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Another “when might this peak” projection

From the Current:

A new study suggests San Antonio’s current shelter-in-place order, which runs through April 9, may not be long enough to ride out the worst of the coronavirus pandemic.

Texas is more than a month away from the peak of the crisis, which is likely to hit the state May 2, according to a state-by-state analysis by the Institute for Health Metrics and Evaluation.

The United States as a whole will hit its peak earlier, on April 15. But that’s still days after the Alamo City’s order expires.

May 2 will mark both the date of the virus’ peak drain on Texas’ hospital resources and the state’s highest number of COVID-19 related deaths, according to the IHME, an independent research center at the University of Washington. It made those projections by modeling statistics collected by the World Health Organization and local and national governments.

[…]

Worth noting: the IHME’s modeling assumes the public is practicing strong social distancing and other protective measures. However, it also assumes Texas Gov. Greg Abbott continues not to implement a statewide stay-at-home order and won’t mandate closure of all non-essential services.

After Texas’ potentially devastating peak, the number of deaths and hospitalizations would drop sharply by the beginning of June, according to IHME’s projections. The virus could run its course by early July.

Even so, IMHE expects 4,150 Texans to die from COVID-19 related causes by August 4. It also predicts more than 82,000 nationwide will succumb to the disease by then.

A previous projection done by UT Health scientists suggested that the Houston area could peak in mid-April, with the pandemic burning out in our area by early May. I don’t know much about epidemiology, but I do know that the assumption of when Day 0 is – that is, the day of the first infection – matters a lot, so a variance of even a couple of days could shift things quite a bit one way or the other. Beyond that, I would recommend taking these different studies and projections with the same level of skepticism and trust one would put into an individual poll result: Illuminating and useful, but still just one data point that doesn’t mean as much as it might without confirmation from other results.

With Dr. Fauci’s estimates of 100K to 200K dead nationwide in a best-case scenario, this seems optimistic to me. Maybe it’s better to think of it as a more formal (if not necessarily more precise) quantification of that best case scenario. Note that the numbers given in this projection represent the midpoint of a range of possible outcomes – those error bars are pretty damn wide. Given the uneven implementation of stay-at-home orders and the lack of a statewide order, I’d be prepared for this to end up being well on the low side. But maybe we’ll get lucky. In the meantime, stay at home. TPM has more.

(You can play with the data yourself here. That’s how I generated the embedded image in this post.)

UPDATE: This Twitter thread from Carol Bergstrom, who is an actual expert, explains the concerns with this much better than I can. His interpretation is similar to mine in that this is a “best case” model, but he posits that the “error bars” are the range of uncertainty for that best case model, not for the entire range of possible outcomes. In other words, if the underlying assumption that social distancing isn’t working as well as we hope, or that we’re not doing it well enough for it to work properly, then the range of outcomes we will get will be considerably worse.

The state of the state’s response

I mean, it’s something.

Gov. Greg Abbott took multiple measures Sunday designed to expand hospital staffing and capacity in Texas, but declined to issue a statewide shelter-in-place order — even as calls for such an action increased as the new coronavirus continued to spread across the state.

In an effort to free up hospital beds in anticipation of an influx of patients sick with COVID-19, the disease caused by the coronavirus, Abbott ordered health care professionals to postpone “all surgeries that are not medically necessary” and suspended regulations to allow hospitals to treat more than one patient in a room.

But he did not order all Texans to shelter in place, noting that there are still many counties in the state without confirmed cases and that he wants to see the full impact of an executive order he issued Thursday. In the meantime, he welcomed local officials to take more restrictive action than he has statewide.

During an afternoon news conference at the state Capitol in Austin, Abbott also announced the formation of a “strike force” to respond to the coronavirus and that the Texas National Guard, which he activated several days ago, would be deployed this week to help hospitals deal with the outbreak.

In the lead-up to Abbott’s news conference, though, attention centered most intensely on whether he would go beyond the executive order that he issued Thursday. That order urged all Texans to limit public gatherings to 10 people, prohibited eating in at restaurants and bars and temporarily closed schools. That order went into effect midnight Friday and goes through midnight April 3.

“We need to see the level of effectiveness of the executive order,” Abbott said. “What we may be right for places like the large urban areas may not be right at this particular point of time for the more than 200 counties that have zero cases of COVID-19.”

[…]

Abbott said that his decision not to issue a statewide order should not stop local officials from issuing such orders in their jurisdictions.

“Local officials have the authority to implement more strict standards than I as governor have implemented in the state of Texas, “Abbott said. “If they choose to do so I would applaud them for doing so, but at this time it is not the appropriate approach to mandate that same strict standard across every area of the state, especially at a time when we are yet to see the results coming out of my most recent executive order.”

See here for the background. I can see the reason for Abbott’s actions, or lack thereof. It’s not clear that this is necessary for rural areas, and for the most part the localities that have needed such action have taken it themselves. (Insert reminder about Abbott’s self-serving relationship with the concept of “local control” here.) Indeed, the next story the Trib ran is about Dallas County prepping a shelter-in-place order. (Harris County Judge Lina Hidalgo has said she is considering such an order but has not yet announced one.) At least some hospitals have already acted to limit or suspend elective procedures as well. What all of this does is mostly make me think that Abbott is behind the curve rather than ahead of it. You know I don’t think much of our Governor, but even for him this seems kind of limp. What could he be doing that isn’t already being done? That’s what I’d like to know.

