ACA in Kentucky

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morriswalters
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ACA in Kentucky

Postby morriswalters » Mon Nov 25, 2013 6:46 pm UTC

Greetings from Mitch McConnell's home state, Kentucky. Red state. Home to both Mitch and Rand Paul. But a Democratic governor. Our health exchange evidently works. We'll see how it plays out politically, but here is an article from the Washington Post. Heavy on Medicaid in this article. The Governor took some risks to do this over the objections of the Legislators.

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Re: ACA in Kenucky

Postby sardia » Mon Nov 25, 2013 8:15 pm UTC

The problem with the medicare expansion isn't the execution, it's the fact that many states, mostly the ones with high percentages of medicare eligible, are refusing to expand medicare. Some of them have concerns, but others are refusing on principle.

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Re: ACA in Kenucky

Postby morriswalters » Tue Nov 26, 2013 1:27 am UTC

Oh, I think it is working as expected. If other states choose not to participate, it's their call. We expect to provide insurance to over a 100,000 uninsured when it is all said and done. If it works, and I hope it does, it will be a better argument than any other.

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Re: ACA in Kenucky

Postby sardia » Tue Nov 26, 2013 3:14 pm UTC

morriswalters wrote:Oh, I think it is working as expected. If other states choose not to participate, it's their call. We expect to provide insurance to over a 100,000 uninsured when it is all said and done. If it works, and I hope it does, it will be a better argument than any other.

Argument for what? That you can help a lot of poor people when big government offers to pick up the tab? We knew that already. The hard part is making sure government does it better than private markets, and convincing people to spend the money in the first place. We're lucky the hardest part, passing higher taxes to pay for it, happened already.

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Re: ACA in Kenucky

Postby Belial » Wed Nov 27, 2013 6:59 pm UTC

sardia wrote:The hard part is making sure government does it better than private markets


In almost all cases, insurance that exists is better than insurance that does not exist. If the private markets weren't covering these folks, and the government is, then by definition they're doing it better than the private markets.
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Re: ACA in Kenucky

Postby sardia » Wed Nov 27, 2013 7:10 pm UTC

I was referring to the botched rollout of the individual federal exchange and the implied corruption that let incompetent contractors win the bid for coding the insurance website.
http://slashdot.org/story/13/10/23/1517 ... y-failures

It's really frustrating to advocate, and take political risks to help people then have this thrown back in our faces. Politicians have nightmares of another Tea Party wave for the alleged governmental overreach.

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Re: ACA in Kenucky

Postby Tyndmyr » Wed Nov 27, 2013 8:43 pm UTC

Belial wrote:
sardia wrote:The hard part is making sure government does it better than private markets


In almost all cases, insurance that exists is better than insurance that does not exist. If the private markets weren't covering these folks, and the government is, then by definition they're doing it better than the private markets.


Well, that argument would seem to have an issue with the policies canceled as a result of the ACA. If you view insurance as universally good, then you'll want to evaluate vs folks newly insured - folks who lost their insurance. It's not impossible that by such a metric, private markets are doing it better....even before you start crunching cost data, etc.

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Re: ACA in Kenucky

Postby morriswalters » Thu Nov 28, 2013 2:11 am UTC

sardia wrote:Argument for what? That you can help a lot of poor people when big government offers to pick up the tab? We knew that already. The hard part is making sure government does it better than private markets, and convincing people to spend the money in the first place. We're lucky the hardest part, passing higher taxes to pay for it, happened already.
If you want to find miracles, go to church. If you want to solve problems start doing something. If Democrats lose Congress and the program works anyway it will have been worth it. If they can't make it work than we should be rid of it, and just maybe the Republicans should have a go. The important part is doing something versus nothing. The point here in Kentucky is the the Governor had the balls to do this over the wishes of the Republican Legislature. My two cents.

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Re: ACA in Kenucky

Postby sardia » Thu Nov 28, 2013 7:15 am UTC

morriswalters wrote:If you want to find miracles, go to church. If you want to solve problems start doing something. If Democrats lose Congress and the program works anyway it will have been worth it. If they can't make it work than we should be rid of it, and just maybe the Republicans should have a go. The important part is doing something versus nothing. The point here in Kentucky is the the Governor had the balls to do this over the wishes of the Republican Legislature. My two cents.

