While there are many facets to this fascinating and important debate, the main sticking point has to do with how the Federal and State governments share the cost of Medicaid. This is the latest challenge of the Federalism that has made "e pluribus unum" the crucible of our democracy since 1776. As we approach the Fourth of July and reflect on the heated states-rights arguments that echoed in the dusty chambers of Independence Hall in Philadelphia, let us not forget "...that all men and women are created equal, that they are endowed by their Creator with certain unalienable Rights, and that among these are Life, Liberty, and the pursuit of Happiness." Because healthcare is integral to Life, Liberty and the pursuit of Happiness, the current debate tests our commitment to the principles enshrined in our hallowed Declaration of Independence.

By way of background, Medicare and Medicaid were signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicaid provides health coverage to over 72.5 million Americans (one in five) making it the single largest source of health coverage in the United States. In terms of dollars spent, Medicaid spending in 2015 was $545 billion as compared to $646 billion spent by Medicare and $1,072 billion spent by private insurance companies. Whereas Medicare is funded entirely by the Federal Government and beneficiaries with no contributions from the states, Medicaid is jointly funded by the Federal and State governments. According to the medicaid.gov website, "the Federal Government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). FMAP varies by state based on per capita income and the amount funded by the state."  The minimum FMAP is 50%. According to the Kaiser Family Foundation, the Federal Government paid 60.6% of New Jersey's Medicaid spending in 2016. Good deal, eh?

Not necessarily!  According to the Kaiser Foundation , "Medicaid is the second largest line item in state capital budgets following elementary and secondary education."  For example, in 2012 total Medicaid spending in New Jersey was about $10.3 billion or $9,400 per enrollee.  If you do the math ($10.3 billion x .394), this means New Jerseyans contribute about $4 billion to Medicaid spending, or just over 10% of state annual spending. 

Then came Medicaid Expansion  in 2014, the provision of Obamacare  that by far has done the most to reduce the ranks of the uninsured, especially in New Jersey.  According to the Kaiser Family Foundation , 552,400 New Jerseyans have been added to the Medicaid roles, approximately one-third of current total state Medicaid enrollment. Persons and families with income up to 133% of the federal poverty line qualified for coverage, including able-bodied, mostly working, adults without dependent children.  Patients who relied on free clinics and emergency rooms suddenly had a doctor to call their own. My practice has participated in the enfranchisement of new Medicaid beneficiaries.

Whereas the Federal Government paid 60% of "Traditional Medicaid," it funded all of the expansion. Governor Christie, a Republican, surprisingly agreed to expand NJ Medicaid.  He correctly saw the infusion of federal dollars as an economic boon to our cash-strapped state.  Even so, nineteen states refused to join the expansion.  Why? Because they saw the expansion as a classical "bait and switch" ploy on the part of the Federal Government to lure states into larger Medicaid budgets as the federal subsidy receded.  In their defense, the Federal Government's share of the Medicaid expansion declines to 95% this year and to 90% by 2020. Though still a good deal for the states, coming up with even 10% of the total spend is a challenge for some states with balanced budget provisions.

Let me dispel the notion that Medicaid coverage is "Cadillac Care." Nothing could be further from the truth.  While beneficiaries pay little or nothing, the payment schedule for providers is so parsimonious that most providers have dropped out of the Medicaid network. The physician participation rate in New Jersey is the lowest in the nation.  While I have kept my large panel of Medicaid patients, I have been forced to turn away new Medicaid patients to stay afloat.  As fewer and fewer doctors accept Medicaid, the system is in dire risk of implosion.  If the Federal Government reduces its investment, as currently proposed, Medicaid as we currently know it will become non-sustainable. 

I believe a strong case can be made for continuation of the shared federal-state Medicaid funding model. Most of my Medicaid patients are working and raising families and need the coverage to stay healthy, minimize sick leave, and increase their productivity.  More than 200,000 New Jersey seniors on Medicare also receive Medicaid. Most of them are nursing home residents.  This allows their families to keep their jobs rather than become stay-at-home caregivers.  Medicaid dollars, as acknowledged by our governor, also represent an economic stimulus to our state.  For all these reasons, it is crucial that we reach a bipartisan consensus on the level of Medicaid spending and a balanced funding formula.  In our federal system, states should have the right to tailor their Medicaid programs to suit their own priorities, especially if their citizens are footing a large share of the bill. There is already considerable heterogeneity among the states. Allowing the states to redesign their Medicaid programs creates best practices while giving electorates the opportunity to fund those insurances that most benefit their communities. 

Repurposed Medicines for Weight Loss

Cardiovascular and Renal Benefits of SGLT2 Inhibitors in Type 2 Diabetes

Patient Portal Please!!

To encourage you to try the  Follow My Health Patient Portal, we decided to offer an incentive. Everyone that communicates with me during the month via email on our secure portal will be placed into a drawing for a $50 AMEX gift certificate. One lucky patient will win the gift certificate each month. I hope this will encourage you to give the Patient Portal a try. Not only will you save time when you need to make an appointment, request a prescription refill, ask me a question, or review your lab results, but you can enjoy dinner on me!

As discussed in previous newsletters, the patient portal is one of the most efficient ways to keep in touch with us and manage your health care. The portal gives you access to your personal health information (PHI), including LabCorp results, and it also allows you to communicate with me using encrypted, HIPAA compliant, email. You will get faster answers and notifications of your lab results. 

If you do not already have a portal account, kindly ask Valerie to send you an invitation today!!!

Now Hear This!

My wife and I will be celebrating our 39 th wedding anniversary this weekend!! I remember that glorious day like it was yesterday! The temperature in Our Lady of Nebraska Chapel in Omaha was 107 degrees, 115 degrees in the choir loft! And I was late! But we were too happy to care and still are!

Valerie, Morgan, Ms. Clark and I wish our patients and their families a wonderful Fourth of July!!