Does Houston have enough hospital capacity?

We sure hope so.

Houston-area hospitals would not have enough resources to respond to a widespread outbreak of the coronavirus unless they take strong action to significantly increase capacity, according to new calculations released by Harvard University.

Even in the most conservative of three outbreak scenarios that it created, the Harvard Global Health Initiative found that Houston-area hospitals would lack the necessary beds to care for all patients in need of hospitalization. In a worst case scenario, it would need four times the number currently available in the region.

In the middle scenario — if 40 percent of adults contract the virus over a 12-month period and a fifth of them require hospitalization — more than 430,000 people would be hospitalized in that time. That would require 14,300 beds on an average day, nearly three times the estimated number currently available in Houston.

“We simply do not have enough hospital capacity to assume all of those people,” Harris County Judge Lina Hidalgo said last week, assuming 30 percent of county residents were to become sick at the same time. “We can’t afford to have a sudden spike in cases.”

The Harvard initiative data, taken from what’s known as a modeling exercise, don’t constitute predictions so much as they provide scenarios that hospital and policymakers can take into account in planning for a possible surge of the epidemic of COVID-19, the respiratory disease caused by the coronavirus. The data was produced at local hospital market-specific levels because “how many beds are available in Boston is irrelevant to a person in Utah,” said Ashish K. Jha, director of the institute.

The study, released Tuesday, modeled nine scenarios. The scenarios use infection rates of 20 percent, 40 percent and 60 percent and outbreak spans of six, 12 and 18 months.

A 20 percent infection rate over 18 months would mean fewer people caught COVID-19 than fell ill to the flu last year, according to an analysis by ProPublica. Previous studies have suggested the virus is more transmissible than the flu.

The study assumes that hospitals will not free up occupied beds by delaying elective procedures or sending people home early. It also assumes hospitals will not add beds.

[…]

The Harvard calculations were criticized by some policy experts and doctors, who said not enough is known about the spread of COVID-19 to make meaningful assumptions.

“It’s incredibly hard to (make) projections about what’s going to happen because this is a unique first-time event and we have so little data,” said Vivian Ho, a Rice University health economist. “Because we don’t have that much testing, we do not know how quickly it’s spreading, what percent of cases are serious, if we can target hot-spot areas and essentially shut them down.”

Ho added, “I hope there’s something wrong with their assumptions because if not, we’re doomed.”

I’m not an expert, but I do know that Houston hospitals are in fact now suspending elective procedures, so that should help. I have hope that all this social distancing we are doing will help, too. Beyond that…man, I don’t know. I can’t wrap my mind around the possible bad outcomes we may face. I have hope because the other options are just too grim.

The Houston healthcare community is preparing for COVID-19

I sure hope it’s enough.

With last week’s new certainty that the novel coronavirus is loose and being transmitted in Houston, the region’s medical providers are bracing for the current handful of known cases to blaze into an outbreak like nothing in modern memory.

“We had been saying, ‘It’s not a matter of if, it’s a matter of when,’” said Umair Shah, executive director of Harris County Public Health. “That’s not the case anymore. It’s now.”

By shutting down events and closing schools, officials aim to “flatten the curve” — to stop too many people from getting sick at the same time and overwhelming the region’s hospitals and medical providers.

Much about the highly contagious new virus remains unknown, and projections of its future behavior vary wildly.

Based on scenarios from the Centers for Disease Control and Prevention, the New York Times estimated that anywhere from 2.4 million to 21 million people in the United States could require hospitalization, “potentially crushing the nation’s medical system, which has only about 925,000 staffed hospital beds.”

For most people, the virus is expected to be mild. But up to 20 percent of cases — mostly people over 60 or with underlying medical conditions — may require hospitalization.

If everyone gets sick more or less at once, area hospitals almost certainly would not have enough rooms, critical care or ventilators. In Italy, where officials waited to control the outbreak, an extraordinary surge of cases has left the medical system on the verge of collapse.

Based on Harris County estimates, County Judge Lina Hidalgo said recently that if 30 percent of Harris County residents were to become sick at the same time and 20 percent of those people needed hospital care, medical infrastructure would be overloaded.

“We simply do not have enough hospital capacity to assume all of those people,” Hidalgo said. “We can’t afford to have a sudden spike in cases.”

Even the best case — a slowed outbreak that continues for months — is almost certain to pose significant challenges to the area’s hospitals, clinics and doctor’s offices.

[…]

The virus poses particular threats to hospital personnel, who will be working long hours under stressful conditions — and facing coronavirus-related personal problems such as a lack of child care due to school closures. In the worst scenario, seen in China, medical personnel become ill themselves, and their colleagues have to take care of them.

Testifying before Congress earlier this month, Dr. Peter Hotez, a Baylor College of Medicine vaccine researcher and infectious disease specialist, urged that special attention be paid to hospital workers.

“If health care professionals are out of work because they’re sick, or if they’re being taken care of by other health care professionals in ICUs, that’s a disaster,” he said.

