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Director’s Letter to the Virginia Senate, 3 January 2018

  • Senator Thomas K. Norment, Jr.
    Senator Emmett W. Hanger, Jr.
    P.O. Box 396
    Pocahontas Building
    Richmond, Virginia 23218
    Subject: Comments on the Governor’s Proposed 2018-2020 Biennial State Budget
    Dear Senator Norment and Senator Hanger,
    Virginians for Quality Healthcare has long opposed Medicaid Expansion under the Affordable Care Act, believing that it is wrong for Virginia. As can be seen from states that did expand Medicaid, spending on this program has grown exponentially, exceeding all estimates and busting open state budgets while adding irresponsibly to the national debt and failing to improve health outcomes for those enrolled. Congress may finally take up welfare reform in 2018, recognizing that Medicaid is unsustainable and inefficient.Virginia would be wise to avoid entrapment in Medicaid Expansion, which amounts to a costly middle-class welfare program, no
    longer a safety net for the most vulnerable individuals. We firmly reject its inclusion in the Governor’s proposed biennial budget,1 and we urge the General Assembly to consider other approaches that are sustainable and that also restore the autonomy of doctors, preserve the sanctity of the patient-physician relationship, and protect patient privacy, while delivering quality care at lower costs.
    We and others who are working to restore health freedom have offered ideas which deserve your serious considerationVirginia should join the growing movement in health care innovation to adopt health care models that do not involve a third party, i.e. where government-insurer control is replaced by patient-doctor autonomy.
      • Physicians abhor the growth of government interference in their profession.                 Administrators are dramatically outnumbering physicians nowadays. Increasingly                           politicians and  bureaucrats exert more control over doctors’ medical practice.”2
     • Legislators should also swiftly repeal antiquated Certificate of Public Need (COPN) laws which artificially restrict competition and also prevent expansion of Virginia’s capacity for health services. Those who complain about lack of care in underserved areas of the state should demand repeal of COPN. It is past time for Virginia to follow the lead of other states that have repealed COPN.
         •“For nearly 40 years, Virginia’s COPN laws have stifled innovation, limited competition,                  unnecessarily raised costs, and limited access to quality healthcare.”3
         •Virginia can foster market-based competition by repealing COPN laws, thereby lowering                 health care costs and improving access to healthcare especially in underserved areas of                   Virginia.
    The General Assembly should carefully study the experiences of states that chose Medicaid Expansion, and not subject Virginians to the same destiny of those states. Government estimates of virtually every aspect of the Affordable Care Act have been wildly unreliable and erroneous, especially concerning Medicaid Expansion. Enrollment and cost projections were severely underestimated, and many expansion states’ budgets are in crisis as a result. What if Virginia’s estimate of 300,000 new Medicaid enrollees turns out to be wrong by as much as 100%?
    Legislators should also examine data on health outcomes for Medicaid beneficiaries. “There is evidence that even uninsured patients, who have the freedom to seek care privately, have better outcomes than Medicaid patients…It is increasingly
    imperative that physicians be free to treat Medicaid patients privately on a case-by-case basis, and that patients be free to pay physicians on a case-by-case basis for both primary and specialty/subspecialty care… Possessing a Medicaid card does not guarantee timely access to medical care rendered by a physician or surgeon. Many doctors do not take Medicaid or have
    stopped seeing new Medicaid patients.”4
    Medicaid is the antithesis of health freedom. “According to CMS 2015 statistics, federal, state and local government sponsored “healthcare” accounts for 46% of all health care spending. …These programs are not sustainable, and they come with such a terrible price to pay: the loss of physician autonomy, efficiency, and innovation…Three proven solutions in operation by
    [physicians] are direct primary care models, third-party-free specialty clinics, and a private cash-based surgical center. Cash, catastrophic insurance, and true charity save money for patients and the states.”5
    _______ @VaQualHC
    Medicaid Expansion promotes dependency. “It is increasingly difficult to extricate a dependent people from government benefits.”6 The goal of public health programs should be to end dependency, by promoting individual responsibility and accountability. Several states have successfully imposed work requirements and health milestones, and some impose lifetime
    caps on Medicaid benefits. Such measures help individuals become healthier and self-reliant.
