Medicare Reform—“MedPac on Steroids” Part 1: An Exciting Proposal

HealthBeat has long argued that Medicare reform will pave the way for healthcare reform, and that the Medicare Payment Advisory Commission’s (MedPac’s) recommendations could serve as a brilliant blue print for overhauling Medicare.  (Also see our Century Foundation report on Getting More Value From Medicare).

Now President Obama appears to be backing a proposal that would empower MedPac to realize its vision for reform.  Yesterday, in a White House meeting with Senate Democrats, the president  reportedly “went out of his way” to mention a bill, introduced by Senator Jay Rockefeller ( D-W.Va)  that would move decisions about Medicare benefits away from Congress, by turning MedPAC into an independent executive agency.  Currently, MedPac is an independent panel that advises Congress. It has no formal power. But under Rockefeller’s bill it would be able to implement its recommendations and fund policy initiatives.

Wednesday afternoon, the White House announced that the President has gone a step further by releasing a letter  from President Obama to Senators Max Baucus and Ted Kennedy.  The letter extends the remarks that the president made yesterday, which came close to endorsing Rockefeller’s bill. Writing to Kennedy and Baucus, the  President indicated that the administration could find another $200 to $300 billion for health care reform, linking that proposal to “giving special consideration to the recommendations of the Medicare Payment Advisory Commission” (MedPAC), “a commission,” he noted, “created by a Republican Congress . . . Under this approach,” the president continued, “MedPAC's recommendations on cost reductions would be adopted unless opposed by a joint resolution of the Congress. This is similar to a process that has been used effectively by a commission charged with closing military bases, and could be a valuable tool to help achieve health care reform in a fiscally responsible way.”

These savings,  he added, “will come not only by adopting new technologies and addressing the vastly different costs of care [in different parts of the country], but from going after the key drivers of skyrocketing health care costs, including unmanaged chronic diseases, duplicated tests, and unnecessary hospital readmissions.”

Giving MedPac the Authority to Take the Politics Out of Fees for Doctors & Hospitals

Under Senator Rockefeller’s bill, MedPac would have the authority to set reimbursements for doctors and hospitals.  As Rockefeller explained in a recent Senate Finace Committee meeting:  “I think that [this is] the best way to take politics out of all of this is to take Congress out of the setting of reimbursements for doctors under Medicare and Medicaid and for hospitals, because there  is a group of 17  . . . completely dispassionate people,” who could do this, Rockefeller explained, referring to MedPac.

“And I think one of the [reasons] you have your $700 billion of wasted money every year,” Rockefeller added,  “is the fact that there are too many political judgments made because there's too much lobbying and Congress can — you know, unless they're all health care experts, can fall victim to that. So the idea of MedPAC having the power to set those fees, reimbursement fees, to me is enormously attractive, takes politics right out of it and takes Congress right out of it.”

At the hearing, White House budget director Peter Orszag indicated circumspect support for Rockefeller’s bill: “Your idea of — I think we've referred to it as  MedPac on steroids, or a much more powerful role for a body that is widely respected– is one approach.”

What Exactly Does MedPac Recommend?

Until now, most reform advocates have ignored MedPac. The reports that the independent advisory panel issues in March and June of each year are long.  They are dense with detail. And they are very, very smart. The commissioners  understand that health care quality could be higher if we spent less on care.

They have digested the Dartmouth research revealing that when patients in some parts of the country receive more aggressive and more expensive care, outcomes often are worse.  They realize that doctors and hospitals should be rewarded for the quality of the care they provide, not the quantity.  As HealthBeat has reported, they know that the fee schedule that Medicare now follows favors specialists while underpaying primary care physicians,  and they have suggested re-distributing Medicare’s dollars “in a budget neutral way”– hiking fees for primary care while lowering fees for some specialists’ services. They have pointed out that some very lucrative procedures appear to be done too often, in part because they pay so well. The Commission has advised targeting these procedures and comp ring them to alternative treatments—just in case a less expensive approach might turn out to be more effective (and not as risky for the patient), as pricier, more aggressive treatments.

Finally, MedPac notes that some hospitals actually make a profit on Medicare’s payments. This is because these hospitals are more efficient: patients typically spend fewer days in the hospital and see fewer specialists. There are fewer readmissions, And generally, outcomes are better. MedPac suggests that when private insurers pay hospitals more, they may simply be rewarding less efficient hospitals for lower quality care. (And of course, private insurers pass those higher payments along to their customers in the form of higher premiums.)