And just this weekend, two ER doctors, one in New Jersey and one in Kirkland, Washington, have tested positive for coronavirus. Even with the best preventative measures, this thing is going to spread. All we can do – all that we must do – is take every action we can to try to limit how quickly it spreads. That’s our best hope.

The robot nurse

We are living in the future, for better and for worse.

https://www.instagram.com/p/B01H56Fn8_0/

A friendly one-armed, bright-eyed robot is roving the hallways of Medical City Dallas’ Heart and Spine hospitals, helping nurses with routine tasks that previously took time away from patient care.

Nicknamed Moxi and regarded as one of the staff, the robot is equipped with sensors to help it navigate, and even anticipate people’s movements, as it travels across hospital floors. Medical City Dallas partnered last fall with Austin-based artificial intelligence firm Diligent Robotics Inc. to become the first North Texas hospital to employ a robot full time in a clinical setting.

“When we were opening up the hospital back in October, one of the things we wanted to really focus on was being an innovation center and bringing new technology to the health care setting,” Medical City Chief Operating Officer Josh Kemph told The Dallas Morning News.

When a nurse is interacting with it in a way that would normally trigger an error message, Moxi instead emits pleasant beeps and chirps to notify them. Some patients even have their own names for the assistant, which has its own Instagram account run by Diligent.

But Moxi is so much more than just a pretty face.

Texas will face a shortage of more than 71,000 nurses by 2030, according to the Texas Health and Human Services Commission. And with the demand for nurses expected to only continue increasing, Medical City Dallas director of surgical and procedural services Stefanie Beavers says she hopes it will also make it easier for the hospital’s existing workforce to optimize their day-to-day work.

“This really offers health care facilities an opportunity for the nursing workforce to focus on patient care and be directly at the bedside versus taking them away, and allowing their time to be truly dedicated to patient care tasks,” Beavers said.

It never crosses the threshold into patient care, instead delivering things like blood samples back and forth to a lab and updating patients’ medical records instantaneously for hospital staff.

“She’s really meant to be a team member that’s supporting you in the background,” Beavers said.

For now, at least, Moxie is a modern version of the FBI mail robot, which does simple drudge work like delivering specimens and allowing the human nurses to do more important things. It’s also a lot cheaper to employ than human nurses, or human nurses’ aides, and in the way of driverless cars, it’s just a matter of time before they have the capability to cross that threshold into patient care. That may be 20 or 30 years down the line, but it’s out there somewhere. I just hope we can have a productive conversation about what that will mean for the rest of us before it happens.

Medicaid and hospitals

I have three things to say about this.

A proposed change in Medicaid rules could cost Texas hospitals billions of dollars, forcing many to cut services and some rural hospitals to close their doors, health care industry officials said.

The change, aimed at increasing the transparency of how the program’s money is spent, narrows the definition of state and local funds that can be used to determine federal matching funds. That, in turn, would reduce federal funding and cost Texas hospitals an estimated $11 billion a year, industry officials said.

Houston hospitals would lose an estimated $500 million a year, said Tim Ottinger, director of governmental relations at CHI St. Luke’s Health.

A drop in funding would mean extreme hardship for many of Texas’ rural hospitals, which stand to lose some $900 million a year. The Texas Organization for Rural and Community Hospitals (TORCH) found that 46 percent of the state’s rural hospitals operate at a loss. Over the last decade, 26 rural hospitals have closed in Texas, the highest rate in the nation.

It’s unclear how many more rural hospitals could close if the proposed rule goes into effect as written, but it would be devastating to pull so much money from their budgets, said John Henderson, president of TORCH.

“A business can’t survive,” Henderson said. “But this isn’t just a business, it’s a service.”

1. I mean, you’d think that a policy that would cost the state billions of dollars and would have such a negative impact on rural areas, where access to health care is already severely lacking, would call for some kind of response from our state government. Turns out they like it, because they say it would let them cut costs. Just in the state budget, though. Counties and hospitals and the rest are on their own.

2. That said, some of those rural communities don’t seem to be too concerned about their hospitals. So maybe I shouldn’t be all that concerned on their behalf.

3. Of course, this proposed change will not survive the end of the Trump administration. None of the Democratic Presidential candidates, whatever their health care plans are, will allow this to stand. So, you know, make sure you vote for one of them this November.

Maybe rural counties don’t want hospitals

That’s what the evidence says.

The voters of Fayette County have spoken, and they’ve said that they don’t need a hospital in this rural community of 322,000 people, one hour southeast of Austin — or at least not enough to pay for it. In a landslide vote Thursday night, county residents overwhelmingly rejected a proposition to create a taxing district for St. Mark’s Medical Center in La Grange, which would have kept the deeply indebted hospital open for the foreseeable future. As the polls closed, it was clear that the idea of propping up the institution with public money didn’t have a snowball’s chance in Central Texas. The final tally was 1,360 for, 5,600 against.

“I’m very proud of the grassroots effort that stood against the taxes,” Deborah Frank, the chair of Fayette County’s Republican Party and a member of Concerned Taxpayers of Fayette County PAC, told the Observer Friday. Her group swiftly mobilized an opposition campaign against the proposition after it was put on the ballot in April, holding public meetings and distributing yard signs reading “NO NEW TAXES.” Their message: People here are already taxed enough and shouldn’t be forced to bail out a private institution simply because it’s made what they see as bad financial decisions.

