Dr Waggoner, they way to become a healthier nation is to give patients/citizens a personal stake in their health. And the only certain way to influence behavior is to link it to the wallet.
    People should pay more if they care for themselves poorly. People with higher BMI should pay higher premiums and people with higher cholesterol, higher HbA1c and higher blood pressure should pay more. If you blood pressure is high, you do not care about yourselt of you are not taking your meds – time to pay, so that all of us do not have to pay for the rehab after the stroke or MI.
    That is the way to make America healthier.
    And yes, everybody has an influence on their health. Don’t come with the “victim stories” and how people just can’t lose weight, just can’t this and cant that….except for rare exceptions, yes, they can….

  2. To start with, there was no “overwhelming support” for Obamacare, it just scratched through with a lot of bribing of representatives and a lot of backroom dealing. A measure with “overwhelming support” would have simply had a majority, got voted on, done. you may be overestimating the support that this law had. Something that has “overwhelming support” is not challenged in the supreme court later, it is happily accepted and implemented. You may be fooling yourself in terms of the support that this law had and has.
    To assume that not implementing the ACA will cause ghettos suffers from one flaw – we are already there. Those states do not have the ACA and they will not have much of it in the future. No change. And “No Change” does not “create ghettos”.
    It will be an interesting experiment about the effect of this law… we will be able to compare how insurance exchanged effect wellbeing of citizens. We should welcome this as a large scale experiment and see what the outcome is. Who knows?

  3. Dr. John “protests too much, methinks.” While David Waggoner sees a more negative outcome for those states that opt for a Federal program instead of setting up their own exchanges than I do, his point about political petulance is clearly correct.

    While your comments are well sourced, Dr. John, your ideology regarding the ACA glimmers through. A few examples:

    “The mandate to purchase ins is too small and won’t be enforced, thus is already a failure.” How can that possibly be known at this early stage? You are predicting failure before the program is implemented.

    “…PPACA stipulates not only all pre-existing conditions are covered, but that the irresponsible pay the same insurance premiums as the
    responsible. That invites a cost explosion.” Two thoughts about this one. (1) many of the ill “irresponsible” as well as healthy “irresponsible” have the means to pay for insurance but they choose not to (I’ve heard the healthy ones referred to as the “Fonzies of the world”). These healthy irresponsibles make up about 40% of the uninsured. We responsible folks are already paying a “cost explosion” at the point of healthcare delivery to cover the care that these folks get when they need it. (2) I have personally known worthy folks who became ill without engaging in any lifestyle behaviors that would suggest that they were responsible for their own illness. Your implication that uninsured sick folks are responsible for their illness has the whiff of ideology about it.

    ” Once Federal funding dries up a few years after implementation, state budgets will explode.” My understanding is that Federal funding, while not remaining at initial levels will, not “dry up”.

    “Punishing hospitals for “preventable errors” such as reducing central line and Foley catheter infections is ineffective.” Perhaps, but the data that reveals that as many as 100,000 preventable hospital deaths per year suggests that putting some financial teeth into hospital safety enforcement is necessary to focus the docs’ minds. (Full disclosure: My oldest is a M.D. currently working in a major trauma hospital and does central line procedures on a numbingly routine basis, a situation that lends itself to the inattentive mistake.)

    “No tort reform has been passed (nor will it ever) which guarantees a clash between doctors and patients over everything not covered (i.e. paid for) yet still subject to malpractice suits if the physician fails to order tests not allowed by USPSTF or IPAB.” The tort reform canard has been around as long as the gullible just assume that medical malpractice insurance costs and judgements drive a major portion of healthcare inflation. That’s just not true. The Congressional Budget Office did a study of the savings associated with proposed Republican legislation regarding capping judgements and found that the savings amounted to less than 2% of total healthcare costs. I agree that nuisance cases and ambulance chasers need a bit of reigning-in, such adjustments, however, won’t change the arithmetic very much.

    “I might suggest the left-leaning New England Journal of Medicine, published in Boston.” This quote stands on its own as evidence that your viewpoint has a political component not necessarily a purely professional one. Are there any right-leaning medical journals that also provide studied criticism of the ACA?

    Of course the ACA is flawed but it’s not chiseled in stone and can adapt and change as failures and victories reveal themselves. Doing nothing isn’t an option. It was a major first-term accomplishment for this administration to break through the entrenched special-interest groups and pass the ACA. I suggest that you use your talents to find ways to make it work better and fix its flaws instead of dismissing it out of hand.