MedPac goes beyond looking at how we pay providers.  Investigating Medicare Advantage, it has described the care that private insurers are providing as somewhere between “disappointing” and “depressing.”  Taking a look at the boom in hospital construction, MedPac noted, in its March 2008 report that “much of the added capacity is located in suburban areas and in particular specialties, raising the possibility that health care costs will increase without significantly improving access to services in lower income areas”. (Here, I can’t help but think about the current controversy over whether Hackensack University Medical Center should be building a new for-profit facility in a nearby suburb.)  

As for the drug industry, in its June 2008 report to Congress  MedPac observed that "researchers have shown that bias in industry-sponsored trials is common.” Because we lack disinterested, “evidence-based” information about new products, MedPac noted “we do not know which treatments are necessary for which types of patients. Guidelines do not exist . . . to delineate how much care is typically needed . . . and when patients are unlikely to improve with additional treatment.” In the same report, MedPac cast a cold eye on just how quickly we adopt bleeding-edge medical product and procedures to treat “most common clinical conditions” without “credible, empirically based information” to tell us “whether they outperform existing treatments and to what extent.” In other words, we need unbiased comparative effectiveness research. Those who make a profit on new products and procedures should not be involved.

These are exactly the radical but truthful recommendations that would make any well-paid health care lobbyist shudder.  No wonder the Bush administration ignored MedPac’s advice for eight years.

Now, a new White House is taking MedPac’s recommendations to heart. And Congressional leaders also seem to recognize the link between Medicare reform and national healthcare reform.  In April, HealthBeat reported that Senate Finance Chairman Max Baucus had declared that Medicare would become “the big driver” behind national health reform. Now, it’s
becoming clear what Baucus meant.

19 thoughts on “Medicare Reform—“MedPac on Steroids” Part 1: An Exciting Proposal

  1. those of us who recall how Congress had to beat the medical establishment at NIH over the head to get them to focus on diseases that primarily impact women have a certain wariness about such proposals.
    if the society thinks its more important to provide a drug benefit to seniors than insure all kids, as it apparently does, who deserves the power to override that decision, however wrong-headed it may be.

  2. There is something sad about the fact that congress would have to tie its own hands so that it couldn’t interfere with the findings of a scientific body.
    It’s sort of like Ulysses being tied to the mast so he wouldn’t yield to the Siren’s songs. Congress has now admitted (for the second time, the first was with base closings) that special interests have more power than they do.
    And yet we expect a new health system that will be to the benefit of all the people…

  3. Robert–
    What a wonderful analogy. I am going to quote you.
    The Sirens are, of course, the lobbyists.
    There is something sad about the fact that lobbyists have such powerful voices (and songs) but I admire Congress (and Jay Rockefeller) for realizing that there are some areas where you just don’t lobbyists shaping policy.
    And the only way to do that is to take the issue away from Congress, and appoint a special agency to oversee the issue.
    We have the Fed to set interest rates. (I can only imagine what woudl happen if lobbyists for the real estate industry, the banking industry, Wall Street, etc. had a hand in setting rates.)
    We have FASB to set accounting rules for corporatoins. (Congress and lobbyists have tried to fight FASB, but in the end FASB won, at least on he issue of recognizing the cost of stock options given to executives. FASB
    has shown remarkable integrity over the years.
    I hope MedPac is able to follow its example.
    Jim-
    Unlike Congress, MedPac realizes that the people in this country who most need better healthcare are not women, or even children, but low-income people of all sexes and ages. That’s why MedPac objects to expanding hospitals in the suburbs when low-income neighborhoods still lack communinitiy clinics.
    And “Congress” did not demand that NIH put more focus on diseases that affect women. Three women from Congress made the demand.
    “Insuring” kids will do little to improve their health — even if insurance leads to access to medical care, access is only a 10% factor in overall health.
    What children need is a healthy diet, a safe place to play and exercise, a good education, a clean envionment, safe clean housing . . . .These are the things that are society does not provide for low-income children.
    See my blogs on Robert Wood Johnson reports showing that poverty and lack of education are the major causes of poor health.

  4. I’m all for reforming Medicare–removing errors, inefficiences and excesses, but the best way to fix the system would be to expand it, implement strong oversight, and fund it adequately.
    All those who scream “entitlement” are eager to see Medicare fail–and the best way to cause a failure of a potentially good program is to starve it for funds.
    Medicare and Medicaid–programs that care for the sickest among us–may be partly responsible for the rise in costs, but the Gawande article reveals that there is plenty of blame to go around. Taxpayers, HMO clients and patients are all being ripped off by more than one sector of the medical industrial complex.
    Why do they get away with it? Because they can.

