To the legislators blocking Medicaid expansion

As a primary care doctor I typically see 20-25 patients a day in my private practice. My community is gearing up for changes and is planning measures to integrate the many private practices locally. I was asked to serve on a committee evaluating software solutions to connect the disparate electronic medical records in the community, and had several hours of meetings at the hospital at the beginning of the week. Also on the calendar was my monthly shift at the local free clinic. I have volunteered at the free clinic for the 5 years I have been practicing here. I sometimes have trouble finding the energy to put in a few hours there on a Tuesday or Thursday night, but I always leave glad that I did.

Last Tuesday at the free clinic was especially poignant for me.

Aside from starting my day with early morning hospital IT meetings and seeing patients in my office, I returned to the hospital Tuesday evening to visit a family member who had been admitted with heart disease. My family member had state of the art care from her cardiologist, coordinated through her excellent primary care physician. After experiencing chest pains, my family member had a stress test as an outpatient. That stress test was abnormal, and within 24 hours had seen a cardiologist, and within days had a cardiac catheterization showing a blockage in one of the heart arteries. Without missing a beat, that blockage underwent angioplasty and stenting, rendering my family member chest pain free. I was able to visit my family member after the stent while recovering overnight in the hospital last Tuesday night.

It’s hard to appreciate as a lay person all that went into this seamless episode of care. From the primary care visit, to the testing, interpretation, and consultation with a specialist finally culminating in a highly specialized procedure there were no gaps in care. My family member has Medicare, and had the assurance that whatever was medically necessary would be completed by the best our healthcare system has to offer.

After spending some time with my family at the hospital, I ventured across the street to the free clinic. Initially, many of the patients I was seeing at the free clinic were doing rather well. I refilled some medications, prescribed some new ones for acute symptoms, provided referrals to needed specialists, and was able to engage in some preventive care for the first several patients I saw last Tuesday night. But my last patient of the night at the free clinic was far from routine.

My last patient was in his early 50s. He was very thin — an unhealthy appearing thin. He had worked in construction his entire life, and fell on hard times when our area’s housing boom burst a few years ago. He seemed very confused. He told me he was in the hospital, but there were no records in his chart to this effect. He could not tell me why he had been in the hospital, or what medical condition prompted his hospital stay.

From there, the clinic director and I turned from medical providers to detectives. We investigated the hospital’s electronic medical records from across the street only to find he had not had an encounter there in several years. A new hospital opened a few years ago about 5 miles south of the free clinic, so we decided to call them (we don’t have electronic access to their records at the free clinic). It took several phone calls to a number of departments to solve the mystery: it was 9pm and the medical records department was closed. After calling the emergency room, I found a helpful nurse who was able to read to me some of the results of his visit 2 weeks prior. He had several abnormal tests.

Despite staying for several days in the hospital, there were more questions than answers regarding his condition. He had reduced blood counts, which could be from any number of causes. The scant information we were able to obtain Tuesday night did not give us many clues. He has findings on radiology imaging suggesting he had prior exposure and toxicity from asbestos – no doubt from his years in construction. But more worrisome than either of these was his confusion. He thankfully was not homeless, but lives with family.

I left the clinic after spending one hour trying to investigate his prior care and determining where next to go. As a patient of the free clinic, every test and every referral needs to be carefully weighed. What tests should I order without exhausting the limited resources of the clinic? Who will follow up those test results? The next physician he is likely to see will be another volunteer like me unfamiliar with his care.

After some deliberation, I ordered some blood tests and asked that the complete records of his hospitalization be sent to the free clinic. I flagged his chart for the medical director of the free clinic so that there would be some continuity to his care. The glaring difference in his care, compared to that of my family member, leaves me worried about his future health.

He is one of the 400,000 Virginians who would benefit from the expansion of Medicaid, and gaining this coverage would allow him to access primary care services rather than rely on the charity of the free clinic. Having a primary care doctor would allow for the same coordination of care that my patients, and my family depend on during episodes of illness. Having Medicaid coverage, and primary care, would also save our local health systems countless dollars — rather than duplicating tests and procedures that may be performed just 5 miles down the road since a primary care doctor could keep track of his diagnostic work up.

Alas, Virginia has not yet accepted the billions of dollars allocated to our Commonwealth to expand Medicaid as prescribed in the Affordable Care Act. As many as two thirds of Americans will not benefit from the life saving access to care afforded through expansion of Medicaid if states like Virginia, Texas, and Florida stand in the way of progress. I only wish those legislators blocking Medicaid expansion had the opportunity to tag along with me last Tuesday.

Chris Lillis is an internal medicine physician who blogs at Progress Notes.

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  • Anthony D

    Are medical services really governed by “supply and demand”?

    Were “supply and demand” the only factor governing medical services, it
    would be reasonably to expect to find higher concentrations of medical
    service providers in colonias and ghettos where demand for medical
    services are higher. So, why are there higher concentrations of medical
    service providers in suburbs?

    All that “supply and demand” curves do is suggest the price point at
    which the demand for medical services would be in equilibrium with the
    supply.

    But there is a cost associated with gaining the skills to provide
    medical services. As a result, providers of medical services will be
    concentrated in areas where income levels are high enough to recover the
    cost of obtaining the skills. In turn, this leads to specialization to
    change the equilibrium price point of “supply and demand”.

    • FL Girl

      This article really has nothing to do with “supply and demand”, vis a vis health insurance or health care. I don’t understand your point.

  • NewMexicoRam

    While I’m in favor of helping improve medical care access, nothing is free in life.
    How many people will lose their jobs because of the increased taxes expanded Medicaid will bring?
    Again, we need realism brought into the midst of altruism.

    • querywoman

      The increased load should also increase Medicaid and related jobs, but governments will probably squeeze more work out of there existing workers.
      Retail pharmacies will receive more Medicaid prescriptions, pulling prescription business from the public hospitals and charity clinics.

  • Anthony D

    In the end, it isn’t the insurance company paying more, it isn’t the
    employer paying more it’s YOU the taxpayer paying more…….

  • Jane

    We pay for the uninsured, who use vital services like the ER for routine care or expensive dialysis due to lack of prophylactic treatment for diabetes or hypertension. Every US citizen deserves affordable health care coverage.

    • Guest

      Every American may “deserve” “affordable” “health care coverage”, but what’s the point in adding 17 to 30 million new “clients” to the Medicaid rolls when a lot of doctors and NPs won’t take Medicaid patients anyway?