  4. Although the specifics of your comment may be accurate from a perspective of the delivery of medical services in a given facility, I think you have missed the bigger picture of what this post addresses, that the political decisions of the governors will create far-reaching sociological and economic barriers on the delivery of care within that state, and additionally, as a matter of ethics and morality regarding the poor and the chronically ill, there is every expectation that those who have the least resources to begin with across a range of issues, will, in fact, find access more difficult. A strategic goal for improving public health must necessarily involve pertinent clinical and socioeconomic factors from a variety of perspectives. Perception of access is as important as actual access. This principle, I would suggest, applies equally both within the borders of a state as much as from beyond it, based on decades of research conducted in the fields of perceptual psychology, sociology, political science, organizational ecology and macroeconomics. I would also take issue with the assertion that the core of the issue of the delivery of quality of care is solely centered on the individual taking personal responsibility for one’s health care; it is certainly a component, but state-designed barriers to access are, in my assessment, of equal importance. Even though the Federal Government through the ACA will reach over the political tantrum of individual governors and their legislatures in an attempt to provide health insurance to those who cannot afford it, I contend that a hostile environment coming from the state house will result in fewer eligible individuals being covered. Over time I would expect this situation to improve, but initially, people who need insurance to get necessary medical attention will be missed. Those states that manifest the political and ideological motives of its elected officials that communicate a refusal to opt-in to the national law broadcast that perceptual barrier loud and clear. In the end, the PPACA is what we have, regardless of its flaws–real or imagined. Neither the Republicans nor the medical community, such as the American Medical Association or other organizations of health care providers, have produced a comprehensive health care reform document or model that matches the scope of the ACA without its flaws. It, frankly, has been disappointing that the physicians across the country have not been able to speak with a single voice on how to fix the problems in the ACA but have spent a great deal of time sniping about their perceptions of its inadequacies. That same disappointment holds true for me regarding the response of national organizations such as AHIP, PhARMA, and other medically-related professional associations that have taken the attitude that everyone else is part of the problem and needs to change, but don’t make me change or take responsibility for what I’m doing because it will hurt my bottom line. In the end, again in my opinion, there has not been a truly free market in health care in the United States because the lobbying of the various associations and corporations in the industry have manipulated the market to their advantage and gotten legislation passed that, all too often, completely obviates any real competition in the market place. The ACA will fix some of that, along with the unjustifiable abuses the industry has committed on its customers for decades, such as refusing to pay for pre-existing conditions, or cancelling insurance when a procedure covered in the policy is deemed too expensive, or the artificial manipulation of drug prices–the list of abuses goes on and on. Without the ACA, the so-called American health system would have continued to reinforce our getting sicker and sicker as a nation. Breaking that cycle required a radical change in the paradigm of the entire system. It’s time we get on with the change; it’s the only way we ultimately will become a healthier nation.

  5. The Federal govt will set up the exchanges in these states, negating the threat of “ghettos.”
    http://www.nola.com/health/index.ssf/2012/11/federal_government_poised_to_c.html

    Failure of the states to set up their own exchanges hardly will cause poor infant and childhood immunization rates as much of that has already been addressed with pre-PPACA legislation. A major cause of poor vaccination rates is noncompliance rather than lack of access. http://www.oregonlive.com/kiddo/index.ssf/2008/08/post_2.html

    PPACA is a deeply flawed law.
    http://www.nejm.org/doi/full/10.1056/NEJMp1210763
    I do not foresee Congress or the Dept. of Health and Human Services (under either a Democratic or Republican administration) being capable of fixing the shortcomings.

    The mandate to purchase ins is too small and won’t be enforced, thus is already a failure.

    Patients taking personal responsibility for their personal lifestyle choices (e.g. smoking, obesity, alcohol and substance abuse, safety issues) would do far more for the overall health of this nation than any law. Healthy responsible patients subsidizing the irresponsible behavior of patients with illnesses (e.g. heart disease, cancers, COPD, strokes) brought on by their poor lifestyle choices encourages further bad behavior, as PPACA stipulates not only all pre-existing conditions are covered, but that the irresponsible pay the same insurance premiums as the responsible. That invites a cost explosion. Just think if auto ins companies had to cover every driver, irrespective of driving record, and charge everybody the same premiums. That involves people not paying their “fair share.”

    Insurance coverage doesn’t equal access. Medicare barely covers office overhead, and Medicaid is even worse. Once Federal funding dries up a few years after implementation, state budgets will explode.

    Punishing hospitals for “preventable errors” such as reducing central line and Foley catheter infections is ineffective. http://www.nejm.org/doi/full/10.1056/NEJMsa1202419 When biologic systems meet technology, there are inherent limitations to perfection. This is not an effective or appropriate means to control health care costs.

    USPSTF is already rationing things (e.g. no routine mammograms under age 50, no prostate cancer screening for any male regardless of age or family history) in disagreement with numerous professional organizations and the American Cancer Society. No tort reform has been passed (nor will it ever) which guarantees a clash between doctors and patients over everything not covered (i.e. paid for) yet still subject to malpractice suits if the physician fails to order tests not allowed by USPSTF or IPAB.

    The author of this post perhaps would benefit from reading through the last several years of perspective articles on health care reform in order to be better informed.
    I might suggest the left-leaning New England Journal of Medicine, published in Boston.
    selected references:
    http://www.nejm.org/doi/full/10.1056/NEJMp1114858
    http://www.nejm.org/doi/full/10.1056/NEJMp1200751
    http://www.nejm.org/doi/full/10.1056/NEJMp0902651
    There have been easily a hundred articles on PPACA since 2009 in NEJM, in great detail examining every facet of health care reform.

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