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Obamacare, the Oregon Experiment, and Medicaid

Tomorrow, as mandated by the Patient Protection and the Affordable Care Act (PPACA, often called just the Affordable Care Act, or ACA, or “Obamacare”), the government-maintained health insurance exchanges will open for business (that is, assuming the likely government shutdown doesn’t stop them temporarily). We here at SBM have written about the ACA quite a few times, but I would like to write about it in perhaps an entirely different context than you’re used to now that the biggest change mandated by the law is here. Just to see the contrast, I’ll mention that Jann Bellamy has written about the ACA in the context of how provisions have been inserted by promoters of “complementary and alternative medicine” (CAM) could potentially provide an “in” for requiring reimbursement of CAM practitioners for their services by insurance plans sold through the exchanges or even how CAM practitioners might promote themselves as primary care providers (PCPs) under Obamacare, as did Matt Roman. I myself warned about legislative meddling that might permit funding of religion-based health care in the exchanges, and Kimball Atwood sounded early warnings about insertion of the provisions that Jann warned about. Instead, view this discussion as a follow-up to a post I did almost a year ago that used a statement by Mitt Romney during the height of the Presidential campaign as a jumping off point to look at the relationship between health insurance status and mortality. While we at SBM try to remain more or less apolitical, in some cases (licensing of naturopaths, for example) it is not possible to disentangle science from politics, and we have to dive in. Also, politics is the art of the possible; so, policy-wise, what is best as determined by science might well not be what is possible politically.

The reason I wanted to revisit this topic is because of a political battle that went on for quite some time over the last several months to expand Medicaid in Michigan according to the dictates of the ACA. The reason that this battle is occurring in many states is because when the Supreme Court ruled last year that the individual mandate requiring that citizens have health insurance was Constitutional, one provision that it ruled unconstitutional was the mandatory expansion of Medicaid in states participating in the Medicaid program to cover all people under 65 up to 133% of the federal poverty level. States thus had to decide whether or not they would accept the Medicaid expansion. In our state, Governor Rick Snyder supported the expansion. Even though he is Republican, he is also a businessman and realized that it was a good deal, with the federal government covering 100% of the cost for the first three years and then phase down to 90% of the cost in 2020. The bill to expand Medicaid managed to pass the House of Representatives, but then it stalled in the Senate. Unfortunately—and this is what got me involved—my state Senator Patrick Colbeck led the opposition to the Medicaid expansion in the Senate, much to my chagrin and disappointment. His argument, which is being repeated elsewhere in the blogosphere, is that Medicaid is worthless and doesn’t improve health outcomes. Instead, he endorsed an alternative that (or so he claimed) places Medicaid-eligible patients into in essence low cost, high deductible concierge practices, with health savings accounts. This was a plan promoted by practices like BlueSky Health. Ultimately Mr. Colbeck lost, and Medicaid was expanded in Michigan in a plan that was characterized by John Z. Ayanian in this week’s New England Journal of Medicine as “a pragmatic pathway to link Republican and Democratic priorities for health care.”

However, the whole kerfuffle got me to thinking. In my post a year ago, I basically asked what the evidence was that access to health insurance improves health outcomes, but I didn’t really stratify the question into kinds of health insurance. Rather, I just looked at being uninsured versus having health insurance. After my little Facebook encounter with one of my elected representatives, I wondered what, exactly, was the state of evidence. So I decided to do this post. In the U.S., currently we have in essence three kinds of health insurance, broadly speaking: private insurance, Medicare, and Medicaid. Medicare, for those of our readers from other countries, is a plan that covers the medical care of people 65 and over and those receiving Social Security disability benefits. It is funded through payroll taxes and directly paid for by the federal government. Medicaid, in contrast, is a plan designed for low income people who fall below certain income levels. Also in contrast, it is jointly funded by the states and the federal government with each participating state administering the plan and having wide leeway to decide eligibility requirements within the limits of federal regulations that determine the minimal standards necessary for states to receive matching funds. Indeed, the loss of this leeway to determine the income level at which a person is eligible for Medicaid is one of the reasons the provision for Medicaid expansion was part of the Supreme Court challenge to the ACA. These days, most Medicaid plans hire private health maintenance organizations (HMOs) to provide insurance. Finally, what needs to be understood is that, compared to private insurance, Medicare reimbursement rates tend to be lower and Medicaid reimbursement rates are lower still, which is part of the reason why a lot of doctors don’t accept Medicaid. Increases in reimbursement under the ACA might well help this situation. (more…)

Posted in: Clinical Trials, Epidemiology, Politics and Regulation, Science and the Media

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When doctors betray their patients and science-based medicine for money

We spend a lot of time on this blog discussing failures of the medical system. Usually, we such discussions occur in the context of how unscientific practices and even outright quackery have managed to infiltrate what should be science-based medicine (SBM) in the form of so-called “complementary and alternative medicine” (CAM) or “integrative medicine,” in which the quackery of alternative medicine is “integrated” with SBM. Our attitude towards this practice is, of course, completely in tune with that of fellow SBM blogger Mark Crislip when he so famously wrote, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.” However, as grave a threat to SBM as CAM and integrative medicine are, there is a threat at least as grave here in the U.S. (and, I presume, in many places in the world). It has little or nothing to do directly with CAM, but often CAM practitioners benefit from it. What I am referring to is the utter ineffectiveness of most state medical boards in reining in quackery and bad physician behavior that endangers patients. A recent story about a prominent Detroit area oncologist named Farid Fata, MD, who has been arrested and charged with administering unnecessary chemotherapy and of diagnosing patients with cancer who turned out not to have cancer in order to defraud Medicare, has led me to think that now might be a good time to revisit this issue. Then I heard about an Ohio spine surgeon indicted for performing unnecessary surgeries to defraud insurance companies, and I knew that now is a good time to revisit the issue.

I’ve discussed this issue before with respect to various practitioners over the years. One that comes to mind immediately is Dr. Rolando Arafiles at the Winkler County Memorial Hospital in Kermit, TX. Basically, a CAM-friendly physician was practicing substandard medicine, and two nurses reported him anonymously to the Texas Medical Board. Dr. Arafiles was a business partner with Winkler County Sheriff Robert Roberts, who left no stone unturned to discover who had complained about his good buddy, leading to the prosecution of the two whistleblowing nurses for violation of patient privacy, even though Texas law explicitly said that using patient information to report substandard care is not a violation of patient privacy. The entire medical establishment seemed to be trying to come down on the two brave nurses like the proverbial ton of bricks. Ultimately, the Texas Medical Board did the right thing, but it took a long time, and two responsible nurses who couldn’t bear seeing Dr. Arafiles continue to betray patient trust. There are many other examples, such as that of Dr. Rashid Buttar, a North Carolina doctor known for using “alternative” treatments for autism and cancer who got off with a slap on the wrist for some truly horrendous violations of the standard of care.

And don’t even get me started on the utter failure of the Texas Medical Board to put a stop to Dr. Stanislaw Burzynski’s unethical abuse of clinical trials and use of an unproven cancer drug for over 36 years or on how it took decades to finally put a stop to Dr. Mark Geier’s autism quackery in the United States. So what about these recent cases have in common? It’s that they were both busted by the feds. The relevant state medical boards in Michigan and Ohio (both states in which I hold a medical license) did not detect the medical misadventures and did, as far as I can tell, basically nothing to stop it.
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Posted in: Health Fraud, Politics and Regulation

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