      A lot of doctors believe that they “deserve” to make a decent living. Without the government forcing all doctors to take patients regardless of insurance type, I can’t see where adding millions and millions of people to the Medicaid rolls is going to help anything anyway.

      • Guest

        What’s the alternative? The current system is inhumane. FYI, I have insurance and always have, but both my husband and I have good jobs.

        • Guest

          The next logical step to the government giving everyone this “free” healthcare that doctors don’t currently want to give away, is to force the doctors to give it away anyway. Doctors will have to make do with a lot less money I guess.

          • Guest

            Unfortunately to cover everyone we will have to see a reduction in quality of healthcare. This is fact. What should happen is there should be a lower level very basic quality of healthcare for those who cannot pay. Those who can pay should receive a higher quality of healthcare. This is how it works in most of the rest of the world.

            However, in America we are not bright and not compassionate, so we are planning on reducing quality for everyone, including those who can pay so that healthcare remains profitable for those with the most powerful lobbyists.

            So, everyone will get midlevels, pay more for “facility fees” and hospitals and insurance companies will be raking in the dough.

          • Cyndee Malowitz

            I’m a nurse practitioner – I’m not a “midlevel.” That implies the care I provide is “middle of the road.” It’s not, it’s just as good as a physician who is practicing at a minor emergency clinic. I can successfully treat 98% of the cases that come to my clinic – the other 2% are referred to a higher level of care, usually an internist.

          • querywoman

            Once again, I agree that you are not a midlevel. If an NP can prescribe my meds, I’m happy.
            I have repeatedly asked, and never received an answer, if an NP or PA might be equal to an old-timey doc, before Xtra years of residency became the rule.
            I assume you probably do a lot of low-tech med, just talking and examining patients?

          • Guest

            I’ve done just about everything – suturing, I&Ds, diagnosed cancer (many times), PAPs, you name it. Many of our patients have never even had medical care and it has caught up to them in their 40′s and 50′s. I’ve seen more at my clinic than I ever saw when I worked for physicians (who refused to accept uninsured patients). My collaborating physician has been amazed at what we see at my clinic – he absolutely loves it. He’s a REAL physician – he WANTS to treat complicated patients. He also wants to help patients in need. He went into medicine for the “right” reason. BTW – he graduated near the top of his class in medical school. He could have gone into any specialty he wanted, but he chose internal medicine. Not all physicians are interested in the almighty dollar.

          • querywoman

            I wonder who is this Guest?

          • Suzi Q 38

            I don’t like the “guests.”
            We don’t know who is talking.
            Some are legitimate, yet others are “trolls.”

          • querywoman

            This “Guest” reads a lot like Cyndee. Maybe she got on the blog where someone else was already using as guest, and started typing too fast.

          • EmilyAnon

            All these ‘guests’ could be one person asking and responding to their own questions. Self trolls.

          • Cyndee Malowitz

            Querywoman – I wrote that post. Every time I try to edit a comment, then repost it, it changes my identity to “guest.” There’s something wrong with this website.

          • querywoman

            Well, thanks for explaining.

          • querywoman

            I bet you also see lots of patients with insurance who have many other alternatives in town.

          • Guest

            But you are paid less than a physician. Therefore, you are more valuable to corp med than a physician. THAT’S what matters, not your skill set.

          • Cyndee Malowitz

            I don’t work for a corporation – I own my practice and work for myself. I don’t understand why all these primary care physicians are crying that they don’t make enough money. I’m well aware of the fact that private insurance companies reimburse them 50% more for the same services that I provide, yet my overhead is just as high or higher. Medicare reimburses me 15% less than a physician – I can live with that. However, I definitely have a problem with private insurance companies reimbursing me 50% less than they do physicians.

          • Guest

            If you want to be paid the same as a doctor, go to med school.

          • Cyndee Malowitz

            I want to be reimbursed the same as a physician for the same level of service. I certainly expect a physician to get paid more for services that require more education and training. Why on earth would an insurance company reimburse a physician 50% more than me for treating strep throat?

            Something else, if I’m getting reimbursed 50% less than physicians, then I want to see physicians get reimbursed 50% less for the services that are provided by their NPs/PAs. If that becomes the case, I have a feeling the physician lobbbyists would jump on the “equal pay for equal work” faster than a jack rabbit on a hot date.

          • Tiredoc

            I agree that the services you provide are equivalent to those provided by a physician. It is for that reason that I believe that there should be a path for full equivalency, similar to that provided to DOs. Both NPs and PAs should have some mechanism by which they can enter the residency system, either through years of supervised practice or testing equivalency. It is fundamentally unfair to assign you a second-class practitioner status for life.

          • querywoman

            How is she second-class? She is practicing within the scope of her license.

          • Tiredoc

            She is second-class for several reasons.

            1. She must have a physician supervising her, even if she has been in practice for 20 years and knows more than the physician supervising her.

            2. She is subject to licensure from the nursing board, which is my state is populated by psychopaths that eat their young and yank NP licenses at the drop of a hat, mostly because they’re RNs and resent NPs.

            3. Every time she calls a doctor she doesn’t know to refer a patient, she has to deal with a snotty RN who won’t let her talk to the MD because she isn’t an MD. On a bad day, it isn’t even an RN but an MA.

            4. She gets paid less than an MD for exactly the same work, on the same patient, by the same insurance company.

            5. No matter how long she practices, no matter how much she publishes, no matter how many patients she treats, she will never be allowed to park in the physicians parking lot at any of our local hospitals.

            I’m not saying that she’s a second-class person or a second-class practitioner, I’m saying that permanently assigning a subservient role to NPs is wrong. I’d be surprised if Cyndee Malowitz disagreed with me.

          • querywoman

            Interesting! Do you think she should eventually be allowed to have an MD or DO title?
            I see mostly specialists these days, but I have a family doc with an NP. A seasoned NP is okay with me.
            Apprenticeship is the classic way of learning. A young woman just sort of attached herself to me to learn ceramics.
            Law and medical schools are new-wave entities.
            I went to my dermatologist today, a practice, research, and training doctor. As usual, I saw a dermatology resident first, then he came in with an internal medicine resident, who wants to be a derm someday.
            A bit of trivia: I commented on his usual order, that’s it, and that I had never seen a family practice resident with him.
            He said he gets one maybe once a year, and that his medical school doesn’t have a family practice residency program.
            Next time I will ask him why I have never seen a pediatric resident. Maybe a pediatric derm gets those, though sometimes I do see children in there.
            Will you share what kind of doc you are, besides a nice, caring doc with a conscious?