Actually, I was expecting all the states to accept the medicaid expansion, but that didn't happen. Then again, I was expecting that States didn't have the right to pick and choose which medicare benefits they wanted, but Robert's court said otherwise. It's a screwy world we live in where free money is refused, Your statement about how someone had the balls to accept free money for several years is ludicrous. Imagine 1/3 of the country refusing to accept farm subsidies, except that one brave governor of Iowa or something, had the balls to accept free money, over the objections of the ________ party.

Craziness aside, I'm glad he did it. Anybody know any other states thinking about joining?

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Re: ACA in Kenucky

Postby morriswalters » Thu Nov 28, 2013 9:44 pm UTC

sardia wrote:Your statement about how someone had the balls to accept free money for several years is ludicrous.
Unless of course you are a politician. He knows there is no such thing as free money. Congress can choose to not fund that part of the law at the level required, and the state would be left holding the bag. He also knows that his opponents are waiting for him to stumble, so the can help him fall. And not just for his future election, he is a lame duck, but his parties control of the statehouse will be tied to his choice. This state elected Rand Paul to the Senate. As well as the Majority leader Mitch McConnell. But if it works as intended then the rural areas which elected both of our Republican Senators will end up a little less red, and make the chances of keeping control of the Governors office a little more likely. The rest of the country can see how it works, if it works.

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Re: ACA in Kenucky

Postby sardia » Fri Nov 29, 2013 8:09 am UTC

There's evidence that government largess, even largess that is effective or popular does not make voters less red or more blue. For example, the majority of old people vote conservative even though the GOP is running on cutting medicare and social security. In addition, the Tea Party runs on small government, except in cases where government spends money in their district, then it's one of necessities that government was designed for. I mean yea, it could happen, but my money is on an expansion of government that becomes so natural that people stop thinking of it as part of the government.

PS: When did you become so optimistic? Getting starry-eyed in your old age?

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Re: ACA in Kenucky

Postby morriswalters » Fri Nov 29, 2013 10:22 am UTC

In rural Kentucky patronage and what have you done for me lately sell. An ugly fact. And yeah I'm all dewy eyed. I'd like to think my normally low opinion of humanity is faulty.

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Re: ACA in Kenucky

Postby Tyndmyr » Fri Nov 29, 2013 11:15 am UTC

sardia wrote:
morriswalters wrote:If you want to find miracles, go to church. If you want to solve problems start doing something. If Democrats lose Congress and the program works anyway it will have been worth it. If they can't make it work than we should be rid of it, and just maybe the Republicans should have a go. The important part is doing something versus nothing. The point here in Kentucky is the the Governor had the balls to do this over the wishes of the Republican Legislature. My two cents.

Actually, I was expecting all the states to accept the medicaid expansion, but that didn't happen. Then again, I was expecting that States didn't have the right to pick and choose which medicare benefits they wanted, but Robert's court said otherwise. It's a screwy world we live in where free money is refused, Your statement about how someone had the balls to accept free money for several years is ludicrous. Imagine 1/3 of the country refusing to accept farm subsidies, except that one brave governor of Iowa or something, had the balls to accept free money, over the objections of the ________ party.

Craziness aside, I'm glad he did it. Anybody know any other states thinking about joining?


Jeeze, I *wish* that states would start turning down farm money.

And yeah, it's not quite free money. Money is involved, sure, but there's obligation there too.

sardia wrote:There's evidence that government largess, even largess that is effective or popular does not make voters less red or more blue. For example, the majority of old people vote conservative even though the GOP is running on cutting medicare and social security. In addition, the Tea Party runs on small government, except in cases where government spends money in their district, then it's one of necessities that government was designed for. I mean yea, it could happen, but my money is on an expansion of government that becomes so natural that people stop thinking of it as part of the government.


Meh, what red and blue have stood for have changed. I think it's reasonable to expect that the perception of normality has been shifted by what government programs exist. I mean, a generation ago, there was a LOT fewer of them, but what exists today is seem as normal. Moderate. Those who want a lesser level(even if it's a level high by historical standards) are labeled conservative, those who want more, liberal(generally speaking). The labels shift with the times.

