The Homa Files

Key Point: NYC Mayor Michael Bloomberg — a supporter of healthcare reform — criticizes the bill’s lack of transparency, sensibility, and consequences

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Many who have long touted health care reform are turning up their noses at the final product.

Michael Bloomberg, New York’s independent mayor, told “Meet the Press” over the weekend:

“I have asked congressperson after congressperson. Not one can explain to me what’s in the bill, even in the House version … And so for them to vote on a bill that they don’t understand whatsoever, really, you’ve got to question how — what kind of government we have.”

The mammoth 2,100-page health care bill passed by the Senate “makes no sense whatsoever — not to conservatives, not to liberals, not to anyone.”

“Rather than reform a system that everyone agrees is a failure, it will subsidize that system and compel participation in it.”  

Mr. Bloomberg added that his own reading of the Senate bill led him to conclude that it would blow a hole in the New York State budget and force closure of perhaps 100 health clinics.

Excerpted from WSJ: Like Mushrooms, Health Care ‘Reform’ Flourishes in the Dark, Dec. 28, 2009
http://online.wsj.com/article/SB10001424052748703278604574624230633163104.html?mod=djemEditorialPage

Everybody in earth orbit knows that Sen Ben Nelson of Nebraska sold his right-to-life principles for a couple of hundred million dollars and cast the deciding vote for ObamaCare.  Apparently, he expected Nebraskans to savor the Medicaid bribe he took on their behalf.  Oops.

It looks like the Nebraska senator’s health-care vote may have killed him politically.

A new Rasmussen Reports poll — the first state-wide poll since the controversial deal he cut in exchange for his deciding vote on the Senate health care bill –shows that if he were running for re-election today, Mr. Nelson would lose to Nebraska’s GOP Governor David Heineman by a stunning 61% to 30%.

Only three years ago, Mr. Nelson won his current term with a solid 64% of the vote.

Clearly, the senator’s fall in public esteem is a direct reaction to his having voted for the health care bill as part of a deal in which Nebraska was exempted from the costs of new federal Medicaid mandates.

The ObamaCare bill was already unpopular enough in Nebraska but became even more so when state residents discovered they would be saddled with it anyway, plus exposed to national ridicule over Mr. Nelson’s sweetheart deal.

Now 53% strongly oppose the bill, while another 11% somewhat oppose it.

Only 17% favor the deal that Mr. Nelson struck in order to vote for the bill.

But the poll also shows a path to redemption.

Asked how they would vote in the 2012 election if Senator Nelson changed his vote and prevented the health care bill from becoming law, Nebraska voters give Governor Heineman a lead of only 47% to 37% … that simply reversing his health-care vote immediately reduces Mr. Nelson’s deficit by two-thirds.

“The poll suggests the anger of Nebraska voters is deep and unusually intense, and not likely to dissipate quickly.”

No doubt it was precisely his concern about the unpopularity of the bill back home that prompted Mr. Nelson to hedge his bets when he announced he would support it — he made clear at the time he might not vote for it again if the final compromise between House and Senate versions tilts too far to the left.

Given the shocking slump in his standing back home, Mr. Nelson might like to keep those remarks handy during the coming weeks as the two bills are hammered together.

Source: WSJ, Ben Nelson’s Purgatory, Dec. 30, 2009
http://online.wsj.com/article/SB10001424052748704152804574628591826272498.html?mod=djemEditorialPage

Ken’s Bet: Nebraska voters are just teasing Nelson with the ray of hope if he changes his vote.  The voters seem more principled than the Senator and smart enough to know that if he betrayed their trust once, he’ll do it again.  In 2013, Nelson will be a high paid lobbyist or Obama’s Ag Secretary.

Reid thinks he was really clever with the ObamaCare provision that limits insurance companies to spending 20% or less of premiums collected on SG&A — sales, general & admin costs — including exec comp.

Ken’s Bet: It’ll cause healthcare costs and premiums to go up.  Here’s why …

Assume that Acme Insurance currently collects $7.5 million in premiums — pays out $5.25 million to healthcare providers (docs, hospitals, pharmacies, etc.) — and spends $2.25 million (30%) on SG&A.

Reid thinks his rule will cut premiums by about $1 million — thanks to a roughly $1 million cut in SG&A.

WRONG !