          • Tiredoc

            DOs have an extra year of internship to get an unencumbered license. I would saw a two year internship for the DRNs after which they take the part 3 boards to be the equivalent of a GP. At that point they could enter the regular residency system if they wanted to.

            I think both NPs and PAs should be under the MD/DO boards to get out from under the RN culture. PAs could do the same as the DRNs except a 3 year surgical internship.

          • querywoman

            A lot of docs would just hate your idea! But an NP or PA who is doing general practice for years learns it!
            I think most states will actually license a person who passes the bar by self-study even if they haven’t been to law school.
            Abraham Lincoln had one year of formal school!

          • Cyndee Malowitz

            I really wish residencies were available for NPs, but they’re not. In my opinion, I believe NPs should have a minimum of 3 years of full-time experience before being allowed to practice independently.

          • Cyndee Malowitz

            I agree with you on some points. First off, I’m from NM where NPs have had independence for over 20 years. I believe 20 states (including D.C.) now allow NPs to practice independently. However, I now own a practice in Texas where I’m required to have a collaborating physician.

            I’m not aware of anyone on our BON who resents NPs. I would hope they support NPs, since we’re the ones usually taking care of medically underserved patients. Seriously, who would resent us for that?

            I’ve never had trouble referring patients. In fact, several specialists gave me their cell number so that I can either call or text message them and they guide me from that point. I would do this whether I practiced independently or not. The physicians I deal with truly want to help patients – that’s our common goal.

            You are “right on” about the insurance reimbursements. It’s something we’re fighting and hopefully we’ll be able to get a law passed that will forbid insurance companies from discriminating against us. These laws have already been passed in a few states, so it’s just a matter of time. I have an overhead to pay, just like everyone else, yet I have to do it with reimbursements that are up to 50% less than what a physician is reimbursed for the exact same service.

            As far as having a parking space at the local hospitals…inpatient care is outside of my scope of practice, so there would not be a need for me to even get credentialed at a hospital. I refer my patients to hospitalists. I used to work as an independent contractor and I was allowed in the doctor’s lounge at the hospital located next to the office. However, I heard of an incident in another city where several physicians got a NP banned from the doctor’s lounge. Her employer was pretty upset, but there wasn’t anything he could do about it.

            Someone alerted me to this website several months ago. After reading all the anti-NP posts, it is apparent that there are people (supposedly physicians) who consider NPs “second class.” Usually, those physicians never reveal their true identity, which makes me wonder if they’re even physicians or just someone who couldn’t make it through NP school.

      • gmlevinmd123

        Yes, if you lose five dollars on every patient and see 100 patients…you lose 500 dollars, so if you see 1000 patients you lose 5,000 dollars…simple math and our legislators and congress like the ‘new math’

    • querywoman

      Then they die more quickly without maintenance services. Who really knows if the costly ER functions are more or less than the cost of maintenance care?

  • Guest

    “this coverage would allow him to access primary care services rather than rely on the charity of the free clinic”

    Right, he would be relying on the forced “charity” of working families to buy him his “free” medical care rather than on the voluntary charity he’s getting today.

    I’m not sure anyone is stopping to think where all this money to buy everyone all the “free” medical care they can eat is going to come from.

    Besides, under Obamacare, he will HAVE to have insurance. It will be illegal for him not to. We taxpayers will be picking up the tabs for everyone’s subsidies. And every extra thousand dollars I’m forced to give to the government’s favorite charity cases, is a thousand dollars I can no longer give to the charities I prefer to give to. In my case, that means our local children’s rehab center misses out. I’ll just explain to the kids and their parents that the government figured someone else needed my charity more urgently than they did.

    Sigh. What a mess this all is.

    • Guest

      Is it a mess? In other countries taxpayers foot the bill for social programs such as public schools, roads AND basic health care. Most of the citizens alive in those countries do not know an alternative. Other countries, however, don’t have the population we do but they do have their fair share of fraud and moochers.

      I think providing basic health care for one another may be something we should just get used to. One day it could be you relying on the kindness of others.

      • Guest

        It’s not “kindness” you’re relying on, if you’re wanting the government to forcibly take money off a stranger and give it to you. It’s coercion. They’re only “helping you” because if they don’t, they’ll end up in jail.

        No “kindness” involved there at all, comrade. Don’t fool yourself. If you can’t rely on the people who love you to help you, but must steal from strangers, telling yourself all the while that you somehow deserve their money more than their own families and loved ones do, that’s sad.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Are you considering “free” public education to also be stealing from strangers?

          • Guest

            I don’t kid myself that strangers want to pay to have my kids educated out of the kindness of their hearts, because if that were the case, if they were doing it out of “kindness”, the government wouldn’t have to threaten them with jail if they failed to pay up.

          • Guest

            Yet you utilize those services, don’t you? Do you consider yourself a thief?

            Basic health care will just become another public service covered by taxpayers like public schools, libraries and road repair. If you are enjoying those “socialist” services then take a look in the mirror, comrade.

          • gmlevinmd123

            I think that is comparing apples with oranges. See my other comments.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            This is probably true, because we don’t have a separate public education system for the poor. Instead we have public education.

            Medicaid is a disgrace and ought to be dismantled in favor of an equitable system for all of us, just like every other developed nation seems to have managed to create and run for less money and with comparable outcomes. Corporations have plenty of other ways to exploit Americans without needing to explicitly profit from fear, sickness and human suffering.

          • Tiredoc

            Making the analogy of the public education system to Medicaid is excellent. They have all of the same problems.

            You take something that already exists, health care for the poor and public education and centralize it, making it a system. That enables large organizations, both in the form of corporations and in the form of public unions, to loot the system. Both are graft cloaked in a veneer of public good.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I don’t think we need to centralize health care. We should centralize the regulatory framework at a federal level, but management (pricing, contracting, etc.) should be delegated down to states and for very large and populous states maybe even down to counties. I hate to bring the Swiss system up again, but over there, the Cantons manage these things based on the national framework, and there is significant variation.
            I think the secret sauce to resolving the health care conundrum is to desegregate the system and stop constantly pitting the old, the poor, the young and the less poor against each other, just so they are distracted enough to not notice how corporations are stealing everybody blind.

