Thursday, December 29, 2016

Alabama's 70-30 mix might become 60-40, then 50-50, then... .

This op-ed from down south does a nice job of quickly laying out the Medicaid block grant problems for a state like Alabama... and the reasons that Republican governors might want to gulp and think twice before they get on that train.

"Alabama contributes only about 30 percent of its Medicaid program's funding, with federal money covering the remaining 70 percent. 
Changing Medicaid to a block grant would limit Alabama's federal Medicaid allocation to a fixed amount each year, regardless of the state contribution. Any cost increases would be borne by the state alone, with no 70-30 federal match."
Obvi, you were thinking, Alabama, so you have to rock that op-ed with the Prancing Elites. Yes I do, that is true. Please see picture above, and videos below. 

But we also have to include the Alabama Shakes, who poignantly critique freezing that federal contribution level in "I Ain't the Same". As an aging population and decreasing social safety net combine to worsen health and threats to health and ability to recover from bad health, well then,

I said I'd never grow old

I can't remember how that used to be
I find myself without the power
I find myself without the glory

People will start losing coverage most under a block grant system when things get worse, because then costs will go up, just when the state needs coverage more. State-level costs increase. But the federal payment still stays the same or goes down.

Who gets cut out? Hard to say for sure before it happens, but with that question, back to the Prancing Elites. Apparently you have to watch the Oxygen channel to know which Prancing Elite needs coverage for antiretrovirals.

(OK, I admit I'm like, years late to the J-sette party, but here's a J-sette battle in Memphis. Aside from wanting to put the "mix" in "Mu-Receptor Mixtape" and rock your health policy musings, another reason I keep showing all kinds of random videos from around the country is this. I want you to look at these crowds and wonder: How many are Medicaid recipients? And what's going to happen to them? In Tennessee in general, and in Memphis also, about 25% of residents are covered by Medicaid.)

Because there's a lot of people who need Medicaid. And they're a potentially powerful force if organized. Remember, everyone, you ain't alone:

Wednesday, December 28, 2016

Gene Sperling vs go-go music: block parties, not block grants

Gene Sperling reminds us: don't get distracted by strategic retreats from Medicare cuts; the Medicaid cuts are coming. And who will stop them?

For this op-ed, no choice but to go with "Numbers Game" sung by Chuck Brown as a guest for the Thievery Corporation. Check the video for a view of the now-departed Godfather of Go-Go, meetin and greetin. About one of three DC residents are Medicaid beneficiaries, and in this video, Chuck Brown isn't driving around the private platinum plan neighborhoods of DC, so figure it's more than a third of the folks in this video.

Wait: You don't know go-go? (That song isn't exactly go-go: it's the DC musical collagists Thievery Corporation digging on go-go, to which I have no objection.) Go-go is kinda like DC statehood: a local idea unjustly kept local.

For me, a record store nerd on the West Coast, the briefly-glimpsed go-go true religion was Trouble Funk, which got together for their 30th year reunion... seven years ago. Like we might say back home... I'm hella old. Anyway, this is go-go, at least to my ears:

Saturday, December 10, 2016

Hepatitis C

To do list item (advice to the brother I don't have):

Get your Hepatitis C treated now. Whatever medication is the right one for you (and people need different Hep C meds depending on various things), you have to do your best to take that medication perfectly. One day at a time... but every day.

12 weeks of most first-line Hepatitis C medication costs more than an SUV, and you gotta ask yourself: is the new Congress going to keep appropriating funds to buy you an SUV? Even if that SUV would save your life?

Awaiting the Dark Lord.

A group of doctors are sitting in a conference room and a lawyer is talking about legal advocacy in the medical setting.

--What if--?

--We really don't know. But it is possible.

--But what if--?

--Again, you're talking about reading tea leaves. But, that is one possibility.

--Can we really be put in that kind of position?

--It is not totally unprecedented from a legal point of view. And it's the kind of thing that President-elect Trump is talking about. So for your patients, it's important to think about that in terms of the kind of documentation you use now. 

