"That means no matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period. If you like your healthcare plan, you'll be able to keep your healthcare plan, period. No one will take it away, no matter what." – Barack Hussein Obama, June 15, 2009.

Promises, Promises. As Americans now know, the promises regarding the Democratically passed and shoved in our faces health care law, known as Obamacare, have turned out to be totally false as evidenced by millions of individuals losing their health care plans they liked and could afford, along with many unable to continue to see their trusted physicians due to a limitation in choice of health care plans. This has been the main focus with many Americans and those who provide information on Obamacare.

However, what has been overlooked is the key central piece of this debacle health care plan – Medicaid expansion in the states that would allow more individuals with low income or uninsured low income individuals to be able to participate in the partially federally funded program. The premise of the expansion of the Medicaid program centered on not only bringing more individual under the umbrella of this program but to improve the medical care of those who were underinsured or uninsured. But, does inclusion into the Medicaid program actually bring about better healthcare outcomes?

According to an article at the Daily Caller by Jason Fodeman, MD, a study published in the JAMA Surgery questions whether the expansion of the states' Medicaid programs actually improved health care outcomes after studying non-elderly adults for one year in the State of Michigan, who had inpatient surgery at 52 hospitals. The surgical outcomes were viewed from an insurance status view. To many, the results are surprising; however, anyone who has been on the inside working with Medicaid, it comes as no surprise whatsoever.

Despite the reality that Medicaid covered individuals tend to be younger, the study revealed that individuals covered by Medicaid suffered a higher percentage of postoperative complications, major complications and even higher mortality rates when compared to individuals who had private insurance. Another alarming factor discovered was that Medicaid covered individuals were "over twice as likely to die after surgery than patients with private insurance." It should be no surprise either that the study concluded that Medicaid covered individuals were more likely to be readmitted and have longer hospital stays. Other research studies conducted and published in peer review journals have reached similar conclusions.

While this addresses surgical patients covered under Medicaid, what about other conditions? A study conducted in 1993 on women who were diagnosed with breast cancer between the years 1985 to 1987 found that overall, the women covered by Medicaid or who were non-insured received their diagnosis later than those on private insurance meaning their cancer was at a more advanced state than private insurance patients. More alarming is the fact that these women with breast cancer covered by Medicaid suffered a death rate 40% higher than those on private insurance.

It is a known fact that Medicaid reimbursement rates for physicians and other services fall far short of private insurance and Medicare rates. Many physicians along with other service providers have refused to accept Medicaid reimbursement, period, or have limited their acceptance of new patients who have Medicaid coverage. This in and of itself can create a gap in access to health care despite having some form of insurance. If total honesty were to be applied in looking at the Medicaid reimbursement rates versus the provision of healthcare, one could say that some physicians who accept Medicaid may be doing just enough to cover their backside when providing care leaving chronic illnesses and diseases left undiagnosed until the symptoms are blatant.

Before readers take too harsh a view for this writer making this statement, think back when some HMO insurance companies were taken to task over keeping health care costs low by almost encouraging physicians not to find problems by paying physicians to provide fewer services.

Saying that Medicaid programs are deeply flawed is an understatement. Even though Medicaid is essentially a state program, the majority of funds for the program comes from the federal government – in essence making it a "federal health care program" with the federal agencies regulating its function through statutes and rules. This is the simplified explanation of how this healthcare reimbursement program works. In some services provided by Medicaid, it is the federal government that established reimbursement limits that cannot be exceeded by the states. Some reimbursements are set limits based on a percentage of Medicare reimbursement while others are based on formulas established for the states to use in determining reimbursement. Missing from this report of factors affecting health care outcomes of Medicaid covered individuals is the fact of the existence of cronyism, back door under the table deals that line pockets and favoritism that wastes taxpayer money which could be used to improve outcomes.

Not all state Medicaid programs are filled with cronyism, lining of the pockets and favoritism regarding the executive and legislative state branches; however, there are plenty that are which affect the health care received by Medicaid covered individuals. Some of these states are still steeped in the "the good ole boy" network whose members/associates tend to maintain the status quo, line their pockets through deals and legislation and place "colleagues/friend" in commissioner positions in charge of administering the Medicaid program. Add to the lack of qualified leadership/management the fraud and abuse inside and outside of the departments administering the program, then it becomes clear there are more issues than meets the eye when it comes to health care outcomes for Medicaid covered individuals.