          • Tiredoc

            I frankly don’t care which system you’re talking about, pretty much all of them do better at the bureaucracy than we do. My personal opinion is that public health should be delivered via a staff model, not through any secondary payors.

            For this generation at least, the organizations that are pulling down cities, counties and states are the public unions. Until the public employee culture changes from pig at the trough to o e of government service, nothing will work, and all of the lofty talk of model will founder on the shoals of legal government graft.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Not sure I understand the staff model you have in mind. Is it a construct similar to FQHCs, but for everybody? I assume public health means the entire public, but I may be wrong….

          • Tiredoc

            Staff model is everyone is paid a salary and sees the patients that come in. The hospital is budgeted like every other government service, directly from the county, state or country. The patient pays the rate that’s posted.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I see… Thanks for the clarification.

    • querywoman

      I bet this clinic gets a lot of federal grant money. Most of them do!

  • gmlevinmd123

    This is an all too familiar story told to us. Compassioinate physicians want their patients to have access to affordable healthcare. However waving a magic wand and accepting a federal subsidy to support a huge expansion will not work forever…grants and subsidies always end and/or cause political turmoil if renewals become necessary to keep the program operating. Most states are not in a position to fund all of the uninsured patients. Further more Medicaid from state to state is run differently with eligibility rules, and administrative requirement that are frankly almost undecipherable to physicians, and patients. States can barely keep up with the current eligibility process as it is. No, states and the feds cannot escape their complicity in having developed an almost unworkable system by throwing billions of dollars at it and then walk away….leaving a mess for the next administration and/or Governor.

  • FL Girl

    In Florida, our Republican Governor realizes that an expansion of Medicaid, while still very problematic, is at least a LITTLE bit better than the status quo. And our Republican House agreed. And so do I, a registered Republican since my early 20s! It is just some purists in our Senate holding things up!

    I put it this way to my State Senator: I can think of at least a dozen very valid criticisms of Medicaid expansion, but that’s still better than the TWO dozen very valid criticisms I have of the way things CURRENTLY work. And I am a nurse, and volunteer one afternoon and one evening a week at a community clinic, so I have some idea what I’m talking about, and as a taxpayer, I am not blind to the fact that I am already paying for these peoples’ medical care, it’s just that I’m paying for it at its most expensive.

    The way uninsured people here are getting medical care is so ad hoc and disorganized (and ultimately expensive and wasteful), so at the very least, putting them on Medicare will start adding a SEMBLANCE of order to things, and then we could fine-tune it from there.

    • gmlevinmd123

      Why would anyone want to expand a cancerous growth ?

      • Guest

        They think they’re going to “fix” the smouldering wreck of Medicaid by pouring petrol on it.

        What could go wrong?

        • Noni

          I do wish that instead of expanding our current broken system to include everyone a real overhaul had occurred limiting insurance with price transparency and gov’t controlled prices for all services. Unfortunately this would hurt too many of Obama and Cos cronies so we end up with more of a broken system.

          Despite my conservative leanings I do think it is really wrong that people are bankrupted by hospital bills. That is repulsive to me and I welcome reform (though the ACA is not what I would have chosen). Baby steps

          • querywoman

            They can’t be forced to pay those bills! Many personal bankruptcies are unnecessary.
            However, Texas has the most generous debtor’s laws in the country, and that’s from whence I speak.

      • querywoman

        There aren’t enough Medicaid providers to qualify the program as a cancerous growth.

  • Kerry Willis

    Not accepting money for Medicaid expansion is choosing to implement healthcare reform in a different manner not to turn our back on those folks in general. Medicaid is a flawed system and choosing to send folks to exchanges and subsidized healthcare through the private sector is a rational choice rather than the brutal choice you frame it as.

    • querywoman

      My Texas governor didn’t want it. Have not paid much attention lately to him. He’s leaving. We may get someone else.
      YoYo Perry really afraid of funding abortions. Of course, he also wanted to dictate that all girls get Gardasil shots.
      Loves to play God and pray in public.
      Was discussing this with another Christian in my liberal church yesterday. Jesus admonished us against praying in public for show and told us to render unto Caesar what is Caesar’s.

  • WesleyV

    Another heartbreaking story about another American not having access to health care. In America selfishness is king as one can read from the comments below. What an awful country filled heartless people. The same people who whine about their taxes helping fellow Americans are the same Americans who go to church on Sundays and pray for Jesus to protect their gun collection.

    • Guest

      Pssssst. You forgot “racist”.

      • Guest

        Yes, everyone who doesn’t want to hand their paycheck over to strangers is “racist”.

    • Cyndee Malowitz

      LOVE your comment and couldn’t agree more!

    • Tiredoc

      Americans spend more on Medicaid to cover our poor than Great Britain spends to cover its entire population, with worse results.

      Americans don’t have a problem supporting the poor, just a problem with enabling incompetent kleptocrats who can’t even produce results with the money they have.

      • Noni

        Yes, yes and yes. I seriously doubt most Americans have a problem helping out their fellow American. Most that I know are kind people. It’s supporting the expansion of an already broken system.

    • Mengles

      Feel free to pay for it with YOUR tax money. How about homes? Everyone deserves to own a house right? We can see how that turned out with the stock market crash.

      • Guest

        “Racist!”

        /s

      • Guest

        You know that was due to widespread banking fraud and deceit, right? I suppose contemporary healthcare is similar, but that comparison is inappropriate.

        I’m surprised you feel it’s inappropriate to cover basic health services for everyone. But for the grace of whomever is up there there goes you. Compassion would suit you well.

        • Guest

          Are you aware that prior to the entitlement boom of the 60s, EVERYONE was in the boat of having to depend on friends/family/private charity to pay for medical care they couldn’t afford?

          This idea that the government should force me to hand over my paycheck to cover a complete stranger’s medical bills is only a fairly recent development.

          • querywoman

            Yes, and then with the advent of Medicare, Medicaid, and private insurance programs, the cost of medical care went way up!
            After Medicare came, senior citizens still paid exactly the same percentage of their incomes as they did before!
            Along with that came the burgeoning cost of education, and the massive debt. Doctors and lawyers get stuck with the most education debt!
            And the universities have greater endowments than ever before!
            Plus, most doctors do not bill patients anymore, accept produce as payment, or work one free day per week!