Doesn't matter what the topic was. Just that... everyone who cares about medical care for poor people is waiting for the shadow to appear overhead.

Soundtrack from SoundCloud: from before the election, on the Mexican side of the line, Borchi decided not to take the Empire that seriously; and farther south, there's an Argentine take:

Thursday, December 1, 2016

Quiet catastrophes: Medicaid block grants

While Trump distracts with visible nightmares, the hidden bad dreams are sneaking up. One of them is Medicaid block grants.

This benign-sounding administrative change to the mechanism of Medicaid funding is so wonky it's hard to explain why it's a horror show. The basic summary: you can set up federal funding for state-run programs in a couple of ways. One is the way Medicaid works now: the feds and the states divide up costs based on meeting the need, as need is defined by legislation and federal rules. Another is block grants: feds and states divide costs based on some pre-defined amount they decide they want to pay. Again, to simplify, this means that needs are defined by the pre-defined cost.

Medicaid block grants are not a new idea, as this 2005 Milbank Quarterly article explains. They are in fact a recurrent bad dream of Republican plots to tear up any social contract that includes caring about the well-being of poor people. And as the article explains, the only benefit they produce from a health policy point of view is creating predictability of federal spending; they would cause people to lose coverage and they would decrease the value of coverage. It's no exaggeration to say: over time, the block grant strategy will start killing people, and if left unchecked, will kill at a faster and faster rate as it evolves into progressive funding cuts.

Republican block grant promoters will say otherwise, but block grants are almost always a way to cut spending and ultimately, the value of programs. "[T]he most predictable result of merging social programs into broad block grants is substantial erosion in funding over time, with negative consequences for efforts to assist people in need," explains a recent think tank analysis.

Which is why, if you care about the well-being of poor people, there is only one kind of block you can support: the city block.

Tell 'em, Becky G:

That's Inglewood she's showing off; it has about a quarter of its people living in poverty. Obamacare's Medicaid expansion covers people up to 133% of the federal poverty level, so that includes a lot of folks in Inglewood.

So when you hear the phrase "block grant", think of Becky on the Block; and keep thinking of Inglewood: not only are there a lot of Medicaid recipients there, but California would be especially hard-hit by the block grant strategy.

#notmyAMA again: Dr. Tom Price, greedy tosser

If a general internist like myself were asked why I never pay up on those "dues payments" envelopes the American Medical Association is always sending to my house (Dear doctors: I have never in my life belonged to the AMA, and I don't owe any freakin dues!), I might say, off-handedly: 

"I mean, some large part of the AMA is like, a bunch of cranky old orthopedic surgeons crying about how they hate Medicare."

Prior to recent events, I could generally admit that is probably a primary-care-righteous parody of a more complex reality. (I mean, JAMA is a pretty decent journal, right?) But now like so much in politics these days, the AMA has just responded with an endorsement: "Yes! We will take your simplistic caricature of us and double down on it! Dr. Tom Price is exactly your exaggerated parody of our point of view and we super-duper endorse him!" 

And yeah, I know a lot of the professional organizations are sending congratulatory messages because a) it could've been worse and b) they want to kiss the ring of the man who will hold the money bags; and on that level it's not about ideology. It's just business.

And that's the problems. I mean, let's leave aside the fact that guys like Tom Price do blustery conservative things like hate gay people and want to ban abortion and on and on. I mean, that stuff is awful and a sign of lots of bad things to come, but it may not be how Tom Price will actually harm the most people.  

The reason he might be most dangerous is why the AMA is actually excited about him: they describe him as "a leader in the development of health policies to advance patient choice and market-based solutions". That means, quietly but surely dismantling Medicare and Medicaid. Among other things, one of his pet causes is allowing doctors to charge fees above Medicare reimbursements. For people who do one-time procedures, like orthopedic surgeons, they can collect relatively nominal fees relative to their income, and still filter out the impoverished and disabled. And if they collect larger fees, even fees accessible to middle-class people, then, they can make some more serious cash money. (Charging, say, an extra $500 bucks per procedure, when a full time orthopedic surgeon does ~30 procedures a month, is going to be within most people's reach given the stakes of having a surgeon you trust--who in turn would earn a decent chunk of change.)