Here’s a more likely outcome:

Acme holds its SG&A constant and simply starts selling more liberal plans (maybe all the way up to the Cadillac limit) to force fit within the 20% limit — for example, Acme charge $11.25 million in premiums to cover $9 million in payouts ( lower co-pays & deductibles, more botox) and allow $2.25 of SG&A (20% of $11.25).

PRESTO!

Rather than healthcare costs coming down and premiums getting reduced, premiums and healthcare expenditures go up by 50% … SG&A stays the same … insurance execs still drive fancy cars.

Ken’s Take: The DC boneheads have zero conception of how businesses run …

I posted this a couple of weeks ago —  an editorial by the head of Johns Hopkins. 

His view: A vast expansion of the Medicaid program — without adequate risk-adjusted reimbursement rates — will impose unsustainable costs on healthcare providers.

With the Senate bill on its way to passage, it’s worth a re-read — a prediction of what’s to come from somebody who knows.

There was an interview on one of the biz shows yesterday — a poor stiff who owned a couple of tanning salons.

They guys was pale .  (Pardon the pun) 

He said: “life savings in the salons … eeking out a living … getting slammed by the recession since tanning is as discretionary as spending gets … was stunned to hear about the 10% tax … will probably have to shut down”

When asked “Were your lobbyists asleep at the switch?”, he answered “Are you kidding, what lobbyists?”

Maybe it’s a good idea to shut down tanning salons — frankly, I don’t have a point of view on that one.

But, raises a couple of questions:

1) How much tax revenue will be raised via the tanning salon tax if all the tanning salons close?

2) Is it right for the full force of the government to come down on a piddly business like tanning salons?

3) Why not tatoo parlors?  Or, funnel cake stands?  Or, (fill in the blank)

Hands off Wall Street, big insurance, big pharma, etc., but nail the tanners … Geez.

Below is the WSJ’s summary.

Big deals:

• Roughly $50 billion per year each from tax increases and Medicare cuts
• Massive expansion of Medicaid … estimated 1/2 of the newly insured
• Roughly 10 million “young healthies” who self-insure mandated to buy insurance
• .9% increase in Medicare taxes if over $250,000
• Excise tax on Cadillac insurance plans (except for longshoremen)
• $10 billion for community health centers

Ken’s Favorite: 10% tax on tanning salons

Pay-offs for votes:

• Nebraska, Louisiana, Vermont and Massachusetts are getting more federal help with Medicaid than other states. In the case of Nebraska — represented by Sen. Ben Nelson, who’s providing the critical 60th vote for the legislation to pass — the federal government is picking up 100 percent of the tab of a planned expansion of the program, in perpetuity.
• Florida’s beneficiaries of Medicare Advantage plans — the private managed-care plans within Medicare —  will have their benefits grandfathered in thanks to a provision tailored by Sen. Bill Nelson.
• Longshoremen were added to the list of workers in high-risk professions who are shielded from the full impact of a proposed new tax on high-value insurance plans.

 From the WSJ: 

http://online.wsj.com/public/resources/documents/info-enlargePic07.html?project=imageShell07&bigImage=wsj_healthpol091220.gif&h=569&w=959&title=WSJ.COM&thePubDate=20080826

The politics of healthcare reform are simply amazing. 

Over 3/4s of Americans are reasonably satisfied with their healthcare insurance and the healthcare they receive — and they expect taxes to go up, insurance premiums to go up, and healthcare to get worse with longer waits and more denied services. 

Still, the Senate passed — on a straight party line vote — a law that roughly 2 out of 3 Americans oppose. 

Now they — the Democrats in general and Pres. Obama specifically — “own” the healthcare system.  Rightly or wrongly, every premium increase, every delayed doctor’s appointment, every service denied, etc., will be chalked up to ObamaCare.  Turnabout is fair play !

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Excerpted from RCP: Democrats Risk Another Jacksonian Moment, December 21, 2009

Democratic leaders are courting disaster with this health care bill. With it, they’ve moved their questionable wheelings and dealings from the margins to the center of American life. Consider some of the special deals:

– Nebraska, Louisiana, Vermont and Massachusetts are getting more federal help with Medicaid than other states. In the case of Nebraska — represented by Sen. Ben Nelson, who’s providing the critical 60th vote for the legislation to pass — the federal government is picking up 100 percent of the tab of a planned expansion of the program, in perpetuity.

– Florida’s beneficiaries of Medicare Advantage plans — the private managed-care plans within Medicare —  will have their benefits grandfathered in thanks to a provision tailored by Sen. Bill Nelson.