Voters apparently took the message to heart.

The resounding loss is expected to push the 65-bed hospital, which is at least $14 million in debt, even closer to financial collapse. And it comes at a time when the headwinds against rural hospitals in Texas are especially strong.

Across the state, roughly 20 rural hospitals have shuttered since 2013 — casualties of low patient volumes, stingy Medicaid and Medicare reimbursement rates, and the burden of operating in Texas, which has more uninsured people than any other state. Seventy-five more are at risk of closing down.

One point to note: I have no idea where that “rural community of 322,000 people” figure comes from. Fayette County had 24,554 people as of the 2010 Census, and while it’s been growing over the past few decades, I’m pretty sure it hasn’t grown that much since then. I don’t live in La Grange and I don’t know anything about St. Mark’s Medical Center, so maybe it was a fiscally sound decision to not try to prop it up with a taxing district. I do know that if I lived in La Grange and faced the prospect having to travel 20 miles to Smithville or 26 miles the other direction to Columbus to find an emergency room, I’d be a little concerned about the risks to my health going forward. But hey, at least their taxes won’t go up.

Now how much would you pay for that emergency room visit?

Guess higher, and it is a guess because who knows what you’ll wind up getting charged for it.

Fifteen months after Texas enacted a law to bring transparency to the state’s for-profit free-standing emergency rooms, many of the facilities continue to send mixed messages about insurance coverage that could expose unsuspecting patients to surprise medical bills.

A Houston Chronicle review of websites representing the 52 free-standing emergency rooms in the Houston area shows a pattern in which many of the facilities prominently advertise that they “accept” all major private insurance. Some even list the insurers’ names and logos.

But often tucked under pull-down tabs or at the bottom of the page is a notice that the facilities are outside the networks of those insurers, followed by a reassurance that under the Texas insurance code, network status does not matter in emergency treatment, implying patients needn’t worry about coverage.

What the websites fail to disclose is that out-of-network status can result in insurance reimbursements far below the charges, leaving patients on the hook for the remainder of the bill — sometimes thousands of dollars.

“The word ‘accept’ means something very different to them than to the consumer, and they know that when they write their websites,” said Stacey Pogue, senior health policy analyst at the Austin-based Center for Public Policy Priorities. “They do not tell the rest of the story.”

For example, many of the Houston-area facilities advertise that they accept Blue Cross and Blue Shield of Texas, the state’s largest insurer. But the Chronicle’s review found that only five — about 10 percent — are in that insurer’s network.

Those findings are consistent with a statewide report by AARP Texas, to be released Monday at a state Senate committee hearing, that found 77 percent of the state’s 215 free-standing emergency rooms said they “take” or “accept” Blue Cross and Blue Shield insurance, but were out-of-network.

Free-standing emergency rooms defend their websites, describing concerns raised by advocacy groups and Texas lawmakers as manufactured outrage.

“I don’t see a problem with saying they ‘accept,’” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program. She insisted that patients understand that accepting someone’s insurance is different from being in that company’s network.

It may seem like a hair-splitting distinction, but it can carry high costs, health policy experts said.

Obvious point #1: It’s ridiculous that we live in a society where basic medical needs, including emergency care, are not met. It’s utterly scandalous that prior to the Affordable Care Act, there were thousands upon thousands of bankruptcies caused every year by medical issues. Plenty of other countries have figured this out. Our standard of medical care is no better than theirs. It’s just more expensive.

Obvious point #2: For those who believe in the power of the free market, why is it that medical services, especially those tied to emergency and hospital care, are so utterly opaque when it comes to their pricing? Think of all the other goods and services you buy. In nearly all of them, you know up front how much it’s going to cost. That is universally untrue for the vast majority of medical services, from basics like painkillers and bandages to anaesthesia and specialist fees to higher-end products like EKGs and colonoscopies. There’s no such thing as a free market with unknowable prices. You want to move towards something like a free market in health care, fix that.

Trumpcare would be a hospital killer

This is hardly a new problem, but it’s yet another aspect of Trumpcare that gets too little attention.

Texas hospitals stand to lose billions under the Republican-backed health plan, as federal Medicaid dollars shrink, leading to a rise in uncompensated care, according to a new analysis by the Commonwealth Fund, a national health policy foundation.

The study looked only at the U.S. House plan passed last month. It has not yet examined the impact of the U.S. Senate’s version unveiled late last week, which experts have predicted will bring even deeper cuts to Medicaid.

In Texas, uncompensated costs in the state’s 304 acute care hospitals could increase by 7 percent, rising to $38.4 billion over the next decade, the study found.

That compares with an estimated $35.8 billion over the next decade under the current Affordable Care Act.

At issue is a spike in the number of the nation’s uninsured whose care is often absorbed by hospitals. As many as 23 million Americans could become uninsured over the next decade under the House bill because of cuts to Medicaid, and the recalculation of insurance plans and how people afford them, the Congressional Budget Office estimated late last month.