  • Cyndee Malowitz

    Dr. Lillis – thank you for volunteering your time taking care of the working poor. I face this every day at my clinic, since more than half of my patients work, but can’t afford insurance. Just the other day I advised a patient to get a screening colonoscopy and she told me she didn’t want one because she was afraid it would reveal cancer. She told me she could never afford to pay for the treatment, so it was best “not knowing.”

    • Cyndee Malowitz

      Why on earth would someone give me a “thumbs down” on my post…seriously?

      • querywoman

        Cyndee, both you and I seem to be magnets for thumbs down.
        But these ratings systems aren’t perfect.
        The thumbs down people may not like it that she can’t pay for the colonscopy and possible future treatment.

        • Cyndee Malowitz

          I’m pretty sure those people who gave me a thumbs down could care less about the poor woman who couldn’t afford a colonoscopy. Evidenced by the fact I received 4 more “thumbs down” when I mentioned it in my next post.

          • querywoman

            Sadly, a lot of people are stingy toward the medical needy.
            I don’t exactly “like” your post about the woman who needs a colonscopy, but I still thumbed it up.
            I researched your clinic and your doctors. I saw on the TX Medical Board that one of your docs is associated with a community clinic.
            Doctors (and NP’s) exist because there are sick people! But so many of them look down on their clientele!
            I know of a psychiatrist who basically farms at all or his work to NP’s and PA’s. He has been in legal trouble for it.
            While his subordinates may be fine at their jobs, I have a problem with people who prostitute themselves out to a sleazy doctor like him.
            You have very high ethics and wont’ work for a sleazeball. I respect you.

          • Guest

            I think people don’t like Cyndee. It wouldn’t matter what she said.

          • Suzi Q 38

            They probably don’t like her because she cares about her patients.

          • querywoman

            They criticize Cyndee, but don’t offer any alternative to the medical services she provides.
            She owns a general medical clinic, and hires doctors, one of whom is her supervising doctor.
            So she is the one responsible for the payroll taxes, utilities, and medical billing. Sounds like a good deal to me!
            Many doctors hate doing the administrative stuff.

          • Cyndee Malowitz

            Actually, my collaborating physician doesn’t work for me – he has a private practice of his own. There are a couple of physicians who see patients at my clinic. They set their own prices and the patients pay them directly.

            NPs aren’t allowed to employ physicians in Texas. Even if I could, I wouldn’t be able to hire one, simply because my reimbursements are so low.

          • querywoman

            Nothing in life is free. Do you “lease” space to your physicians? That’s how a lot of beauty shops work: lease stations.
            There are so many ways to do things.

      • Tiredoc

        Not that I gave you a thumbs down, but the best answer to your patient is that a screening colonoscopy would allow resection of precancerous polyps, thereby avoiding cancer treatment altogether.

        Unlike other medical procedures, colonoscopy can be performed inexpensively in a doctor’s office, as long as the patient is willing to have the procedure performed without general anesthesia or conscious sedation.

        I see many working poor patients for cash. I negotiate prices with other docs, clinics, radiology clinics and labs for the patients. As long as there’s no ER or hospital involved it’s cheaper than car repairs.

        Finally, it’s easier to get treatment for cancer for free than it is to get a colonoscopy for free. Your patient just can’t deal with mortality and doesn’t want to think about it. She probably didn’t have a pap for the ten years before she saw you, either. Insurance doesn’t have anything to so with it, it’s just her excuse.

        • querywoman

          My years as a public welfare worker taught me that there are all kinds of free health care programs, but not dental.

        • Suzi Q 38

          Thank you for your explanation.
          You were helpful.

        • Guest

          Poor people are often poor because they make poor decisions.

        • Cyndee Malowitz

          There are a couple of physicians I refer to who charge Medicare rates for uninsured patients who need colonoscopies. Unfortunately, even at the lower rates, some patients can’t afford it. I treat a lot of people who fall through the cracks – they make too much for subsidized healthcare, but too little to afford discounted testing.

          There are a limited number of specialists in our area and there are only a few of them who will treat uninsured patients. Frankly, those specialists are already overwhelmed with their patient load. However, there are a couple of dermatologists in my area who don’t even accept insurance – it’s all cash. Unfortunately, they charge a premium for their services, so it doesn’t help if you can’t afford their prices.

          • Tiredoc

            You need to develop a thicker skin. It costs $100 to fill up a truck these days. A pack of cigarettes is $5. They just don’t want to spend money on something that hurts and is for the off chance that something might be found early. For the most part, they don’t think they’re worth spending money on. Insist that they are.

      • Suzi Q 38

        Because they are “immature losers” on any given day.
        Ignore them.

  • Tiredoc

    The author has drawn a conclusion unwarranted by the evidence presented.

    There are two separable points.

    First, should there be some system to coordinate and provide quality care to those that cannot afford it? I would agree with the need for a system to provide care for patients such as the man you describe.

    The second question is should Medicaid be the system to provide this care? In my opinion as a Medicaid provider, the answer is no.

    The problem with Medicaid can be supplied with an example. I saw a patient this week from a Medicaid nursing home. Because she is non-ambulatory she was brought by ambulance. She also required dialysis three times weekly, again transported by ambulance. So, this one patient was responsible for approximately $15,000 in Medicaid expenditures.

    There is no particular reason that she could not receive dialysis in the nursing home. It is a service that can be done at home. Likewise, there is no reason to pay $400 to transport a patient to a doctor and $0 for the doctor to come to the patient. The reason for all of this is simple. The organization with the best lobbyists wins. Medicaid is not a healthcare delivery system, but a pig trough for the well connected.

    In short, there is no reason to expand a broken system in the name of the poor. It doesn’t help them. They receive better care from the free clinic.

    • querywoman

      Thank you. I did not know dialysis could be done in a nursing home. Medicaid is paying for ambulances and other transport providers. It keeps the drivers in business.
      What would be nice would be if Medicaid allowed patients to see a private doc by appointment. But private doctors who take Medicaid are very limited!
      I read that George W. Bush expanded community clinics. That’s one way of providing care.
      The free and community clinics already get money from one source. As more of the zero and really low income go on Medicaid, these clinics will surely get more of their dollars from Medicaid.
      Many people like this patient find it easiest to go to the community clinics. For a lot of these patients, paperwork is also hard.
      The clinics need people to enroll these patients for new programs. Then more tests and medicines will be covered by Medicaid.

