the Medicaid expansion gap



Last week, Pennsylvania Governor Tom Corbett announced that the state had worked out an alternative Medicaid expansion plan with the federal government, bringing 500,000 low-income Pennsylvanians to the Medicaid rolls.

According to numbers from the Kaiser Family Foundation, about 281,000 of those people were falling into what’s known as the “coverage gap.” All state Medicaid programs generally cover some low-income adult populations with certain stipulations – for example, those with disabilities or single mothers.  Under the original terms of the Affordable Care Act, states would “expand Medicaid eligibility” to all low-income adults earning up to 133% of the federal poverty level (roughly $15,500).   In the wake of the Supreme Court’s ruling on the ACA, states no longer were obligated to expand Medicaid eligibility.  These people fall in the gap, they don’t qualify for a non-expanded Medicaid but also don’t get subsidies for purchasing insurance on their own since they don’t make more than the federal poverty level either. According to the Kaiser Family Foundation, about 4.5 million people across the country fall into this coverage gap.

Currently, 23 states aren’t expanding Medicaid – but there are rumblings that a few more may follow in Pennsylvania’s footsteps.

Medicaid coverage gap

Sunshine State marriage equality


After a series of state district courts in Florida ruled that the state’s ban on same-sex marriage was unconstitutional, a federal District Court judge came to the same determination today.

U.S. District Judge Robert Hinkle ruled today that the Florida ban violates the “due process” and “equal protection” provisions in the U.S. Constitution.  The state’s ban was first put into law in 1977 and then written into the state’s constitution after a 2008 referendum.  Judge Hinkle’s ruling applies both to whether same-sex couples can marry in Florida as well as whether their marriages elsewhere should be recognized in the Sunshine State.

In his ruling, Hinkle writes,

The founders of this nation said in the preamble to the United States Constitution that a goal was to secure the blessings of liberty to themselves and their posterity. Liberty has come more slowly for some than for others. It was 1967, nearly two centuries after the Constitution was adopted, before the Supreme Court struck down state laws prohibiting interracial marriage, thus protecting the liberty of individuals whose chosen life partner was of a different race. Now, nearly 50 years later, the arguments supporting the ban on interracial marriage seem an obvious pretext for racism; it must be hard for those who were not then of age to understand just how sincerely those views were held. When observers look back 50 years from now, the arguments supporting Florida’s ban on same-sex marriage, though just as sincerely held, will again seem an obvious pretext for discrimination. Observers who are not now of age will wonder just how those views could have been held.

He also writes, “The Florida provisions that prohibit the recognition of same-sex marriages lawfully entered elsewhere, like the federal provision, are unconstitutional. So is the Florida ban on entering same-sex marriages.”

Hinkle’s immediately stayed his ruling pending a likely appeal.

the changing landscape of LGBT rights


In case you’ve become confusing with the dizzying number of court cases regarding same-sex marriage, and you’re looking for a place to find all the info in one spot – look no further.  A few months ago, The Guardian published an awesome infographic about LGBT rights in the United States – state by state.  Below is the main infographic, but check out the website where they break each of the right down and cluster them into areas of the country.  It’s pretty amazing that for how much progress has been made, some areas – namely the Southeast – still have a lot of work to do.

LGBT rights state by state



Let’s say you live in New Jersey and find a better insurance plan across the river in New York.  Sorry.  You’re out of luck.  But don’t worry, you’re told.  Your state insurance regulators are doing their job, upholding standards and protecting your interests.  Naturally, they can’t protect you in another state.  So you pay more.

This makes little sense.  You regularly cross the Hudson River for dinner on the town – and entrust your health to New York restaurant regulators.  You drive through a tunnel and count on highway safety as regulated by New York’s Department of Motor Vehicles.  But out-of-staters cannot buy insurance there.  Ask yourself this: Who are those law protecting?

Jonathan Bush doesn’t directly say it, but clearly these laws are protecting insurance companies…

A tale of two medicines



I’m currently reading Jonathan Bush’s new book Where Does It Hurt? and it definitely got me thinking about a lot of issues in health care.  More on that to come for sure, but in the meantime a little story.

A few weeks ago, a good friend of mine had an allergic reaction to something he ate.  He broke out in hives, and his face became swollen.  Out of concern for his health, he visited the Emergency Department at a local community hospital.  His story continues from here and highlights the failings of our health care system and questions why our system can’t and won’t perform better.

My friend spent four hours in the Emergency Department before he finally gave up and left.  In the intervening four hours, he had to recount his full health history, his religious affiliation and his emergency contact information multiple times. (Anyone reading this is probably not surprised – having to recount your story multiple times is pretty much a standard when visiting a hospital.)  An EKG was performed, he never actually saw a physician and the nurse assigned to take care of him was minimally present.  He left without a prescription for prednisone.