  5. One of my other quixotic areas of interest has to do with education. When one steps back enough it is possible to see that both areas are embroiled in the same sorts of debates: public vs private service providers and public vs private funding.
    Then there are the areas of measuring “effectiveness” and where to place the blame for deficient outcomes.
    Finally there are the proposals for change, bottom up or top down.
    Fundamentally it all comes down to how one views the world and human nature. To over simplify, one side sees the problems of the weakest as being the result of failed social policies while the other sees those in need as having responsibility for their condition.
    This irreconcilable difference in how human nature is viewed goes back thousands of years and which view has been predominant has shifted over time.
    It looked like the humanist view was gaining in the 20th Century with the rise of various civil and worker rights movements, but it suffered a reversal in the past 40 years.
    It is unclear whether we have reached another turning point. Obama understands and is sympathetic, but the forces of the status quo have been in place for a long time and he has few arrows in his quiver.

  6. robertdfeinman wrote:
    “To over simplify, one side sees the problems of the weakest as being the result of failed social policies while the other sees those in need as having responsibility for their condition.”
    ————–
    In terms of making social policy, I do agree with this as a description of how the left and right look at such things. However, I also believe there is much hidden danger in medical care as currently provided in this country that was touched upon by that IOM study in ? 1999. I believe they claimed that errors in Medical care were conservatively the 7th largest cause of death and maybe much higher if you include such things as adverse drug reactions and future unknown drug effects. My point is that this study never saw the light of day among the masses, or at least not to the level that it should have. The induced demand potential that our for-profit system fosters may do a lot more harm than good to those with plentiful access to care. Do we really know?
    I think when in comes to healthcare system reform, there is a lot more at stake just under the surface that effects both the weakest and also maybe the opposite, the strongest or those with best access. How much can we really say until we know much more about true effectiveness and accountability for good results among all patients both potential patients and active ones. You would think that everyone, both conservatives and progressives would want to know the true effectiveness of processes before they were subjected to them. By logic the biggest cry out there should be, “make sure my treatments are safe and effective”. Instead all I hear from conservatives is let the caveat emptor approach to healthcare continue and indeed get more entrenched. Why??

  7. NG:
    ” Instead all I hear from conservatives is let the caveat emptor approach to healthcare continue and indeed get more entrenched. Why???”
    No what are hearing is what “conservative” shills are saying. Evidence-based medical treatment decisions would eliminate many products from the market because they offered no benefit over cheaper alternatives.
    Those who market those products have a lot at stake in muddying the waters. There is also the wishful thinking mentality as seen in the billion plus unregulated dietary “supplement” market. People want to believe that some weed has magical properties and taking away this choice plays into their fears.
    Just look at the studies on the success rates of dieting and substance abuse plans to see the gap between reality and the promotion. Most efforts result in a 15-40% long-range behavior modification, but the claims make it sound like everyone will be helped.
    Even those cases that fail are then attributed to moral failing on the part of the participants. Snake oil never goes out of fashion.

  8. I never heard of MedPac before this news came out. Who are they, how do we know they can’t be bought off like congress?

  9. To control the pain we must attend to the specialist because we can give him what is appropriate and what we need, for example I take hydrocodone, vicodin which is medicine used to counter the chronic pain that I have for years, but I rioja prescribing doctor, I take it in moderation because I read in findrxonline which is a medicine that causes anxiety, and we must control it as it can affect your nervous system, so do not take medicines without consultation because it really can be dangerous.