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Re: ACA in Kenucky

Postby sardia » Fri Nov 29, 2013 6:25 pm UTC

I was referring to morris's prediction that the expansion of medicare would make Kentucky a little less red, which I don't think is going to happen. What do you think about that prediction?

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Re: ACA in Kenucky

Postby Tyndmyr » Mon Dec 02, 2013 2:04 pm UTC

Kentucky's gonna stay red regardless. How red? I don't know the demographics there well enough to say. So, I can't predict accurately on the specific case.

As a more general principle, I would say that expanding social programs does not change the number on each side of the divide over the long term...a two party system will always trend towards a 50/50 split. It might, however, change where the split occurs. While the repub/dem split has remained fairly constant over the long term, the issues championed have not. Some issues are not controversial, some are, and of course, this changes. Affecting what things people fight over is a strong power in it's own right, and yeah, social programs might affect that.

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Re: ACA in Kenucky

Postby davidstarlingm » Mon Dec 02, 2013 3:07 pm UTC

Tyndmyr wrote:Kentucky's gonna stay red regardless. How red? I don't know the demographics there well enough to say. So, I can't predict accurately on the specific case.

Having grown up in Central KY, I always found it profoundly curious (or at least moderately curious) that local politics were almost exclusively Dem-dominated while national politics were strongly red. Despite being a raving neocon at age 18, I registered Democrat so I could actually have a vote in the primaries.

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Re: ACA in Kenucky

Postby morriswalters » Mon Dec 02, 2013 3:08 pm UTC

There are two Kentucky's, rural(Red) and urban(mostly Blue). You don't have to turn the state from Red to Blue. You just have to buy enough votes close enough to the election to swing the balance for that election. Secondary fallout. Indiana didn't and we did. Along the river you have the oddball fact that people working in Indiana who live in Kentucky now are eligible for Medicaid, while co-workers in Indiana who are residents, are without. It's a bitch being a burger flipper in Indiana.

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Re: ACA in Kenucky

Postby sardia » Mon Dec 02, 2013 3:51 pm UTC

morriswalters wrote:There are two Kentucky's, rural(Red) and urban(mostly Blue). You don't have to turn the state from Red to Blue. You just have to buy enough votes close enough to the election to swing the balance for that election. Secondary fallout. Indiana didn't and we did. Along the river you have the oddball fact that people working in Indiana who live in Kentucky now are eligible for Medicaid, while co-workers in Indiana who are residents, are without. It's a bitch being a burger flipper in Indiana.

The urban rural divide is a common trend across the country. Are there any states with cities that are red and have blue rural countrysides? By the way, buying votes is worth something, but Ketucky voted 22 points with Romney, are you asking for a 11 point swing out of Medicare? It seems a little much. Now North Carolina, that went Red by only 2 points, a much easier goal, not to mention the demographic changes/ black vote. Kentucky would require another George Bush followed by a Obama/McCain combo.

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Re: ACA in Kenucky

Postby morriswalters » Mon Dec 02, 2013 5:10 pm UTC

sardia wrote:
morriswalters wrote:There are two Kentucky's, rural(Red) and urban(mostly Blue). You don't have to turn the state from Red to Blue. You just have to buy enough votes close enough to the election to swing the balance for that election. Secondary fallout. Indiana didn't and we did. Along the river you have the oddball fact that people working in Indiana who live in Kentucky now are eligible for Medicaid, while co-workers in Indiana who are residents, are without. It's a bitch being a burger flipper in Indiana.

The urban rural divide is a common trend across the country. Are there any states with cities that are red and have blue rural countrysides? By the way, buying votes is worth something, but Ketucky voted 22 points with Romney, are you asking for a 11 point swing out of Medicare? It seems a little much. Now North Carolina, that went Red by only 2 points, a much easier goal, not to mention the demographic changes/ black vote. Kentucky would require another George Bush followed by a Obama/McCain combo.
What I care about is the Governors office and the Federal Legislative seats. Even though the Medicaid expansion was blocked in other places, the Governor here was able to set up the exchange executive by decree. That is the degree of power a Governor has here. It is not an accident that only one Governor since 71 has been a Republican, and up the legislature. And Mitch McConnell is vulnerable. This will be fought out in the states. I don't really care about the President.