    Medicaid Expansion would be unjust for Virginians enrolled in traditional Medicaid. “The ACA Medicaid Expansion”7 payment rate is inequitable…[and] makes little policy sense…the federal government [covers] 100% of costs for childless adults above the poverty line, but only 57% for children in poverty.” Expanding Medicaid in Virginia will immediately exacerbate this inequity and imperil those who truly need public assistance.
    Medicaid expands social and economic inequality. “Medicaid’s constant inexorable growth in state budgets has left less money for education of all types — not least higher education.”8 As a result many public colleges and universities, including Virginia’s, have shifted their financial strategy toward attracting out-of-state students who pay higher tuition than in-state students pay. Fewer admissions are offered to Virginia residents, putting children from working-class Virginia families, in particular, at a great disadvantage. Do we really want to limit opportunities for a quality education (and getting good jobs after graduation) for these Virginia students?
         •In Virginia, Medicaid’s share of the state budget has grown from 6% in FY 1985 to 23% in FY        2018, whereas Education’s share has declined from 55% to 40% over that same period. Of              that share, Higher Education decreased from 19% to 10%. QED.”9
    What is Virginia’s capacity to absorb 300,000 new enrollees? Where would these Virginians get medical care? Will they compete with the traditional Medicaid population for health care? Are there enough physicians in Virginia who accept Medicaid patients? Where are these individuals located, and would they have access to facilities where they live? Are new facilities needed? What kind of wait times will these new enrollees encounter to receive care?
    It would be illogical to expand a program that wastes taxpayers’ money. Medicaid should be reformed, not expanded. As taxpayers we are interested in a forensic accounting of Medicaid in Virginia. How much money goes to actual medical care for the patient vs. administrative overhead? How much is transferred to other state agencies? We applaud the General Assembly’s past work in commissioning the Joint Legislative Audit and Review Commission to audit Medicaid. Much more needs to be done — swiftly — to find and stop fraud, waste, and abuse .”10
    Common sense Medicaid goals, suggested by physicians and surgeons, would be:
         •to drastically reduce or eliminate red tape
         •let the patient learn to be responsible and to manage Medicaid Health Savings Accounts                (HSAs)
         •expand HSA coverage to out-of-network physicians care
         •improve the options for consultations, diagnostics, and therapeutics.”11
    Fundamentally, we oppose Medicaid Expansion and its parent legislation, the ACA, because we believe individuals — not governments —are the rightful owners of healthcare decisions. We believe also that States, not the federal government, should regulate health insurance for their citizens. (The regulations imposed by the ACA are widely acknowledged as the principal reason
    for the high and ever-rising costs of health insurance.) A free market health sector that promotes choice and competition is absolutely necessary to secure affordable, quality health care.
    Medicaid Expansion may be the “easy” choice for some, but it is not the right choice for Virginia, for reasons explained above. We urge the General Assembly to reject Medicaid Expansion outright, and we would welcome an opportunity to meet with you for further discussion on policies that are better for Virginia.
    Nancy J. Piotter
    Executive Director
    Virginians for Quality Healthcare
    P.O. Box 223472
    Chantilly, VA 20153
    Twitter: @VaQualHC
    1 The target population of Medicaid Expansion is the lower-income middle class: able bodied working age adults earning up to 138% of the federal poverty level.
    2 Michael J.A. Robb, M.D., “Don’t Tread on Us” Association of American Physicians and Surgeons. 214 Dec. 2017.
    3“Virginia Legislature Poised to Take On COPN in 2017” 17 Aug. 2017.
    4 Robb reports that Medicaid’s General Counsel, in July 2017, agreed that Medicaid patients can pay privately for medical andsurgical services offered by a non-enrolled, non-contracted doctor. The Association of American Physicians and Surgeons is developing a prototype doctor-patient agreement for such option.
    5 Robb, among numerous other sources not cited here.
    6 Robb.
    7 Charles Blahous, “Why the ACA Medicaid Expansion Needs To Be Fixed” originally published by the Mercatus Center at George Mason University, 13 March 2017. Republished in “Handbook for Healthcare Reform” December 2017.
    8 Christopher Jacobs, “How Medicaid Expands Social and Economic Inequality” 10 Nov.2017. medicaid-expands-social-economic-inequality/
    “9 Trends in Virginia Medicaid and Opportunities to Shift the Cost Curve.” Senate Finance Committee presentation, 17 Nov. 2017.
    10 See, for example, audit results in “Arizona Health Care Cost Containment System”
    11 Robb

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