  10. Everyone, I’m swamped right now, so am replying to comments one by one.
    I’ll be back.
    Ray Gridley–
    Welcome. (I don’t recognize you name, unless you usually just sign “Ray”.)
    And think you for an excellent question.
    You write: “Never heard of MedPac before this news came out. Who are they, how do we know they can’t be bought off like congress?”
    I hadn’t heard of them either until, maybe, three years ago.
    Then I began reading their very long reports . . .clearly a very intelligent group, not at all intimidated by lobbyists.
    The people on the MedPac
    panel are appointed by the Comptroller General. Not sure how that happend, but the Comptroller General is not a DC celebrity– and
    neither are the people on MedPac.
    I think lobbyists just didn’t take them very seriously because they write these are very long, extremely intelligentt
    reports that don’t exactly “sing.”
    No slogans. A great many facts. All true. (I began reading the MedPac reports after I spent 3 years, 24/7, writing my book on Money-Driven Medicine.
    So I knew a great many facts–and I learned more from MedPac.
    I’ve interviewed the chairman of MedPac, Glen Hackbarth (he may now be former chaiman.)
    And I’ve read much of his testimony before Congress. (Even though the Bush administration ignored MedPac’s reports, smart Congressmen and committees did ask MedPac to testify.)
    Hackbarth’s testimony was excellent. Again, fact-filled, never inflammatory, always honest.
    The reports also are very candid in pointing out areas where “some on the MedPac Commission thinks this, but not everyone agrees.”
    At the same time, they’re not wishy-washy. MedPac takes a stand in a great many areas– often a stand that
    would upset many lobbyists.
    I’ve asked around in D.C. and have been told that, there, , MedPac is seen as largely apolitical.
    These people are healthcare wonks/experts–they’re not advocates for a
    particular ideology.
    They are very practical, and looking for what works, without regard to who will profit or lose.
    They remind me of FASB– a
    similar group that is charged with making rules for corporate accoutning. FASB is made up of accoutnign wonks.
    FASB is based in Norwalk, CT, they’ve been called “the gnomes of NOrwalk.” (Think old-fashioned accoutants wearing green eyeshades)
    I think that being in Norwalk helps insulate FASB from DC politics.
    If MedPac is put in charge of Medicare, I’d recommend putting their headquarters in Minnesota or Colorado . .
    One of my few concerns about Rockefeller’s bill is that it calls for MedPac
    appointments to be confirmed by Congress.
    I’d rather see the Comptroler General’s office pick them. They’ve been doing an excellent job.
    Someone should confirm them, but it needs to be an apolitical group of health care experts–a group like the panel that the Institute of Medicine has naemd to oversee compartive effectiveness research. They are mainly physicians who have no financial stake in their decisions.