You can also predict an incoherent emphasis on "responsibility" and "empowerment" and "choice" in opaque policies that hurt the most impoverished and benefit insurers and doctors and hospitals. If you look at Indiana's Medicaid expansion--where poor people are penalized for not paying small premiums, costs don't decrease, and doctors get paid more--you might get a sense of how this is going to go just based on regulatory choices, without even having to pass legislation. (Look here at the difference between HIP Plus and HIP Basic; or here and here.) Of note: the architect of Indiana's Medicaid expansion is now going to be the director of the Centers for Medicare and Medicaid Services. 

The good news is that Republican congresspeople are already starting to back away from Medicare privatization like it's radioactive poop in the pool. The bad news? They won't have any such hesitation on Medicaid block grants and other punish-the-poor tactics.

Mu-receptor mixtape track of the day: a throwback 2011 health policy rap from the UK, taking a stand against conservative plans for the National Health Service:

(edited slightly Dec 10)

Monday, November 28, 2016

Pursuit of happiness.

This is from 2009: Kid Cudi, who like many great people from Cleveland, got outta Cleveland; and a song (featuring a bit of get-in-your-sacral-spine synth grind from Ratatat and MGMT) called "Pursuit of Happiness." I missed this song until recently, which I'm going to blame on the fact that I was a medical resident at the time.

If you don't watch the whole thing you might miss the ambivalence.

There's a Steve Aoki remix which subtracts most of what Ratatat and MGMT did, and adds a big techno festival sound, like the kind of thing where you're waiting for the DJ to go, "Whassup Helsinkiiiiiiiiii!!!" (beat drop, pause, four-on-the-floor beat with ascending synth air raid siren sound, etc)--which seems to be trying to take the ambivalence away and make it into a straight-up party anthem. But unlike "We Found Love" the lyrics between the chorus really count:

I'm on the pursuit of happiness and I know
Everything that's shine ain't always gonna be gold (hey)
I'll be fine once I get it, get it in, I'll be good
Tell me what you know about dreamin' (dreamin')
You ain't really know bout nothin' (nothin')
Tell me what you know about the night terrors every night
5 A-M cold sweats, waking up to the sky
Tell me what you know about dreams (dreams)
Tell me what you know about night terrors nothin'
You don't really care about the trials of tomorrow
Rather lay awake in the bed full of sorrow

Night terrors don't just go away. As of this posting, Kid Cudi is in an inpatient rehab stay struggling with depression, which he's often talked about in the past. Best wishes to Kid Cudi.

Sunday, November 27, 2016

T-shirts I used to own

A t-shirt I had in high school:

In San Francisco, before effective HIV therapy arrived:

(From Frankie Goes to Hollywood, and Jenny Holzer, respectively; t-shirt images from other people's t-shirts.)

No joke.

Saturday, November 26, 2016

We found love.

If there is an anthem for this blog, it might have to be "We Found Love". Thoughtless people might call this a dumb song, because Rihanna keeps just repeating "We found love in a hopeless place." But to me, that is the lyric that dance music producers had been looking for and not finding, for at least two decades. In 2011, it was found.

There are a couple of verses, which are totally forgettable. People smarter than me about dance music can tell me why they need to be there. Were I a remixer, however, I'd add a bigger bass line and take out everything except the chorus, and just play it again and again.

We found love in a hopeless place. 
We found love in a hopeless place. 
We found love in a hopeless place. 
We found love in a hopeless place. 

We found love in a hopeless place. 
We found love in a hopeless place. 
We found love in a hopeless place. 
We found love in a hopeless place.