      • Tiredoc

        I misspoke. There is no medical reason why dialysis isn’t performed in nursing homes. The reason it isn’t is that the dialysis centers have good lobbyists and have blocked nursing homes from providing the service.

        • querywoman

          Wow! I did not know that. My brother lived and died in a nursing home. One of his roommates went out 3x weekly for dialysis.
          A nurse, outside the nursing home, told me they invented nursing homes as cheap ways to die. Not exactly, though.
          You know, a hospital sends a dying patient to a nursing home to get them out of the costly hospital.

          • Guest

            If they don’t need acute care, they don’t belong in a hospital.

          • querywoman

            I’ve known of people dying in a half day’s time in a nursing home after sent there from a hospital.
            The definitions of who is allowed to be in a hospital changes all the time.
            Anyway, hospitals were once dread places to which you were sent to die. Now it’s like a privilege to be in a hospital. Since they can’t turn emergencies away, anyone can go there.
            Some of the hospitals are still dread places.

  • karen3

    Boy, is there a difference in what you see depending on where you sit. If you think that Medicare coverage ensures proper care, you are dreaming. My mother was abused to death at a Medicare paid for facility, at the cost of hundreds of thousands of dollars, with the full approval of Virginia and Medicare employees.

    I wouldn’t support the corrupt Virginia DOH getting a penny more of my tax money.

    As for the difficulty with getting medical records, it took weeks of threats to get my mother’s medical records — records showing that the hospital knew she had lung cancer and failed to tell the family or her other health care providers about it — on purpose. Of course, by the time we got the information it was too late. You got the concierge service.

    Reform private insurance for affordability — not adding costly Christmas tree list extras. I support it.

    Reform the VDOH political spoils system of allocating the medical market place, which increases hospital costs, radiology costs, etc. All for it.

    Put teeth in the physician and nurse oversight process. Sure. It’s broken.

    Give this current more money to abuse patients. Not a chance.

  • PLOTCH

    Notice how an artificially created entity named money is always used as
    the excuse that we as humans cannot help others because somehow we are
    slaves to the fictitious money god. It is simply an excuse for really
    saying, we have limited resources on this planet and we cannot help everyone out, too bad for you.

    The question remains then why is human life on this planet anyway? None
    of it really matters in the end as we all leave it all anyway. So why
    not make it bearable for others if this is all there is? Are we as a
    race that dumb that keeps us from asking, that just maybe we can think
    beyond money for a change and just do something good for someone else at
    my expense because it is simply right?

    OK, I’ll give you that paradise may be a pipe dream here on this earth and you can call me a dreamer, that is OK…however then, maybe the next few paragraphs could help us.

    Now for you money
    worshippers here is a workable plan from the New England Journal of
    Medicine that should have been implemented 20 years ago.

    Here is a small abstract of the problem from the New England Journal of Medicine.

    “Reprinted from the New England Journal of Medicine 320:102-108 (January 12), 1989.

    Abstract:

    Our health care system is failing. Tens of millions of people are
    uninsured, costs are sky-rocketing, and the bureaucracy is expanding.
    Patchwork reforms succeed only in exchanging old problems for new ones.
    It is time for basic change in American medicine. We propose a national
    health program that would (1) fully cover everyone under a single,
    comprehensive public insurance program; (2) pay hospitals and nursing
    homes a total (global) annual amount to cover all operating expenses;
    (3) fund capital costs through separate appropriations; (4) pay for
    physicians services and ambulatory services in any of three ways:
    through fee-for-service payments with a simplified fee schedule and
    mandatory acceptance of the national health program payment as the total
    payment for a service or procedure (assignment), through global budgets
    for hospitals and clinics employing salaried physicians, or on a per
    capital basis (capitation); (5) be funded, at least initially, from the
    same sources as at present, but with payments disbursed from a single
    pool; and (6) contain costs through savings on billing and bureaucracy,
    improved health planning, and the ability of the national health
    program, as the single payer for services to establish overall spending
    limits. Through this proposal, we hope to provide a pragmatic framework
    for public debate of fundamental health-policy reform. (N Engl J Med
    1989; 320: 102-8.)”.

    Notice the date was from 1989, why so long letting a problem like this fester?

    And for those negative commentators with old and tired argument, who is
    going to pay for this?, well, the abstract gives a workable solution do
    you not think?

    You know, I really hope there is a Creator that when we die we do go home to a paradise that offers true happiness and peace compared to this life that offers nothing but problems that never seem to end. I am ashamed that we humans allow so much suffering and grief to continue when we could solve so much by just accepting that we do have the power to change the status quo.

    Here are more solutions that could be offered to accept Medicaid right now:

    1) drop the taxation on the doctors business income and personal income tax
    2) provide free housing and a car to the doctors accepting Medicaid patients
    3) free tuition for medical students
    4) patients that are cured could contribute some form of skill such as painting a house, or cleaning the doctors home as a form of barter for services rendered to the patient

    These are a few. Instead of complaining let us try something new as we humans have the power to change but it starts with us.

    The rest of you negative commentators here I will close by asking this: If the shoe is on your foot now where you need coverage and have none, would you like to be told the same things you wrote in your comments against Medicaid expansion? Would you feel alone now and desperate for help for your health situation and find very limited help? Are you not human you say to yourself, then why is there no help for another human in need? Yes, you would ask these questions and more and unfortunately for you, you most likely will realize you could die if you do not get the help that is available, but you are denied access to it. Would you accept this? I doubt it.

    We humans have to be better than this, as I still believe we are despite all the negativity I find in today’s world.

  • Julie Carpenter Long

    I’m sure this very unfortunate patient’s hospital bill is astronomical. He obviously will never be able to pay. Who do you think absorbs the costs of his hospital care? Yes, it is still the American tax payer! Band-aid treatments from hospitals for patients without health insurance who require frequent admissions (or frequent ER visits) due to out of control chronic diseases are an ENORMOUS cost to taxpayers. Most people don’t think of it this way, nor do they realize providing patients like this one with insurance and a primary care provider would actually be saving huge tax dollars in the long run. I am employed by a clinic owned by a disproportionate share hospital and I see the following happen routinely: Uninsured patient presents to the ER with a blood glucose in the 500′s. The ER stabilizes the patient with one or two doses of insulin, his blood glucose improves and they send him on his way. They do not provide prescription for insulin because ER’s are not designed to provide follow up care for diabetes. The patient cannot find a PCP to see him without insurance and he does not have the means to pay upfront for care. The patient returns 9-10 times to the ER for the same thing before finally being admitted to ICU in diabetic ketoacidosis. Total cost of care is almost $100,000 by the time all is said and done. Where is the logic in this? Now the patient has permanent kidney damage and will likely need dialysis. Now he qualifies for Medicaid (which will pay for the dialysis that could have been avoided if the patient would’ve had a PCP to treat his diabetes before it progressed to this). Health care should be a basic human right like access to clean water, education and EMTALA. It shouldn’t only be a privilege for only those who can pay for insurance. It is easy to say you don’t want to pay for this if you are not the guy who just lost his job and can’t afford the over $1000 a month for Cobra or a personal health insurance plan. Why do you think the US has the highest health care costs and only mediocre outcomes when compared to other countries? Wake up America!