  11. Sheldon, Pat S. Robert, Chris J., Michael K, Gregg, Jane, Jim J.
    and Ray Gridley (see my earlier oomment to you on a separate commetn)
    Sheldon–
    Welcome.
    You write: “Physicians, like most everyone else, respond to financial incentives. As long as the incentives are for more volume, and physicians largely control the demand for services, we’ll continue to get more tests, more procedures, and more costs.”
    You add “Private insurers have rarely been at the forefront of payment reform. So Medicare, as usual, will have to lead the way. Although this has been evident for decades, the political will to pull it off hasn’t been there. Until now, perhaps.Let’s not lose this opportunity”
    Well-put. I totally agree.
    Pat S.—
    First, yes, of course, Mayo is not an insurer. (my mistake for including it in at list that suggested it was.)
    But Mayo is taking on financial risk because doctors are on salary and are not even made aware of which services bring in more money for Mayo.
    Docs are left on their own to do what they think is best for the patient (while consulting with each other.)
    That docs don’t know how much money their various servicdes bring in is very unusual in U.S. healthcare.
    Geisinger, however is an insurer, as I say in the post. (For info on Geinsinger as insurer, see ehttp://www.thehealthplan.com/
    Their providers also take patients covered by other insurance. But much of what makes the Geisiger model work is that they are both provider and insurer.
    The antagonism between privders and insurers undermines so much healthcare.
    This is not to say that most providers should get into the business of financing healthccare. But
    it is a useful model.
    When the two are are on one taam, they have a common mission: lifting quality while containing costs.
    But this is not the only good model for reform.
    We are going to need to experiment with a number of models –ACOs that are more like Mayo, medical homes. hospital/physician networks that take “bundled payments.”
    We’ll find others.
    And my guess is that if we do this well, we’ll wind up with of a number of different models that work better in diffrerent situations–rural, cities, etc.
    What all of the most successful models have in common is this: they are non-profit
    MedPac, Gawande and others who I respect udnerstand that there are many models for health delivery that can work, and that we need to experiment.
    Robert– You suggest that we need to protect healthcare from political “mischief” and at the same time, you suggest that it can be done:
    ” SS for all the attacks on its benefit schedule, has remained mostly unaffected. With healthcare the situation will be more fraught, there will need to be many more rules created and the possibilities for mischief much greater .”
    I agree.
    I think Obama’s most recent suggestion–putting MedPac in charge of Medicare, and letting its
    decisions shape what a public-sector option does, and what private insurers do–is excellent.
    MedPac really understands the system, and the ocmission is lagely apolitical. It would be an ideal regulator. (See my comment on “Who MedPac is” on the MedPac post.)
    Chris–
    Thank you. Yes, as you say,”everything flows from first principles. If medicine is seen as just another profit-driven endeavor, then everything will conspire to figure out ways to maximize that profit. On the other hand, if medicine is seen as a social good, then the goal becomes figuring out the best way to organize and deliver that social good. That is the struggle for the soul of medicine.”
    Occasionally readers ask why I quote what a commenter said; after all, he/she knows what she/he said!
    I’m trying to call attention to sections of comments that I think many readers might find useful.
    Michael Kirch:
    Thanks very much for your comment.
    I think you are right that “it may take another generation for doctors to teach their patients that less medicine means more healing. (www.MDWhistleblower.blogspot.com)”
    It’s also going to take a while to teach many doctors.
    This is why I think that we’re going to have to have some top-down regulation from somone like MedPac (the commission that Obama thinks shoudl be running Medicare), raising co-pays and lowering fees for ineffective treatments.
    Gregg–
    Good to hear from you. Thanks very much.
    Yes– McAllen vs. Mayo
    says it all.
    Jane Jaobs,
    You are entirely right: the Dartmouth research shows that the least efficient hospitals are reimbursed more becuase their patinets spend more time in the hopsital, undergo more tests before the hopsital gets the diagnois right, and undergo more procedures.
    Meanwhile, outocmes are no beter, often worse. And both patient and doctor satisfaction are lower.
    (Btw, Gawande reserach,indlucing data on McCallen, comes from DArtmouth.)
    It really doesn’t make sense to pay hospitals more for being less effcient, not just becuase it is a waste of money, but becuase it means paying more for patients who suffer more.
    (IN less efficient hospitals, patients are also more likely to be re-admitted, and more likely to die in an ICU–probably the loneliest way to die.
    Jim– You write: “but wouldn’t Mayo and other similar efficient operations make out like bandits (you should pardon the politically incorrect phrase) in Medicare Advantage? . . .What am i missing?
    Jim, what you’re missing is that Mayo isn’t looking for more patients.
    Unlike any other academic medical center in the country, it doens’t advertrise.
    With such high quality and lower costs, it doesn’t need to.
    And Mayo takes many Medicaid and uninsured patients.
    Minnesota has become a big draw for many very poor immigrants, particulary from South East Asia.
    Why would these people move to such a cold part of the country?
    Because Minnesota makes unemployed immigrants very welcome, and various groups in Minnesota go out of their way to find jobs for these immigrants–including many who can’t speak English
    I interviewed a doctor who spent a number of years at Mayo, and number of years at a hospital the Bronx,. Ultimately, he went back to Mayo.
    He reports that the percentage of very poor patients was about the same in each place.
    But they got better care at Mayo.
    I think the post was titled:
    “What Makes Mayo Differnt”
    The answer: Mayo isn’t profit-driven.

  12. Maggie,
    I agree with you about MedPAC in every area except the one I know most about and one you did not include, home health care. MedPAC seems hell-bent on reducing the Medicare payment rate to home care and will not consider, will not listen, to the industry’s case that such cuts will raise Medicare’s overall costs. Save a dollar in the home care budget and you have to add ten or more to hospital and long-term care expenditures. I would like to believe you that the members are so smart but, in this instance, their recommendations seem oddly biased toward defeating their stated goals.

  13. Tim–
    A good point. I know that the 2009 MedPac report advises cutting fees for
    home health care.
    I was suprised. Home health care is far more eocnomical than having people in hospitals & nursing homes. And most people would rather be at home.
    I know someone who works in home health care, and she , like most of her colleagues is not well paid. A great many home-health care workers are fairly recent Latino and other immigrants.
    But MedPac reports that profit margins for Health Health Care agencies are very high.
    I can believe this: they pay the home health care workers very low wages, and reap fat profits.
    Probably (I’m guessing) the home health care industry needs to be examined and cleaned up– just like the nursing home industry.
    As in the nursing home world, there are probably home health care agencies that are good. But I wouldn’t be surprised if they were in the minority.
    So many opportunities to exploit people–the patients, the workers. . .
    I do know that MedPac udersttands the advantage of home health care. But when they see such high profit margins . . They know that someone is profiteering.