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Re: ACA in Kenucky

Postby sardia » Mon Dec 02, 2013 5:32 pm UTC

The presidential race is a good proxy for how Democratic a state will vote since it correlates pretty well. This is in addition to the off year nature of elections. (Nonpresidential elections means only partisans vote). I always thought that the Democrats were getting their asses kicked in the local and state level elections, mostly because it's easier to be crazy when you're running local and because Democrats have more competitive seats to lose.

Are the Kentucky races relatively close? What seats are you expecting to pick up that you didn't already have?

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Re: ACA in Kenucky

Postby Tyndmyr » Mon Dec 02, 2013 5:54 pm UTC

davidstarlingm wrote:
Tyndmyr wrote:Kentucky's gonna stay red regardless. How red? I don't know the demographics there well enough to say. So, I can't predict accurately on the specific case.

Having grown up in Central KY, I always found it profoundly curious (or at least moderately curious) that local politics were almost exclusively Dem-dominated while national politics were strongly red. Despite being a raving neocon at age 18, I registered Democrat so I could actually have a vote in the primaries.


I'm in a section of MD where the local politics are all red, but the overall state is blue as hell. There ends up being a huge partisan divide within the state. Essentially the Baltimore-dominated urban areas have enough people, and are sufficiently blue(over 90% for Obama was not uncommon in some precincts) that on the state-wide elections, the rest of the state is irrelevant. Looking at voting patterns on a county level, you can pretty much tag urban areas by the islands of blue.

So, there's quite a lot of areas where the local politics are distinctly different from state-level politics. They usually make good political hay railing against the other party, of course.

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Re: ACA in Kenucky

Postby morriswalters » Mon Dec 02, 2013 6:06 pm UTC

sardia wrote:The presidential race is a good proxy for how Democratic a state will vote since it correlates pretty well. This is in addition to the off year nature of elections. (Nonpresidential elections means only partisans vote). I always thought that the Democrats were getting their asses kicked in the local and state level elections, mostly because it's easier to be crazy when you're running local and because Democrats have more competitive seats to lose.

Are the Kentucky races relatively close? What seats are you expecting to pick up that you didn't already have?
Optimistically, Mitch McConnell's. And hold even everywhere else. And of course retain the Governors seat. People have short memories. If the ACA is working next September we could do better. Maybe get back the seat we lost in 2012.

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Re: ACA in Kenucky

Postby Tyndmyr » Mon Dec 02, 2013 8:16 pm UTC

morriswalters wrote:
sardia wrote:The presidential race is a good proxy for how Democratic a state will vote since it correlates pretty well. This is in addition to the off year nature of elections. (Nonpresidential elections means only partisans vote). I always thought that the Democrats were getting their asses kicked in the local and state level elections, mostly because it's easier to be crazy when you're running local and because Democrats have more competitive seats to lose.

Are the Kentucky races relatively close? What seats are you expecting to pick up that you didn't already have?
Optimistically, Mitch McConnell's. And hold even everywhere else. And of course retain the Governors seat. People have short memories. If the ACA is working next September we could do better. Maybe get back the seat we lost in 2012.


Don't know that I'd hold out too much for the ACA working. Some of the functional bits will likely be patched up, but the deeper systemic problems likely can't be by then. Even if adaptations get made relatively quickly, it takes a while for software to get changed, insurance companies to catch up, and so forth. Nine months really isn't a ton of time to turn a massive program around.

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Re: ACA in Kentucky

Postby morriswalters » Mon Dec 02, 2013 9:10 pm UTC

You may be right, however I will use the old fashioned method of time travel and find out. I have been surprised before.

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Re: ACA in Kenucky

Postby Arariel » Wed Jan 08, 2014 5:34 am UTC

Belial wrote:
sardia wrote:The hard part is making sure government does it better than private markets


In almost all cases, insurance that exists is better than insurance that does not exist. If the private markets weren't covering these folks, and the government is, then by definition they're doing it better than the private markets.


Hm.

USA Today wrote:That's because extensive research indicates that Medicaid recipients actually do worse than people without any insurance at all. A University of Virginia study found that Medicaid patients hospitalized for major surgery were actually 13% more likely to die in the hospital than those without any health insurance. Likewise, the National Cancer Institute found that late-stage prostate cancer, late-stage breast cancer, and late-stage melanoma were actually much more common in Medicaid recipients than in the uninsured. And a Johns Hopkins study of patients receiving lung transplants found that Medicaid patients were 29% more likely to die within three years.