    • Michael Rack

      A minor point: the need for chronic dialysis qualifies a person for MEDICARE.

  • Guest

    I’m sure this very unfortunate patient’s hospital bill is astronomical. He obviously will never be able to pay. Who do you think absorbs the costs of his hospital care? Yes, it is still the American tax payer! Band-aid treatments from hospitals for patients without health insurance who require frequent admissions (or frequent ER visits) due to out of control chronic diseases are an ENORMOUS cost to taxpayers. Most people don’t think of it this way, nor do they realize providing patients like this one with insurance and a primary care provider would actually be saving huge tax dollars in the long run. I am employed by a clinic owned by a disproportionate share hospital and I see the following happen routinely: Uninsured patient presents to the ER with a blood glucose in the 500′s. The ER stabilizes the patient with one or two doses of insulin, his blood glucose improves and they send him on his way. They do not provide prescription for insulin because ER’s are not designed to provide follow up care for diabetes. The patient cannot find a PCP to see him without insurance and he does not have the means to pay upfront for care. The patient returns 9-10 times to the ER for the same thing before finally being admitted to ICU in diabetic ketoacidosis. Total cost of care is almost $100,000 by the time all is said and done. Where is the logic in this? Now the patient has permanent kidney damage and will likely need dialysis. Now he qualifies for Medicaid (which will pay for the dialysis that could have been avoided if the patient would’ve had a PCP to treat his diabetes before it progressed to this). Health care should be a basic human right like access to clean water, education and EMTALA. It shouldn’t only be a privilege for only those who can pay for insurance. It is easy to say you don’t want to pay for this if you are not the guy who just lost his job and can’t afford the over $1000 a month for Cobra or a personal health insurance plan. Why do you think the US has the highest health care costs and only mediocre outcomes when compared to other countries? Wake up America!

    • Guest

      “Health care should be a basic human right like access to clean water, education and EMTALA.”

      You are inventing “basic human rights”. That never ends well.

      • Julz7777777

        That’s the only reply you can come up with? Whatever you want to call it then… Everyone should have easy access to it. You will pay for it as a taxpayer either way.

        • Guest

          Politicians declared that it was a “basic human right” to own a home. I’m pretty sure we’re ALL still paying for that.

          It never ends well.

          • Guest

            Interesting how so many profited from that “basic human right,” but when the stuff hit the fan it became the taxpayers problem.

            I see the same thing in healthcare. Private profits, public losses/liability.

            There’s the problem to start. We have a long way to go. Part of the solution, however, is that working people are going to have to get used to paying for the poor to get basic care.

          • Guest

            ///

            ‘Interesting how so many profited from that “basic human right,” but when the stuff hit the fan it became the taxpayers problem.’

            ///

            Yes, that demonstrates that politicians should stop giving away what is not theirs to give away.

          • KG

            You can’t compare owning a home to receiving life-saving medical care. If you can’t “own” a home the government will surely assist you by providing section 8 housing. If you can’t afford food they’ll give you food stamps. If you have 5 babies before the age of 25 with no daddy to help out they will pay for your college and daycare too. But if you work your whole life and suddenly lose your job you had better not get seriously ill or in an accident because you will either face financial ruin or you could possibly die from not getting the care you need.

          • querywoman

            Section 8 has terrible waiting lists in many parts of the country.
            I’ve been a public welfare worker dishing out the food stamps and the welfare checks to parents.
            I think housing is the biggest social problem in this country.
            The truth is, nevertheless, and I live in Texas. the most socially chinchy state, that most government assistance is for families with innocent children under 18.
            It’s very hard for working people who bottom out after years of work to get assistance.
            Hospitals have to provide emergency care.

          • querywoman

            I can’t own a home because of bad credit due to medical debt; not to the medical providers who forced me to use credit cards years ago.
            Most of my bad debts should be beyond the 2 year limit for getting many mortgage loans, but I prefer to rent.
            Many mortgagers disregard medical bills.

      • KG

        What or who do you think health care should be provided for? Only the working? Only wealthy people? Is it ethical to provide proper health care to only those who have a certain level of paying ability? Who knows what circumstance any person is in at any given time that hinders their ability to work or have insurance. Are you saying they do not have the “right” to access the same health care as you? Maybe it is like genocide- except it is the uninsured poor with chronic diseases we are killing off instead.

    • querywoman

      His unpaid hospital bill is passed on to paying patients as higher rates now.

    • KG

      The commenter is correct. The government subsidizes hospitals that provide care for the indigent. With tax payer dollars. That is a lot of unwisely invested money. Let’s think about prevention. How many people could have received care from a primary care doctor with that $100,000 instead?

  • Eric Thompson

    Most of these comments are dealing with whether or not to provide the ‘free’ healthcare either by volunteers or taxes. What is missed was the author’s comments on how he had to weigh what he ordered so as not to waste precious funds for the free clinic. That thoughtfulness was totally lacking in the health care provided to his family member. In the socialist countries in Europe, all is weighed prior to prescription. It saves money and gets good outcomes, but many fall through the cracks. Health care is rationed. But it does work.

    • querywoman

      Yes, he talked about tests being rationed. If the clinic takes Medicaid and has more clients on Medicaid, then Medicaid will pay them a piddly amount for some procedures.

  • guest

    If you’re getting mad about where taxpayer’s money is going from this article that is small compared to below article in the NY Times that I think better captures the problem with Healthcare taxpayer dollars.