– Longshoremen were added to the list of workers in high-risk professions who are shielded from the full impact of a proposed new tax on high-value insurance plans.

We might be on the verge of another Jacksonian moment: a time when the people awake from their slumber, angrily exercise their sovereign authority, and mercilessly fire the leaders who have for too long catered to the elites rather than average people.

In true Jacksonian fashion, the country fired the Republicans in 2006 and 2008 because they bungled the war in Iraq and allowed the economy to sink into recession.

The people might soon have another Jacksonian moment, and fire these equally useless Democrats for hampering the recovery, exploding the deficit, and playing politics with health care.

The fact that the President can’t find a single Republican vote out of more than 200 potential supporters is a strong indication that this is a bad bill.

Ben Nelson sits in the middle of the Senate. He could be a Democrat or a Republican. If he were a Republican, but everything else about him were the same, would he have voted for this? Of course not. That should tell you everything you need to know about this bill: partisanship and pay-offs. 

Full article:
http://www.realclearpolitics.com/horseraceblog/2009/12/democrats_risk_another_jackson_1.html

TakeAway: The problem with health care is not that we can’t afford insurance. The problem is that we can’t afford health care.

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Excerpted from Reason: The Problem is Cost of Care – Understanding America’s dysfunctional health care system, December 10, 2009

The U.S. has the world’s most expensive health care, $8,000 per person per year, eating up 16 percent of our GDP.

There are many ways of paying these costs, of course, ranging from private insurance such as Blue Cross to public insurance such as Medicare. Many people pay out of their pockets, and local and state taxpayers pick up the rest.

The problem is that health care costs have increased at an annual rate double, or more than double, the rate of inflation for the last two decades.

Right now, our attempts at reform are doomed by a law of accounting physics: Insurance can’t cost less than the health care it insures.  That means that subsidizing insurance likely makes the problem worse.  

Consider: I have car insurance. But my insurance doesn’t pay for oil changes.

Instead, I go down to the Happy Lube, without an appointment, get a diagnosis of the needs of my car, and choose services based on a price list published online.

Now, if I fail to get my car’s oil changed, or to perform other needed services, the engine will be damaged. That’s expensive to fix, but my insurance does not cover the costs. I bear the costs, so I care for the engine.

Health care is a little different.

Many of us have “engines,” or other parts, that may not work very well, especially as we grow older.

Things happen that may not be our fault, and even if they are we’d like to be able to buy some insurance against the worst consequences, the catastrophic injuries or illnesses that are part of every human society. The problem is that how we pay affects how much we pay.

Again, compare it to car insurance, for two people.

Imagine neither of us has to pay for our car repairs, from accidents or engine wear. We can go to the garage as often as we like, and get whatever service we want, for free.

The car repair shop can charge our insurance whatever they want, because insurance pays everything. An oil change would bill out at $600; an alignment would bill our insurance $2,200, with another $800 tacked on to pay for micro-digital wheel axis imaging.  

Of course, the services aren’t really free. At the end of every year, we sum the total repair costs for both people, and each of us pays half of that total.  

The cost of that free car care would be enormous, because of all the unnecessary and overly expensive charges. Of course, the government could subsidize the final bill; would that help? The answer is no, for two clear reasons.

First, having the government (meaning taxpayers) subsidize the total would do nothing to reduce the runaway cost increases. Buyers won’t shop around if they don’t know or care about real costs. Subsidies mean I don’t pay if I spend, and I don’t save if I’m frugal.

Second, let’s expand the example from two people (each paying half) to 300 million people getting free care (but paying an equal share of total costs). We have met the public option, and it is us! Once we are all paying ourselves, there is no one else to hit up to help with the costs. We are simply taking each person’s money in taxes, then giving some of it back in subsidies. There is no saving, even to individuals.

The French economist, Frederic Bastiat, diagnosed the problem long ago when he said, “The public option is the conceit that each of us should have free health care at the expense of all of us.”

The solution is out there, but it will require a fundamental change in the way we think.

Competition among insurers, without decreases in underlying medical costs, may actually harm people through bad service and arbitrary denial of claims.

Instead, we need competition among medical providers, just like oil change services now.

LASIK surgery, one of the few areas of medical services open to competition and listed prices, has fallen in cost by 70 percent or more in the last 15 years. And quality has gone up dramatically.

