Here's an essay by Sen. Bill Frist (R-TN, retired) that encapsulates the problem Republicans will have in trying to block the expansion of health care insurance for those who are not insured. Writing in The Week:
Why both parties should embrace ObamaCare's state exchangesWhile you may remember Bill Frist as an ex-majority leader in the Senate during the Bush years, don't forget this part of Frist's resume:
Largely lost in the fight over ObamaCare is a worthy provision that lets states develop insurance systems that are right for them — but they must act soon
posted on July 18, 2012
He is a fourth-generation Tennessean. His great-great grandfather was one of the founders of Chattanooga, Tennessee, and his father was a doctor and founded the health care business organization which became Hospital Corporation of America. Frist's brother, Thomas Jr., became chairman and chief executive of Hospital Corporation of America in 1997.Have any doubts that Frist is aiming at GOP governors? Here's what he pointedly says:
Enacting some sort of exchange establishment legislation is expected to be crucial to receiving federal approval for a state-run exchange. And though some GOP governors refuse to set up an exchange of their own, I see little advantage for states to default to the federally designed, one-size-fits-all exchange when they can design and run their own.On the one hand there will be political pressure to avoid any cooperation at all. This effort (pdf), for example, is a letter from Republican members of Congress encouraging governors to avoid any cooperation with state exchanges.
(Continue reading below the fold.)
On the other hand, hospitals will put a tremendous amount of pressure on governors in every state (not just blue ones) to go forward with health reform. And there will be powerful lobbyists with good political connections like Frist who will be doing the pushing. Here's another example of that:
And hospitals in opt-out states would still get hit with cuts programmed in the law under the assumption that every state would take the Medicaid expansion and fewer uninsured people would be needing charity care.How might hospitals be helped? The obvious way is insurance expansion. There are two main ways the underinsured can be helped: expansion of Medicaid, and the use of state insurance exchanges. This handy calculator from Kaiser Family Foundation maps those effects (in my Northeast area, 12 percent of the non-elderly population could benefit from the ACA coverage expansions. The map shows a disproportionate concentration of higher percentages in red states—the database is searchable by zip code).
"You are still paying for that coverage expansion but not getting the benefit of it," said Herb Kuhn, president of the Missouri Hospital Association. "So you as a state are exporting your dollars to another state. If you have some adjoining state that accepts (the Medicaid expansion) then you are basically sending your dollars to your neighbor."
How does that affect hospitals? This table (article from Health Affairs, 2003) shows the estimated share of discharges for uninsured patients, generally around 5 percent on average, but with a huge range:
While the average share of uninsured inpatient discharges is 4.8 percent, the average share for the top decile of hospitals—that is, those with the highest shares—was 14.6 percent, with individual hospitals ranging from 8.6 percent to 43.3 percent.Who pays for those who can't pay? You do, one way or the other, be it higher insurance rates or tax money in some fashion.
The result is dialogue like this:
"I will not be party to socializing health care and bankrupting my state in direct contradiction to our Constitution and our founding principles of limited government," Texas Gov. Perry said last week. About one-fourth of Texas residents are uninsured, the highest percentage of any state.Bill Frist's lobbying effort is just the tip of the iceberg, and it is unclear how long the Republicans will be able to fight reality and stonewall reform.
But John Hawkins, top lobbyist for the Texas Hospital Association, says his group isn't dropping the subject.
"We have told the governor we are willing to continue the discussion," said Hawkins. "It's hard to imagine how you get from here to there without accessing federal funds at some level."
In fact, I suspect the answer is not "forever."