[…]

Texas already leads the nation in the number of uninsured and hospital executives have cautioned that their institutions would be hard pressed to take a bigger hit should the uninsured rate go higher.

“If people think Harris Health can absorb this, that is a miscalculation,” said George Masi, president and CEO of Harris Health System, in a January interview with the Chronicle.

This is basically what the world was like before the Affordable Care Act. People who had no insurance would use hospital emergency rooms for care when they really needed it, which is inefficient and dangerous and super expensive and many other negative things, all of which get picked up by local taxpayers. There are so many things that are wrong with and bad about the GOP’s “health care” plan that it’s hard to focus on any one thing and even harder to prioritize, but this one is really big. And it will hurt rural areas at least as much as urban areas. Not that the Republicans who represent rural areas care, and it’s not clear that the voters who would be affected have figured it out, or if they have if they’re capable of getting past their faith in the Charlatan in Chief. But the facts are stubborn things. The Rivard Report has more.

Rural hospitals

If this story was meant to evoke my sympathy, I’m afraid it failed.

It's constitutional - deal with it

It’s constitutional – deal with it

Since the hospital closed in Paducah, a town 30 miles to the north, patients in Guthrie have 60 long miles to travel to Childress for care. It’s a feeling of isolation that has crept up on other rural corners of the state following a spate of 10 hospital closures in the past two years. And financial data collected by the state and federal government shows revenue is falling for other rural hospitals, suggesting more may be on the brink.

Policymakers, operating on tight budgets, must decide whether they are willing to spend more money on small hospitals serving a limited number of patients, hospitals that in most cases could not keep their doors open without government assistance. But without them, people, inevitably, will die.

“We’ve all seen the crash that’s coming in the next five years,” said Kell Mercer, an Austin-based lawyer who has worked on hospital bankruptcy cases. “The Legislature’s more interested in cutting revenue and cutting services than providing the basic services for these rural communities. This is a perfect storm of events that’s going to hit the state, hard.”

Texas’ rural hospitals have long struggled to stay afloat, but new threats to their survival have mounted in recent years. Undelivered promises of federal health reform, payment cuts by both government programs and private insurers, falling patient volumes and a declining rural population overall have been tough on business — a phenomenon one health care executive called “death by a thousand paper cuts.” Add to that Texas’ distinction as the state with the highest percentage of people without health insurance and you get a financially hostile landscape for rural hospital operators.

“Hospital operating margins, and this is probably true of the big guys and the small guys, too, are very small, if not negative,” said John Henderson, chief executive of the Childress Regional Medical Center. “In a way, Texas rural hospitals are kind of in a worst-case scenario situation, because we lead the nation in uninsured, and we took Medicare cuts hoping that we could cover more people.”

[…]

The sum of all these changes has people like Don McBeath, who lobbies for rural hospitals, warning of a repeat of the widespread hospital closures Texas experienced three decades ago. In 1983, the federal government restructured the way Medicare made payments to hospitals, meant to reward efficient care. Those changes proved untenable for small hospitals with low patient volume, heralding decades of closures that claimed more than 200 small Texas hospitals as casualties, McBeath said.

Some counties can afford to raise taxes to keep their hospitals open; others cannot, or find that raising taxes is politically impossible.

And when a small county hospital closes, often the hospital in the next county over must shoulder a bigger burden of uninsured patients. Even patients with insurance face higher deductibles and often can’t pay their bills.

“When it closes, you’re forced to make other decisions, other plans,” said Becky Wilbanks, a judge in East Texas’ Cass County, which saw a hospital closure last year. “That’s an economic hit that we took.”

Rural hospitals are often one of the biggest and highest-paying employers in a community, Wilbanks said.

And when they close, it can have a domino effect on other local businesses, said Hall County Judge Ray Powell. When his county’s hospital closed in 2002, it prompted the local farm equipment dealership to close its doors and move to Childress.

“It was a big loss,” he said. “It was devastating.”

Across Texas, rural counties are seeing their populations dwindle. King County, home to Guthrie, is one of Texas’ 46 rural counties that are projected to lose population over the next four decades — at a time when the rest of the state’s population is expected to double.

Maybe I’m just a jerk, but my first reaction to stories like this is to check the most recent election results in the counties named.

In Cass County, Greg Abbott got 74.64% of the vote.
In Hall County, Greg Abbott got 85.09% of the vote.
In King County, Greg Abbott got 96.77% of the vote. Ninety-three people voted in total, and 90 of them went for Abbott.

In other words, the voters in these counties have gotten what they voted for. Perhaps someone should point that out to them if and when more of these rural hospitals close.

This isn’t entirely fair. Declining population in these counties is nobody’s fault. A change in Medicare payments in 2002 caused a lot of upheaval. But the problems they’re facing now are entirely the result of Republican intransigence on Obamacare and hostility to Medicaid. It’s abundantly clear by now that Medicaid expansion has been a boon for the states that have done it, while states like Texas are feeling the downside good and hard. If you want to blame Wendy Davis for not adequately communicating the issue to these voters, you have to equally blame Greg Abbott for continually lying about the need for “freedom” from the “tyranny” of Obamacare. Elections have consequences. This is one of them.

No Medicaid expansion for you!