Walk-in clinics and fee-for-service arrangements for check-ups, or simple diagnoses like strep throat or  infected thumbs, are already widely available, cost relatively little, and require no appointment.

Subsidizing insurance is a terrible idea. But that is the main focus of the health care reform bills passed by the House, and now being considered in the Senate.

Why pin all our hopes on an approach that can’t possibly succeed?

Full article:
http://reason.com/archives/2009/12/10/the-problem-is-cost-of-care

Bottom line: Why not fix what’s broken rather than just creating mayhem ?

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Excerpted from WSJ: Health Care’s ‘Radical Improver’, Dec. 12, 2009

Choice & Rationing

For all the talk about expanding coverage, the real problem is that “You can’t buy what you want.”

(Politicians are) living in this alternate universe where there’s no such thing as a market in health care and they don’t understand why one might be remotely useful.”

The profound problem with U.S. health care is that there’s “no landscape of choices, or choosers.” Due to the complexity of America’s third-party laundromat for health dollars—your doctor’s clerical staff bills your treatment to an insurance company picked by your employer, and it pays him with your money via premiums or foregone wages—”few doctors in America know the actual value of the services they render.”

The government imposes standardized rules and mandates with no concern for how much they will cost or who will bear the burden. Given the choice, consumers might decide on cheaper policies that cover some services but not others, or decide to run more risk.

Another way of putting it is that if the politicians have their way, “everyone will have access to transportation, and it will be a black Escalade, with spinners. That’s it. There’s no Hyundais, no bicycles, no nothing.”

And that’s scandalously unfair. “These poor people who clip the things off the backs of cans to make the tomatoes cheaper are subsidizing the hypochondriac who gets his shoulder done with an arthroscope because it clicks when he serves at tennis.”

Under ObamaCare, Mr. Bush says, “everyone is going to get health care according to the wise-men benefit panel, who will tell you exactly what it is, and then they’ll run out of money, so every year the wise panel will just squish the benefit a little. People will start to say, well, that’s not going to work for me.”

Central health planning won’t have any longevity, and eventually people “will start leaking out into the [private] market once we run out of money.”

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A Digital Revolution ?

Now, most transactions are conducted on paper. Few people really understand how to navigate the dense and bewildering coding rules for dozens of different insurers or the fee schedules for government payers like Medicaid. Claims were denied with no explanation or vaporized in purgatory.

One reason the digital revolution has so far passed over the health sector is sheer bad product. The adoption of EMR in health systems across the country has been dogged by cumbersome interfaces, error propagation and other drawbacks.

Much of the the nearly $47 billion in stimulus cash the White House has budgeted to prime the pump for health IT adoption is going to legacy software companies, with code that was written in the ’70s.  They’re getting federally sponsored life support.

The irony is that … the status quo for all its flaws is capable of organic change and real progress without the blunt-force trauma Congress is likely to inflict. Or in spite of it.

Athena is one of the country’s most innovative health IT firms. Its core business helps doctors manage their practices and get paid, but the larger purpose of the company, is to try to shore up health care’s resemblance to a normal market.

Athena designed a program to digitize records and automate billing. It now colonizes the wilderness of paperwork and habitual financial chaos that defines running a doctors office, and it is also moving into clinical record-keeping for individual patients. Some 15,000 physicians in 43 states use Athena as a virtual office, a number that is growing at an annual 30% clip.

It is a massive logistical undertaking. Athena’s main facility is housed in a decommissioned World War II arsenal on the Charles, where 30,000 pounds of paper is processed every month, most of the tonnage being paper checks.

Incredibly, doctors also receive on average 1,185 faxes each month—mostly lab results—and those are handled too.

State Medicaid programs, by the way, are easily the worst payers. In New York, for instance, claims must be tendered on a dead-tree form instead of electronically and in blue ink—black is grounds for rejection—and then go on to spend a full 161 days, or almost a half year, in accounts receivable.

While streamlining this disorder frees up time for the company’s clients to treat patients, it also throws off vast data, which are fed in central servers, aggregated and analyzed.

This “athenanet” system is among the few health-tech offerings based on “cloud computing”—in the sense that the applications are accessed on the Web, instead of a computer’s hard drive, allowing constant updates and refinements. If a regulation changes or an insurer adjusts a payment policy, it is reflected on athenanet almost in real time; on the clinical side, the program can adapt at the same rapid pace as medicine itself.

Full article:
http://online.wsj.com/article/SB10001424052748704240504574586260904799386.