What's more, a University of Pennsylvania study (published in the journal Cancer) found that colon cancer patients with Medicaid had a higher mortality rate than uninsured patients, and a higher rate of surgical complications. And these findings hold up even when you correct for age and socioeconomic status.

Why Medicaid recipients do worse isn't entirely clear, but it's likely because the best doctors seldom accept Medicaid, leaving patients with subpar physicians. In addition, Roy opens with the story of Deamonte Driver, a seventh grader with a tooth abscess who wound up dying when it turned into a brain infection, after being shuffled from doctor to doctor for weeks. Uninsured patients probably go straight to the Emergency Room or to a free clinic, while Medicaid recipients may waste precious days, weeks, or months trying to navigate the bureaucracy.

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Re: ACA in Kentucky

Postby morriswalters » Wed Jan 08, 2014 1:06 pm UTC

Well, the article may well be true. However no one did anything before Obama. Whatever the failings of ACA, the desire to do something isn't it. Consider this quote from the The Medicaid Mess: How The Affordable Care Act Makes It Worse by Avik Roy, Senior Fellow, Manhattan Institute. Cited by the article.
They then examined three measurements of surgical outcome quality: the rate of in-hospital mortality; average length of stay in the hospital (longer stays in the hospital are a marker of poorer outcomes); and total costs.

The in-hospital death rate for surgical patients with private insurance was 1.3 percent. Medicare, uninsured, and Medicaid patients were 54 percent, 74 percent, and 97 percent, respectively, more likely to die than those with private insurance.
Rather than stating the rates for all he states the rates for the insured and gives the rest as percentages of the rates of the insured, the numbers sound more dire than they are rather than 2.02,2.262,2.561 as rates.

The average length of stay in the hospital was 7.38 days for those with private insurance; on an adjusted basis, those with Medicare stayed 19 percent longer; the uninsured stayed 5 percent shorter; and those with Medicaid stayed 42 percent longer.
Total costs per patient were $63,057 for private insurance; Medicare patients cost 10 percent more; uninsured patients 4 percent more; and Medicaid patients 26 percent more.
Ask yourself what this is telling you. If the cost to private insurance is 63k, and the cost to Medicaid is 79.5k why is the outcome worse for a Medicaid patient?

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Re: ACA in Kentucky

Postby CorruptUser » Wed Jan 08, 2014 1:34 pm UTC

Don't people on Medicaid tend to be unhealthier than the general population? It could be that they are just unhealthier.

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Re: ACA in Kentucky

Postby Diadem » Wed Jan 08, 2014 1:40 pm UTC

CorruptUser wrote:Don't people on Medicaid tend to be unhealthier than the general population? It could be that they are just unhealthier.

Well it says 'adjusted', so they should have accounted for that. Or at least they are claiming they have accounted for that. Whether they properly accounted for it is question you can't answer without digging deep into their research. Always a problem when comparing dissimilar groups.
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Re: ACA in Kentucky

Postby morriswalters » Wed Jan 08, 2014 1:53 pm UTC

The poor generally are. But if you are going to suggest the correlations that the article makes, then you need follow the money. If the uninsured get bounced out before the Medicaid patient,
The average length of stay in the hospital was 7.38 days for those with private insurance; on an adjusted basis, those with Medicare stayed 19 percent longer; the uninsured stayed 5 percent shorter; and those with Medicaid stayed 42 percent longer.
and the Medicaid patient had worse outcomes than the uninsured,
The in-hospital death rate for surgical patients with private insurance was 1.3 percent. Medicare, uninsured, and Medicaid patients were 54 percent, 74 percent, and 97 percent, respectively, more likely to die than those with private insurance.
then you have to wonder why exactly that is. One possible inference is that the longer stays for Medicaid patients have nothing to do with better care or worse care, rather greater reimbursement.

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Re: ACA in Kentucky

Postby CorruptUser » Wed Jan 08, 2014 2:19 pm UTC

Umm... Doctors and hospitals get paid shit for Medicaid patients. You can't meet overhead on Medicaid alone, at least not without committing outright fraud like the medical mills do.