    ABOUT a year ago, President Obama signed a law that was supposed to end chronic shortages of lifesaving drugs. But the critical lack of generic drugs continues unabated. It is a preventable crisis that is inflicting suffering on patients and, in some cases, causing needless deaths.
    According to the American Society of Health-System Pharmacists, a group that maintains a closely watched drug-shortage database, 302 drugs were in short supply as of July 31, up from 211 about a year earlier.

    The new law, which among other things requires manufacturers to report anticipated shortages, is ineffective because it addresses symptoms, not the underlying economic cause. Policy makers apparently failed to ask the important question: How could this happen in a free-market economy? That would have steered them to the giant purchasing organizations that control the procurement of up to $300 billion in drugs, devices and supplies annually for some 5,000 health care facilities. These cartels have undermined the laws of supply and demand.

    Most of the drugs in short supply are sterile injectables that have been cheap mainstays for decades. They’re generally administered in hospitals and outpatient clinics and sold through hospital purchasing organization contracts, not through retail pharmacies or pharmacy benefit managers.

    Scarce or unavailable drugs include anesthetics, chemotherapeutic agents, antibiotics, nutrients for malnourished infants, painkillers and even intravenous solutions. Physicians have been forced to improvise with less desirable or more expensive substitutes. One study reported in an issue of The New England Journal of Medicine last December found that children with Hodgkin’s disease were at greater risk of relapse because the most effective generic, mechlorethamine, wasn’t available. Propofol, the preferred anesthetic for many surgical procedures, is scarce because there’s just one supplier of the generic in the United States in full production.

    Improvisation has caused some patients to wake up during operations — or not at all. A March 2012 survey by the American Society of Anesthesiologists, in which about 3,000 members responded (out of around 50,000), attributed six deaths, as well as other adverse outcomes, to shortages of drugs.

    A deadly outbreak of fungal meningitis, which was first identified last September in Tennessee, was triggered by shortages of a steroid painkiller, prompting providers to turn to the now bankrupt New England Compounding Center, which, as a so-called compounding pharmacy, was not held by the Food and Drug Administration to the same stringent standards as regular drug manufacturers. The pharmacy’s sister company, Ameridose, which has also been closed, had supply contracts with five of the largest American hospital purchasing organizations: MedAssets, Novation, Premier, HealthTrust and Amerinet. This tragedy had killed 63 and sickened 749, according to the Centers for Disease Control and Prevention.

    The Government Accountability Office is investigating the role of the group purchasing organizations in the shortages and the meningitis debacle. The agency’s report is expected in 2014.

    The F.D.A. has permitted temporary imports, which almost surely have created shortages in other countries. That’s because there is finite global manufacturing capacity; production cannot be ramped up overnight. Hospitals are rationing medications, while their pharmacists spend untold hours scrambling to find them.

    The economic root cause is simple: the purchasing organizations have squeezed manufacturers’ operating margins to razor-thin levels. By awarding select suppliers exclusive contracts in return for exorbitant (and undisclosed) “administrative,” marketing and other fees, they have reduced the number of suppliers to just one or two for many generics. Further, they’ve crimped investment in maintenance and quality control, resulting in adverse F.D.A. inspections and plant closings.

    This perverse system was created in 1987 when Congress enacted the Medicare anti-kickback “safe harbor,” which exempted these buying organizations from criminal prosecution for accepting vendor kickbacks. Spurred by a 2002 New York Times investigation into anticompetitive purchasing group practices, Congress held several hearings to determine whether greater federal regulation was needed. Antitrust lawsuits and more government investigations and exposés followed. A study in fall 2011 issue of the Journal of Contemporary Health Law and Policy found that group purchasing organization kickbacks inflated supply costs by at least $30 billion annually. But little has changed because of the enormous political clout of the industry’s lobby, which includes the Healthcare Supply Chain Association and the American Hospital Association.

    The Obama administration and Congress must protect patients by repealing the anti-kickback safe harbor and restoring free-market competition to the hospital purchasing industry.Margaret Clapp is a former chief pharmacy officer at Massachusetts General Hospital.Michael A. Rie is associate professor of anesthesiology at the University of Kentucky College of Medicine and co-chairman of Physicians Against Drug Shortages, wherePhillip L. Zweig is the executive director.

  • guest

    I was very interested in the responses here. There is quite a discussion on the whether the poor are the problem so to speak of making hard working folk pay for others healthcare. But here is something rather eye opening in the NY Times that might get you wondering.
    It discusses the corruption in payments in healthcare. Many believe that we run a free market without monopolies in the US but we don’t. The gov’t pays the asking price from Big Pharma for medications. Big Pharma can PAY Generic manufacturers to NOT PRODUCE (or severely cut down supply) thus driving up costs for generics. THey have created a shortage of generic medications such as for pain and cancer, as well as antibiotics. Go figure. We are talking I believe they mentioned 30 billion in excess for these monopolies.

    Next time you get upset at paying for other folks think about the wealthy-not the poor. As taxpayers, unfortunately everyone’s hard earned money is going to these monopolies. The poor are still poor and without much help or medical funding at the end of the day. But they do get us to squabble about them and get our minds off of the more real and destructive problem at hand. But what do you think?

  • querywoman

    Most thinking docs should agree that medical education has grown into two many years!
    The universities are a business! They don’t want to shorten educational periods for anyone!
    The university are real self-perpetuating money banks that have enriched themselves at public expense!
    They have huge endowments!

    • Cyndee Malowitz

      Let’s not forget the NP diploma mills that are making millions by offering “online” degrees. Seriously, there needs to be more oversight.

      • querywoman

        Oh…wow! Cyndee can even criticize her own profession!
        Doctors, pay attention!
        Perhaps her honesty is hard for a lot of people posting on kevinmd to grasp.

  • Renee

    Reading the comments, all I have to say it this: its all good and well to whine about taxes being “stolen” from you until YOU need care. Don’t be so smug, YOU are getting protection from the ACA as well, every one of you with a kid that can stay on your insurance longer, to those that couldn’t get insurance due to existing issues, and those that had run out their max benefits. YOU can lose your insurance and be one of the 43 million without too. Do not think you are so special.

    There is no reason we cannot have health care for all like all other industrialized nations. Oh wait, there is a reason, and it is the greed and hatred of ‘Muricans, that are too busy whining about “their tax dollars”, while waging unneeded wars and giving huge tax breaks to profitable companies. Go ahead, keep telling yourselves the problem is working class and poor uninsured in America, while the plutocrats rob you blind with your enthusiastic permission.

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