After leaving the Emergency Department, he texted me in desperation asking for a prescription for prednisone.  As a general rule, I don’t like writing random prescriptions for people who’s medical history I don’t actually know.  My friend was desperate though because it was Sunday.  His physician’s office was closed, the on call physician refused to help (a problem all in its own), and the local community health center was also closed.  I finally convinced him to come to the Emergency Department at my hospital after promising to call down to the ED so his wait would be shorter and checking to see how busy things in the ED were.  I’m thankful he had a good experience – though I imagine part of that was because I told colleagues in the ED that he would be showing up – but why should it be so hard?  Why couldn’t the system take care of a non-life threatening medical problem on a weekend without requiring a trip to the Emergency Department?

Every aspect of my friend’s story illustrates yet another failing of the health care system.  There are so many things wrong that it’s almost hard to know where to start.  For example, the community hospital didn’t have access to my friend’s health records – something that likely would have decreased the number of questions he was asked in the Emergency Department.  But the hospital and his primary care doctor do not share an electronic medical record, barring the hospital access to the most important information in his health history.  The simple solution is a nationwide electronic medical record, so that any physician anywhere could access your health information when needed.  More to come on that too.

The greater failing is that my friend couldn’t access health care outside of an Emergency Department on a weekend.  But how many of us have had a non-life threatening medical event occur “after hours” and had to go to the Emergency Department to get care?  You’re more likely to find a plumber or electrician available in the wee hours of the night than a physician.  Health problems occur 24/7, so why has our system, and the American people, become comfortable with a medical profession that doesn’t provide 24 hour outpatient comprehensive care?  When did we let the Emergency Department become the default?

In days long since gone, physicians saw their patients in their homes.  Time, cost, and reimbursement concerns moved the physician visit out of the home and into a centralized office, and in the process physician hours changed.  There has been some movement to change that; for medical practices to be certified as a Patient Centered Medical Home, “extended hour” appointments with “medical professionals” out of the normal work day are required – a regulation brought about by the Affordable Care Act.  But that’s hardly enough incentive (and truthfully, being fully patient centered would mean going back into the home).  Jonathan Bush comments in his book on the need for business outsiders to enter into the health care industry in order to change the status quo, create competition, and hopefully lower prices.  These outsiders will begin by focusing on the medical system’s inefficiencies and finding ways to profit.  Enter the pharmacy based clinic.

Pharmacy based clinics only came about because some smart entrepreneur or thinker at CVS and Walgreens saw an opportunity to profit off of the medical system’s inadequacies.  They realized that people get sick all hours of the day, not just from 8am to 5pm, and that you can’t plan on getting sick and making an appointment.  They realized that people would love having a convenient located option to get a flu shot or check for strep throat that didn’t require a doctor’s appointment, wait time, and price tag.  People with chronic illnesses could easily stop at a “Minute Clinic” to have their blood pressure checked or their diabetes meds altered.  After all – the pharmacy is five feet away.  And CVS and Walgreens had the resources to overcome the health care system’s intense regulatory environment.  Physicians initially derided these clinics as money-making opportunities headed by nurse practitioners and physician assistants with less training than physicians (with the undertone being worse quality), but we should take note.  These clinics were born out of our failure as a profession to offer convenient, comprehensive service to the public.

If you argue that health care needs to change in slow incremental changes, then it’s only a matter of time before some other corporation keys into another growth opportunity in health care – and one that could have much wider reverberations and affect far more than just the physician’s office.  If there’s any good news, it’s that the outsiders are slowly revolutionizing medicine, chipping away at the Berlin Wall that the status quo has for so long help up in their way.  One day they will succeed in turning the industry upside down, and health care as we know it will be forever changed.

The Case For Ina Garten’s World Domination (How Easy Is That!)



I love food, and Ina Garten’s is some delicious stuff. But if only she wasn’t so pretentious

Originally posted on Thought Catalog:

Political views aside, I think we can all agree that Ina Garten (also known as The Barefoot Contessa) is the Martin Luther King, Jr. of our generation. A plethora of cookbooks and an award-winning television series on the Food Network, this East Hamptonite has managed to draw in millions of fans and single-handedly fuel the recovery of our economy.

How does one achieve such success? Here are 10 reasons for Ina’s rise to complete world domination as conveyed through her show, The Barefoot Contessa:

1. For Ina, everything is easy as shit to make.

One of Ina’s copyrighted catchphrases (more on that later) is, “How easy is that!” It doesn’t matter if she is explaining how to pump gas or grow one’s own grapes in a backyard vineyard to make a peppery, full-bodied Malbec over the course of 5-10 years. It’s. All. So. Fucking. Easy. For…

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