So much for that.

Texas will not expand Medicaid or establish a health insurance exchange, two major tenets of the federal health reform that the U.S. Supreme Court upheld last month, Gov. Rick Perry said in an early morning announcement.

“I stand proudly with the growing chorus of governors who reject the Obamacare power grab,” he said in a statement. “Neither a ‘state’ exchange nor the expansion of Medicaid under this program would result in better ‘patient protection’ or in more ‘affordable care.’ They would only make Texas a mere appendage of the federal government when it comes to health care.”

Perry’s office said he’s sending a letter to U.S. Health and Human Services Secretary Kathleen Sebelius [Monday] morning asserting his opposition, both to accepting more than a hundred million federal dollars to put more poor Texas adults onto Medicaid, and to creating an Orbitz-style online insurance marketplace for consumers.

Of course, opting out of creating a state exchange means that the federal government will create one instead. It does not mean there will be no exchange in Texas. This is why some Republican legislators like Rep. John Zerwas tried to pass a bill to create an exchange, so that it would be implemented by Texas instead of the federal government. The rationale for not implementing the state-run exchange confounds me, but I have never been Rick Perry’s intended audience.

As for the refusal to expand Medicaid, just on Friday the Dallas Morning News reported that Perry was still thinking about it.

Gov. Rick Perry won’t say whether Texas should take or reject the federal largesse that could allow the state’s Medicaid program to cover more poor adults.

But a spokeswoman confirmed Friday that his aides have begun canvassing health care provider groups for their opinions about expanding Medicaid and creating a state health-insurance exchange

Though he’s a staunch opponent of President Barack Obama’s federal health care law, Perry’s reluctance to declare immediate opposition to the Medicaid expansion after the Supreme Court’s ruling last week puts him at odds with several other Republican governors. Some, such as Florida’s Rick Scott, have already vowed to keep their states on the sidelines, taking advantage of the court’s ruling that they can do so without jeopardizing the funds they already receive.

Perry spokeswoman Catherine Frazier played down the calls as routine outreach on a major issue. But several health-care lobbyists and experts said it’s shrewd for Perry to say little because the Supreme Court ruling gives him leverage to negotiate with the Obama administration for tighter Medicaid eligibility rules and leaner benefits before agreeing to the expansion, which would take place starting in 2014.

“It’s smart politics because there’s no need to make a decision at this time, and he and a lot of Republicans are playing for more flexibility within the program,” said Tom Banning, chief executive and executive vice president of the Texas Academy of Family Physicians.

Apparently, he didn’t listen very closely to what the health care providers want, because they have made their preference quite clear.

Getting the Medicaid expansion in place has already become the “number one priority” for the Texas Hospital Association, said John Hawkins, the senior vice president for advocacy and public policy at the organization. “It’s the kind of thing that hits our members right on the margin when they’re trying to digest other payment cuts,” he said.

Twenty-seven percent of working-age Texans, or more than 6.1 million people, were uninsured in 2010, according to the Kaiser Family Foundation. That’s the highest rate in the nation and the second-highest number to California’s 7 million people. Under the Medicaid expansion, 2.5 million Texans would qualify, the Urban Institute estimates.

But Texas Gov. Rick Perry (R) has been a staunch opponent of health care reform and his administration has indicated a willingness to opt out of the Medicaid expansion. For Texas hospitals, which absorbed $4.6 billion in unpaid bills and charity care in 2010, that’s a problem, Hawkins said.

I’m thinking that will provide for some interesting fundraising pitches this fall. My advice to them is to start donating to Democrats now.

So now Rick Perry will take a victory lap on Fox News and bask in the adulation of his cultish supporters. Everyone else will have to deal with the reality of this, starting with county taxpayers.

It's constitutional - deal with it

Unlike many states, Texas does not directly subsidize the cost of caring for the uninsured. Instead, taxpayers in Dallas County and elsewhere help pick up that tab through property taxes that support safety-net hospitals such as Parkland Memorial Hospital.

Last year, Parkland reported that its own cost for delivering uncompensated care was $335 million. Dallas County taxpayers funded $425 million, or 35 percent, of the hospital’s operating budget.

For the average Dallas County homeowner, that created a hospital tax bill of $370.

Some advocates of health reform say the new revenue from Medicaid payments is large enough that hospital districts — whose budgets are controlled by county commissioners — could reduce their tax rates.

[…]

Some experts expect that Texas will eventually accept the Medicaid funding. After all, the federal government would cover the entire cost of the expansion between 2014 and 2016. Hospitals that have struggled to find ways to offset charity care are certain to demand that state lawmakers take the money.

“It really depends on the political pressure they get from the counties and the hospitals that benefit from having these people covered,” said John Holahan, director of the Urban Institute’s Health Policy Center. “To leave all this federal money on the table will create an intense debate.”

The hospitals are big losers as well.

Hospitals regularly get stuck with bills that the uninsured cannot afford to pay. Every year, the American Hospital Association adds all those bills up to calculate the total amount of uncompensated care that its members provide. Every year, the number gets bigger and bigger, hitting $39.3 billion in 2010. Here’s a chart I put together with the AHA data:

Under the health reform law, hospitals will see reductions in some of their Medicare reimbursement rates. They will be forced to deliver higher quality or see financial consequences.