  14. Maggie,
    As with most things, the devil is in the details. MedPAC ‘finds’ an average 16% profit margin in Medicare home care by examining selected types of agencies. Their studies exclude hospital-owned home care providers. Plus, the margins they publicize are averages. So, do they recommend the difficult-but-fair path of seeking out the agencies that pull the average up? No, they take the easy road and slash pay rates for all, including those struggling for survival at 1%-3% profit margins. Smart, the MedPAC members are; but don’t paint them as being more noble than they deserve. In the end, if they get their way with home care cuts, Medicare goes bellyup sooner, not later. If they were to take the opposite tactic and increase pay to agencies that invest in technology and become more efficient, patients would be discharged from those expensive, germy, dangerous hospitals in much larger numbers and Medicare would be swimming in cash.

  15. “So many opportunities to exploit people–the patients, the workers”
    Aside from Medicare patients who are discharged from a hospital to a nursing home or rehab center, long term care and home health care generally do not need a doctor’s order to access services. There are ample opportunities for outright fraud, provision of inappropriate services, and demands for services from patients and families who may be able get along without them. In a similar vein, following one of my hospital stays in a NYC Academic Medical Center, my roommate, who was on Medicaid and was being discharged at about the same time as I was, requested an ambulette service to take him home to Queens. The discharge nurse had to tell him that he was not eligible for one because he was ambulatory. When someone else is paying, patients and their families are not shy about demanding services and providers are all too happy to oblige for a price that includes a hefty profit margin.
    I think it’s much easier to identify doctors and hospitals that drive excess utilization of healthcare services than to distinguish between appropriate and inappropriate nursing home care and home healthcare services on a timely basis. I’ve said before that this could be addressed, at least in part, by paying PCP’s enough to properly supervise care, at least in nursing homes.

  16. Barry Carol,
    I’m not sure what your level of familiarity is with home care regulations but Medicare-certified home care agencies can’t even apply a Band-Aid without a doctor’s order. You might be confusing them with Patient Pay home nursing services or non-medical homemaker services companies. But without that physician signature and reams of paperwork, Medicare does not pay a dime for skilled nursing care, physical therapy, occupational therapy, speech therapy or Medical Social Worker services. Then, up to two years later, they send in their commission-based auditors who look for excuses to take huge chunks of the money back.

  17. Tim,
    I understand that a doctor’s order is required for physical, occupational and speech therapy, either in the patient’s own home, nursing home or rehab center. I know from personal experience with nursing homes that patients are often subjected to more therapy than is appropriate for them or likely to benefit them because it helps to drive revenue for the nursing home. I think similar issues could be at work with home health. It is not precisely determinable just how much therapy is appropriate in each individual circumstance, so it’s easy to recommend more rather than less therapy as long as the payer will pay and a subsequent audit, if any, will find that the treatment fell within a broadly defined zone of reasonableness.
    I know that Medicare does not pay for custodial care but Medicaid does if the patient satisfies the program’s income and asset eligibility criteria. In home care intended to help the patient with ADL limitations is prone to considerable abuse. Several years ago, the NY Times, in a three part series of articles, documented widespread fraud and abuse in the NY Medicaid program which is, by far, the most expensive in the country even though NY is not the most populous state. This is another good reason to track utilization of healthcare and related services, both annually and cumulatively, at the individual patient level whether it’s Medicare, Medicaid, the VA or private insurers who are paying the bills.

  18. Barry–
    You write: “In a similar vein, following one of my hospital stays in a NYC Academic Medical Center, my roommate, who was on Medicaid and was being discharged at about the same time as I was, requested an ambulette service to take him home to Queens. The discharge nurse had to tell him that he was not eligible for one because he was ambulatory.”
    I realize that this happened to be the one case where you saw a patient asking for (“demading”) and ambulette that probably wasn’t necessary.
    But the fact that it was a Mediciad patient reinforces the false notion that overspending on heathcare is driven, by a significant degree, by
    “demanding” poor people on Mediciad.
    As your story illustrates, the Medicaid patient didn’t get the ambulette.
    If he had been an upper-middle-class person on a good (expensive) employer-based insurance plan, there is a very good chance, that, by calling the insurers’ customer service number he could have gotten the ambulette plan.
    And, of course, the insurer would have passed along the extra cost of that ambulette (and many others) to all of its cutomers in the form of higher prmemiusm.
    The poor are not driving health care inflation. Indeed, as many doctors told me when I interviewd them for the book, poor people are surprisingly passive; they rarely “demand”‘ they accept watiing in long lines, not getting appointments, giving up after 10 hours in an ER without being seen.. .
    As one source put it: “Ronald Reagan made us all look down upon the poor lies about “welfare queens, etc.] –and Regan even made the poo look down on themseleves for being poor– even though their only crime was to be born into a poor family.