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Re: ACA in Kentucky

Postby morriswalters » Wed Jan 08, 2014 2:41 pm UTC

CorruptUser wrote:You can't meet overhead on Medicaid alone, at least not without committing outright fraud like the medical mills do
Yes I'm aware? Do you think that gaming the system is limited to medical mills?

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Re: ACA in Kentucky

Postby CorruptUser » Wed Jan 08, 2014 2:47 pm UTC

But you just said that Medicaid patients stay longer because of greater reimbursement...

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Re: ACA in Kentucky

Postby Tyndmyr » Wed Jan 08, 2014 3:28 pm UTC

CorruptUser wrote:Umm... Doctors and hospitals get paid shit for Medicaid patients. You can't meet overhead on Medicaid alone, at least not without committing outright fraud like the medical mills do.


True overall of medicare patients, but does not preclude the existance of padding. It may be that some areas are still profitable within medicare areas, even if many are not, and thus, padding in this areas still improves the overall financial take from these patients. Even if it's a loss both ways, a lower loss is preferable.

Gaming the system happens. Medicare is big enough that I'm sure hospitals have done the math on how to best recover costs/make money from it.

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Re: ACA in Kentucky

Postby morriswalters » Wed Jan 08, 2014 4:17 pm UTC

CorruptUser wrote:But you just said that Medicaid patients stay longer because of greater reimbursement...
No, I said,
morriswalters wrote:One possible inference is that the longer stays for Medicaid patients have nothing to do with better care or worse care, rather greater reimbursement.
Since to the best of my knowledge no one outside the hospitals know what it costs them, how would you know what their real overhead is? Perhaps that knowledge is available and I am unaware of it.

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Re: ACA in Kentucky

Postby Arariel » Wed Jan 08, 2014 11:56 pm UTC

CorruptUser wrote:Don't people on Medicaid tend to be unhealthier than the general population? It could be that they are just unhealthier.

The studies compared patients treated for the same or similar issues, such as hospitalisation for major surgery, lung transplants, and colon cancer, and in each of these cases the Medicaid patients did worse than those uninsured; this insurance does appear to be worse than no insurance, then.

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Re: ACA in Kentucky

Postby morriswalters » Thu Jan 09, 2014 12:19 am UTC

Arariel wrote:
CorruptUser wrote:Don't people on Medicaid tend to be unhealthier than the general population? It could be that they are just unhealthier.

The studies compared patients treated for the same or similar issues, such as hospitalisation for major surgery, lung transplants, and colon cancer, and in each of these cases the Medicaid patients did worse than those uninsured; this insurance does appear to be worse than no insurance, then.
Could you link to the studies?

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Re: ACA in Kentucky

Postby Arariel » Thu Jan 09, 2014 12:32 am UTC

morriswalters wrote:
Arariel wrote:
CorruptUser wrote:Don't people on Medicaid tend to be unhealthier than the general population? It could be that they are just unhealthier.

The studies compared patients treated for the same or similar issues, such as hospitalisation for major surgery, lung transplants, and colon cancer, and in each of these cases the Medicaid patients did worse than those uninsured; this insurance does appear to be worse than no insurance, then.
Could you link to the studies?

All the links are in the USA Today article. The studies are by the University of Virginia, John Hopkins, and the University of Pennsylvania, respectively.

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Re: ACA in Kentucky

Postby CorruptUser » Thu Jan 09, 2014 1:38 am UTC

The people not on medicaid are by definition wealthier than those that are. As wealth correlates very heavily with health, it's hard to form a baseline to compare medicaid to. Of the uninsured, many are voluntarily uninsured; young healthy males that don't want to pay far more than their insurance is worth to subsidize everyone else.

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Re: ACA in Kentucky

Postby morriswalters » Thu Jan 09, 2014 1:42 am UTC

I've looked at three, quickly and indeed you are correct. The reason why however seems to be due to the lack of access to care early and discovery of symptoms later. In addition to some belief that because you don't have private insurance you don't get better doctors. In other words because you are poor, you will see doctors less, be diagnosed later, and so on. Which seems to be the case anyway.

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Re: ACA in Kentucky

Postby CorruptUser » Thu Jan 09, 2014 2:01 am UTC

I think every doctor I know wishes everyone on Medicaid was like that. Admittedly it's anecdotal, but it seems (to them) like every person on Medicaid comes in every time they need a bandaid.


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