All of that was worth it, in hospitals’ eyes, because of the insurance expansion. That would finally put someone on the hook for the medical bills that have, for decades, gone unpaid.

If states opt-out of the Medicaid expansion, that essentially means there’s no one on the hook for some of the poorest patients. And that explains why Bruce Siegel, president of the National Association of Public Hospitals, calls states opting out a “potentially disastrous outcome” and is urging Congress to come up with a fix. For them, the status quo is the worst possible outcome: One where they have accepted cuts to Medicare, and still get stuck with billions in unpaid bills.

Remember, a part of the Affordable Care Act was a reduction in the federal subsidy for uncompensated care costs because it assumed the expansion of Medicaid would greatly reduce the number of uninsured patients. Unfortunately, no one foresaw the SCOTUS decision striking down the provision that states would lose existing Medicaid funding if they didn’t accept the subsidies to expand it, and so here we are. Just as a reminder, states like Texas that have a lot of uninsured people would have benefited greatly from it as a result. It was a simple case of red state/blue state math.

The deal the federal government is offering states on Medicaid is too good to refuse. And that’s particularly true for the red states. If Mitt Romney loses the election and Republicans lose their chance to repeal the Affordable Care Act, they’re going to end up participating in the law. They can’t afford not to.

Medicaid is jointly administered between states and the federal government, and the states are given considerable leeway to set eligibility rules. Texas covers only working adults up to 26 percent of the poverty line. The poverty line for an individual is $11,170. So, you could be a single person making $3,000 a year and you’re still not poor enough to qualify for Medicaid in Texas. That’s part of the reason Texas has the highest uninsured rate in the nation.

Massachusetts, by contrast, covers working adults up to 133 percent of the poverty line — partly due to a former governor whose name rhymes with Schmitt Schmomney. It’s a big reason it has the lowest uninsured rate in the nation.

The Affordable Care Act wants to make the whole country like Schmitt Schmomney’s Massachusetts. Everyone earning up to 133 percent of the poverty line, which is less than $15,000 for an individual, gets Medicaid. And the way it does that is by telling states the feds will cover 100 percent of the difference between wherever the state is now and where the law wants them to go for the first three years, and 90 percent after 2020.

To get a sense of what an incredibly, astonishingly, unbelievably good deal that is, consider this: The federal government currently pays 57 percent of Medicaid’s costs. States pay the rest. And every state thinks that a sufficiently good deal to participate.

But, somewhat perversely, the states that get the best deal under the law are states like Texas, which have stingy Medicaid programs right now, and where the federal government is thus going to pick up the bill for insuring millions and millions of people. In states like Massachusetts, where the Medicaid program is already generous and the state is shouldering much of the cost, there’s no difference for the federal government to pay.

So if Texas had accepted Medicaid expansion, it would have gotten a vastly better deal than states like New York, California, and Massachusetts. Now that Texas has decided to “send that money back” to Washington, we will subsidizing the Medicaid expansions of New York, California, and Massachusetts, and getting nothing in return. Does that sound like a good idea to you? BOR, Neil, EoW, Juanita, Hair Balls, Ed Kilgore, Sarah Kliff, and Rep. Garnet Coleman have more, and statements from Rep. Jessica Farrar and Sen. Rodney Ellis are beneath the fold.

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Tough times for teaching hospitals

Oh, who needs doctors, anyway?

Texas teaching hospitals are bracing for a big hit in the federal deficit-reduction plans under consideration, just a few weeks after the state Legislature slashed funding to the same doctor-training programs.

The cuts will exacerbate a crisis in which Texas, ranked 42nd in the number of physicians per population, loses potential doctors because the state doesn’t have enough residency slots to train the medical students it pays to educate.

“There’s a perfect storm forming in Texas — a growing, aging population, an increase in students and, now more than ever, a decrease in residency slots,” said Dr. Kenneth Shine, the University of Texas System’s executive vice chancellor for health affairs. “The impact of the state cuts and likely federal cuts pose a grave threat to our ability to provide health care to all Texans.”

Congressional proposals, still in flux, would cut Texas’ doctor-training funding by 60 percent. State cuts, passed earlier this month, will reduce the funding of one doctor-training program by 74 percent and another by 30 percent. Together, they’d cost Texas about $165 million of the $306 million it currently gets in government funding to train new doctors.

The cuts loom six months after Texas officials expressed concern that the state was losing 45 percent of its medical school graduates to out-of-state residencies, in part because its residency-to-graduate ratio is less than 1-1 — far below, say, New York’s 3-1 ratio. The Texas ratio will get significantly worse under the cuts.

And here I thought tort “reform” was going to solve all of our doctor shortage problems. Seriously, I cannot see how this is a good idea. We’re not doing this because we’re trying to control a long-term cost that we expect to grow at an unmanageable rate. We’re doing it because as with most of the other budget cuts we’re doing or may be doing, the constituency that is affected by them has less power than certain other constituencies, none of which are being made to “sacrifice” in any meaningful way. We’re not doing what’s smart or what’s fair, we’re doing what’s left to do after a whole range of other options are taken off the table.