Excerpted fron RCP: The Liberals’ Weaselly Panic, by Rich Lowry, December 15, 2009 

President Obama and Harry Reid can rightly claim to be making history.

If he passes health-care reform, they’ll depend on a series of historic “firsts.”

• It’d be the first time Congress had passed a major new entitlement program without bipartisan support;
  [Unless you count the Congressional dude from Louisiana.]
• It’d be the first time it passed such a program without popular support;
  [A CNN poll last week found the public against it by a nearly 2-1 margin.]
• It’d be the first time that such a large-scale program would be passed without anybody knowing (or particularly caring) what’s in it.
  [This is bipartisanship Harry Reid style – nontransparency for everyone. Who needs openness and legislative details when you’re remaking one-sixth of the economy?’

Full article:
http://www.realclearpolitics.com/articles/2009/12/15/the_liberals_weaselly_panic_99557.html

I received the following “personal” email from Sen. Mark Warner (D-VA).

Ken —

I wanted to take just a moment of your time to provide an update on my efforts to improve the Senate health care reform bill.

I led 10 other Senate freshmen on Tuesday in announcing a package of amendments which will we believe will encourage a broader — and quicker — shift toward a more innovative, 21st Century health care system.

[couple of paragraphs of talking points]

I was elected to bring common-sense reforms to government. I will only support a final bill if I am convinced it will lower the deficit, drive down health care costs over the long term, and improve the value and quality of the health care Virginians receive.

Thanks,
Mark Warner

Since I don’t think he reads my emails to him, I thought I’d give you a peek at my reply.

Mark —

I have 3 questions for you:

(1) When you ran a company, did you run debt ratios comparable to those you’re now foisting on American taxpayers?

(2) Aren’t you supposed to be representing the people of Virginia? 

According to the most recent Rasmussen survey, 54% of Virginians oppose the health care plan proposed by the president and congressional Democrats … 85% of them (46% of the total) strongly oppose the proposed healthcare plan.

(3) Do you think the 28% of Virginians who strongly favor the proposed health care proposal will be enough to re-elect you? 

Please stop voting like a lemming and keep your commitment to bring “common-sense reforms to government”.

Thanks,

Ken Homa

I’ll keep you in the loop when “Mark” replies.

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Rasmussen Reports

54% in Virginia Oppose Health Care Plan, December 09, 2009

A new Rasmussen Reports survey of Virginia voters finds that 54% oppose the health care plan proposed by the president and congressional Democrats … 85% of them (46% of the total) strongly oppose the proposed healthcare plan.

Forty-five percent (45%) favor the plan …  only about 1 in 4 people in the total sample strongly favor the plan.

http://www.rasmussenreports.com/public_content/politics/general_state_surveys/virginia/54_in_virginia_oppose_health_care_plan

Elections have consequences … you elected us (hah-hah) …  now, we’ll do what we damn well please (because we’re way smarter and way more moral than you are) … and, oh yeah, we won’t even let you see what we’re doing (you can’t handle the truth)

That’s what the politicians seem to be saying these days.

Practically every poll — save for ones fabricated by NBC, CBS, ABC — say the same thing: a CLEAR MAJORITY of Americans DISAPPROVE of current ObamaCare plans. RealClearPolitics’ poll of polls have the approve-disapprove split approaching 2/3s – 1/3.

Do the Washington nitwits really think that there won’t be mayhem and backlash if they ram in their half-baked programs?

Go figure.

http://www.pollster.com/polls/us/jobapproval-presobama-health.php?xml=http://www.pollster.com/flashcharts/content/xml/USObamaJobPresHealth.xml&choices=Disapprove,Approve&phone=&ivr=&internet=&mail=&smoothing=&from_date=&to_date=&min_pct=&max_pct=&grid=&points=1&lines=1&colors=Disapprove-BF0014,Approve-000000,Undecided-68228B

http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html#polls

TakeAway: Another study predicts higher insurance prices.  The culprit: adverse selection.

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Excerpted from WSJ: Blue Cross Blue Patients, Dec 5, 2009

The Blue Cross Blue Shield Association has found that premiums in the individual market will rise on average by 54% over the status quo, which translates into an extra $3,341 a year for families and $1,576 for singles.

The Congressional Budget Office also found this week that ObamaCare will boost premiums in the individual market by as much as 13%. But the White House called that a triumph because the higher costs will be offset by taxpayer subsidies that will be transferred to the federal balance sheet.

