Medicaid expansion must remain safe in healthcare reform

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Lori Rousche, MDThe repeal and replace of The Affordable Care Act, or Obamacare, has failed. The current White House’s push to rewrite healthcare is on hold. As per our president, he is waiting for Obamacare to explode, and then maybe change will happen. Obamacare certainly has its flaws. Premiums are increasing at an untenable pace and several million United States citizens remain uncovered.

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 Although I am no great fan, there is a very favorable element of the ACA that I would be loath to see disappear. That is the program’s expansion of Medicaid. Medicaid is a joint federal and state program that covers millions of low income Americans, including families and children, pregnant women, many nursing home residents and some people with disabilities. If the Medicaid expansion was repealed and federal spending on Medicaid was decreased as planned, many patients who are currently covered would lose that coverage. That leaves some of our most needy patients in a potential healthcare crisis.

Let’s consider Mr. K.’s situation: He is the stereotype of the vulnerable elderly. This is a 94-year-old widower who lives with his cat. He has multiple medical problems including heart disease, heart failure, hypertension and venous stasis. His biggest issue, however, is mobility.

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Due to spinal stenosis, he has an extremely difficult time ambulating. At some point in the near future, he will be forced to leave his home and reside in a nursing facility. Mr. K. should have been in an assisted living community years ago, truth be told. He reports he just doesn’t have the money for admission anywhere, especially somewhere that would allow him to keep his cat. Because property taxes in our part of Pennsylvania are so high, he has had to take a loan out just to cover the taxes for the last three years. His income is fixed, with just his social security money available.  

Next: This is a patient who definitely needs Medicaid

Mr. K. is mentally savvy and understands the perils of his situation. He cannot clean his house or cook because of his medical conditions. There is no railing to his second floor and he can’t make it up the steps without it, so he doesn’t use the second floor anymore. He cannot safely get in or out of a shower, so he just washes up at the sink. He is unable to pick up after himself or afford a housekeeper. There are newspapers and magazines and books all over his rancher, many on the floor as potential tripping hazards. If he drops anything, it is dangerous for him to pick it up, because of his leg weakness and balance disorder.

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Navigating a walker through his living room could be perilous. His floors are an obstacle course. Mr. K. has been hospitalized three times in the last seven months. The first one with a compression fracture of L2, from a fall. He had pneumonia at the time. His pain was too severe for him to walk, so he spent two months in a nursing home. He was discharged home only to fall again shortly thereafter and suffer rhabdomyolysis and dehydration after lying on the floor for two days because he couldn’t get up.

After that admission, he was again discharged home with the plan that his two sons would check on him every Tuesday, Thursday and Sunday, and also do his shopping. Unfortunately, there are a lot of hours between those days, and he was recently bitten by a feral cat (he encourages the cat to come around by leaving food in his garage). By the time his son came, Mr. K.’s arm was three times its normal size, and he was just admitted again with cellulitis.

He refuses visiting nurses or home care companions mainly because he is concerned they will see the condition of his house and make him leave. He cannot afford a ‘life alert’ button. He would rather use that money to feed the cats.

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This is a patient who definitely needs nursing home placement. The ideal situation would be an assisted living that would accept Mr. K. and his cat. In our area, that is only available if you have a significant amount of money in the bank and can afford a hefty monthly fee. I doubt Mr. K. will make it to his death without permanent placement in a nursing facility.

Next: This dear man will need Medicaid! 

If, however, Medicaid is not available and doesn’t cover his nursing home admission as was proposed with the new and improved Affordable Health Act, Mr. K. won’t be able to stay in the necessary environment. He will follow a pattern known to most physicians of repeated admissions with a bounce back to his home (which, by the way, is not worth much money because of the patient’s inability to provide upkeep over the last many years, so can’t be used as a down payment for nursing home care) where he will ultimately fall again and end up in the hospital.

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At some point, life in his home will just become too dangerous and difficult. If there is no Medicaid available for the patient, he has nowhere to go. Neither son is capable for various reasons of taking him into their homes. There is not enough money for 24/7 aides or visiting nurses, even if Mr. K. would allow it.

This dear man will need Medicaid! For now, it seems as though it will be available at least for the limited future. The current battle over Obamacare’s overhaul is on the back burner. Let’s hope if it comes back into the political realm for reevaluation that the replacement or changes include a humane proposal that includes ongoing Medicaid for our most vulnerable patients. I don’t think there is a doctor anywhere, republican, democrat, or independent, that would disagree with that.