Trauma centers feel the pinch, too

Like everything else in the state, trauma centers at hospitals will see their funding get cut, and they are warning about the consequences.

The officials from Memorial Hermann, Ben Taub and the University of Texas Medical Branch at Galveston came together to say the Legislature’s proposal to allot trauma centers nearly 20 percent less than usual from the state’s dedicated fund will have tragic consequences.

“When we don’t have enough funding, we have to divert patients to other hospital ERs,” said Dr. John Holcomb, chief of trauma surgery at Memorial Hermann. “Studies show that when diversion goes up, delaying care, mortality goes up.”

There’s a dedicated fund that was created in 2003 to help trauma centers offset the cost of their care. It has $120 million in it, but like pretty much every dedicated fund in the budget, some of that routinely gets diverted to other things, because it’s easier to do that than it is to properly fund the budget through taxation. This particular fund gets its money from traffic citations (including, as of 2007, red light camera tickets), and the fund itself has the money it’s supposed to, it’s just that the Lege doesn’t let the trauma centers have all of it. Previously, they got $70 million of the $120 million; this time, it’s $57.5 million. Keep that in mind when you read about an accident victim dying en route to a trauma center miles away from where they were injured.

Rep. John Zerwas, R-Richmond, a member of the House appropriations and public health committees, called it “very frustrating” to have funding dedicated for trauma care and not be able to distribute it. Zerwas added that he’s looking for a long-term solution.

But he also noted that the trauma money is hardly alone among dedicated funds, and said the big question is still how the Legislature balances its budget with all its needs.

Of course, as Rep. Zerwas fails to note, the Republicans in the Legislature have steadfastly refused to use the Rainy Day Fund, which could provide billions of dollars to offset a chunk of the shortfall. The Republicans have also steadfastly refused to address the structural deficit, in which the business margins tax and other revenue sources created in 2006 to pay for the massive property tax cut that was passed then has consistently fallen short and has by now accumulated billions more in unfunded needs. To put it simply, the Republicans didn’t even try to solve these problems in their budget deal, they mostly spent their time moving money around from one need to another and making ludicrous statements about “living within our means”. Tell that to the trauma centers, y’all.

Hospital infections

There’s something missing from this story. Do you know what it is?

The most common hospital-contracted malady among older patients in Houston is systemic vascular infections, a problem often caused by unsanitary or improper procedures during their hospital stay, a new study of Medicare claims shows.

Among 46 hospitals within a 50-mile radius of the city of Houston, half reported vascular infections in Medicare patients through catheters, the tubing used for various procedures.

A total of 472 “hospital-acquired conditions” were reported from the 234,200 Medicare discharges from October 2008 through June 2010. That’s two incidents per 1,000 Medicare discharges in Houston.

Allowing the public to see information about mishaps and errors that occur during a patient’s hospital stay has been a contentious issue for hospital personnel, who believe the public could misread it. To date, there’s no universal ranking system for the public to determine the safety of the nation’s hospitals.

The reports released this month by the Centers for Medicare and Medicaid Services is the first to look strictly at how many times bedsores, surgical errors and falls and trauma, for example, occur among Medicare patients.

“We wanted to bring transparency to the fact that patients are exposed to potentially unsafe occurrences at America’s hospitals, said Donald McLeod, a spokesman for the U.S. Department of Health and Human Services. “We hope that by making the data public, we will spur hospitals to work with care providers to reduce — or even eliminate – these hospital-acquired conditions from happening again to even a single patient.”

Have you figured it out yet? Here’s the answer:

Health and Human Services Secretary Kathleen Sebelius on Tuesday pledged “up to $1 billion” for a new “Partnership for Patients.” The initiative aims to reduce preventable hospital infections and patient readmissions after they have been discharged.

“Every time a patient gets an infection in the hospital, or is readmitted because they didn’t get the right follow-up care, our nation’s health care bill goes up,” Sebelius said at a news conference at the National Press Club in Washington, D.C.

The proposal builds on existing rules for Medicare hospital payments, which impose financial penalties against hospitals for patients who experience preventable complications. Among the types of complications hospitals will be asked to examine are those associated with adverse drug reactions, bed sores, childbirth and surgical site infections.

The billion dollars is to come from the Affordable Care Act, last year’s health overhaul. According to HHS, if health care professionals are successful in reaching the goals laid out in the initiative, the initial $1 billion investment could reap as much as $35 billion in savings over the next three years, including $10 billion for Medicare alone.

“As the country’s largest payer for care, Medicare has a powerful ability to be a catalyst for change,” said Sebelius.

Yes, what’s missing from this story is any mention of the Affordable Care Act. One provision of the ACA that went into effect this January was that hospitals will now have to track and report to the Centers for Disease Control and Prevention’s National Healthcare Safety Network when patients get central line associated bloodstream infections (CLABSIs) in intensive care units. The point of this is partly to make this information more transparent to the public, and partly to reduce the incidence and cost of these infections, which represent a huge amount of money being spent and which can be prevented by such simple practices as better hand-washing and more care with catheters. I don’t know why the Affordable Care Act and the role it is playing in reducing hospital-acquired infections and their associated costs weren’t mentioned in this story, but now at least you know they should have been.