The Blue Cross study is in fact more precise than CBO’s because it is based on real market data, rather than modeling assumptions. The association mined the actuarial data from its six million individual or small-business policies, nearly one-eighth of those sold in the U.S.

Lo and behold, Blue Cross found costs will rise if Democrats force insurers to cover anyone who applies and then limit how much insurers are allowed to charge based on age or health condition. Economists call this adverse selection; people will wait until they’re sick to buy coverage, and the Democratic rules make it perfectly rational for them to do so. 

The reality is that all health-care costs are ultimately borne by consumers, whether through more expensive premiums, lower wages or higher taxes.

The regulatory schemes favored by Democrats can’t change that law of economics …

Full article:
http://online.wsj.com/article/SB10001424052748704007804574574170859847850.html?mod=djemEditorialPage

Anti-ObamaCare groups have started running ads in swing states (Louisiana, Arkansas, Maine) targeted at healthy young adults who currently choose to self-insure for healthcare — that is, they realize that healthcare insurance is — for them — way most costly than just “paying retail” for the limited healthcare services they use.

Under ObamaCare, all of these folks will be “mandated” (i.e. forced) to buy health insurance.  If the insurance costs more than 12% of their earnings, then they get taxpayer subsidies to close the gap. 

The ads hit the point that these young healthies will — in effect — be subsidizing the folks whose healthcare expenses exceed their premiums.

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Click arrow to watch

TakeAway: A vast expansion of the Medicaid program — without adequate risk-adjusted reimbursement rates — will impose unsustainable costs on healthcare providers.

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Excerpted from WSJ:  Health Reform Could Harm Medicaid Patients, Dec. 4, 2009 

Both the House and Senate health-care reform bills call for a large increase in Medicaid—about 18 million more people will begin enrolling in Medicaid under the House bill starting in 2013.

A flood of new patients will be seeking health services, many of whom have never seen a doctor on more than a sporadic basis. Some will also have multiple and costly chronic conditions. And almost all of them will come from poor or disadvantaged backgrounds.

Johns Hopkins’  Priority Partners handles Medicaid patients under a capitated system — that is, it receives a set payment per individual per month from the state.

Over time, we’ve developed the ability to manage the care of these individuals in a way that is both cost effective and that provides them with quality care. We’ve done it by tapping into our extensive delivery system, which includes four hospitals, a nursing home, the largest community-based primary care group in Maryland, and much more.

We’ve hit above-national benchmarks on all clinical quality measures, reduced monthly costs for patients with substance abuse and highly complex medical needs, and 70% of our patients tell us they’re satisfied with our care.

The key fact is that for years the state did not cover all the costs our Medicaid program incurred. As a result of new patients whose costs were not completely covered by the state, Priority Partners lost $57.2 million from 1997 to 2005.

We stanched the losses by ensuring that the payment from the state was appropriately risk adjusted to match the health conditions of our members, and by investing heavily in primary-care and care-management and disease-management programs.

Yet this past year the losses began again, because the state expanded the program’s eligibility to 116% of the federal poverty level up from 40%.

So we are struggling with a large group of new patients—about 30,000 people. Today, like in the late 1990s, a health-care surge is overwhelming our managed-care system. The capitated rate for the new beneficiaries is not yet risk-adjusted. Priority Partners has lost a devastating $15 million in just nine months.

Congress can help, or at least learn from our experience to use the reform legislation to bend the cost curve if it encourages other states to institute and appropriately fund capitated systems that allow capable providers to adjust payments based on risk. The key is that federal support to states for Medicaid must appropriately adjust rates to match the risk of providing health care to the group of people who are covered by Medicaid.

The Senate bill would increase eligibility for Medicaid to those who make 133% or less of the federal poverty level. The Kaiser Family Foundation reports there are 308,000 people who meet that threshold in Maryland.

Even if only half of those individuals seek Medicaid coverage, such a large expansion would likely have an excruciating impact on the state’s budget.

Without an understanding by policy makers of what a large Medicaid expansion actually means, and without delivery-system reform and adequate risk-adjusted reimbursement the current health-care legislation will have catastrophic effects on those of us who provide society’s health-care safety-net.

In time, those effects will be felt by all of us.

Full article:
http://online.wsj.com/article/SB10001424052748703939404574567981549184844.html?mod=djemEditorialPage