In the State of Georgia, there occurred many instances of abuse. For example, under a program to care for disabled children in the home, the Georgia Medicaid program provided 24 hour a day care, seven days per week to an infant who was considered brain dead by medical doctors despite repeated notifications from nurses and physicians engaged in this infant's care. While the program reimbursed for the care of this infant, it denied another child care in the amount of a few hours a day, a few days per week because of a technicality determining eligibility – a technicality which could have been cleared easily should the powers at be at the state level chose to investigate.

One individual receiving Medicaid services was allowed to participate in two mutually exclusive programs (if you received services under one program, you could not receive services under another that provided duplicate services) because of a request made by a legislator and agency commissioner. This same individual covered under Medicaid, who was a disabled quadriplegic female, received a Medicaid reimbursed abortion after becoming pregnant while disabled. All at the behest of a legislator and commissioner on the request of the individual's father.

In another instance, a mother received a non-covered service for her Medicaid covered baby at the request of the commissioner of the agency at the time. The agency providing care for this mother's child even exaggerated incidences through falsifying records to justify continued care. And, a prominent judge procured excessive services for his Medicaid covered grand-child through pressure exerted on the state agency through the legislature. Many other instances of abuse were and are prevalent as far as provision of services; but, you get the idea. Of course, it doesn't help that one of the largest health care organizations in the State of Georgia, holding home health agencies, nursing home facilities, hospice agencies, and a myriad of other health care services, was owned by a state legislator at the time and more than likely continues to enjoy some inside legislative perks.

It is also reported that Georgia Medicaid had to cover Viagra, at one time, since someone considered it "a fertility drug."

Meanwhile, during this time, analysts and specialists were encouraged to find areas to reduce the cost of other Medicaid programs by limiting and/or denying services.

About twelve years ago, when the State of Georgia's contract with a fiscal agent (the entity responsible for paying out submitted claims for services) was nearing its end and another one needed to be chosen, the mandate came from the commissioner of the Medicaid agency at the time that the current fiscal agent could not receive the contract because of "past personal issues" that occurred between the commissioner and the administrator of the fiscal agent. Therefore, a new fiscal agent was awarded the contract – a procurement not based on a better system or service, but one based on a past romantic interest gone bad. This less than business decision ended up costing the state dearly.

When Georgia implemented its new claims payment system through the new contractor, it was three months later that the state Medicaid agency requested emergency funds from the legislature in order to pay claims since it went broke. The new system was nowhere near ready to implement as many analysts had warned the powers that be; however, the governor at the time along with the commissioner mandated the system to "go live." The result was many of the same claims being paid more than once, in some cases three times, some claims not being paid at all, and a claim being paid to a provider of services so large, the provider disappeared, unable to be found.

Not only did analysts warn about the state of readiness, analysts also warned the powers that be about the ability of the system to handle the entire business of the Georgia Medicaid program. Those warnings went unheeded. Many health care providers refused to take on new clients who were Medicaid covered individuals and limited services to existing Medicaid clients because of payment difficulties. An almost mass exodus of providers occurred resulting in health care gaps in the state.

Additionally, the Medicaid agency required this fiscal agent to provide some type of audit trails in order for certain elements to be tracked, keeping the fiscal agent honest and providing an accurate accounting of the operation of the system. Unfortunately, this never materialized. The fiscal agent, at that time, engaged in massive employee turn-over, undermined agency policies – administrative as well as fiscal – by engaging in subversive activities and in some instances, individuals at the fiscal agent could not even provide instruction on how some of the subsystems functioned that guided the overall payment system.

Because of the repeated claim system problem that resulting in enormous waste of tax dollars in not only paying for the system, but in attempting to fix an inadequate system and reduce inappropriate payments and non-payments and difficulty with the customer service provided by that fiscal agent, the Medicaid agency eventually resorted to filing a breach of contract action. The outcome from this was an "instruction" by the then sitting governor to "play nice with one another." Just for clarification, the tax dollars received to procure and implement this payment system was partially funded by the federal government. These are your federal tax dollars at work.

Of course, it was not unusual to see the board of directors of the Georgia Medicaid agency recommending their friends' companies or companies they had an interest it to receive contracts for services needed. One such service involved auditing. The cronies benefited much from the Medicaid agency that was to "improve the quality of care for all Georgians."

While many may think these stories of fancy or exaggeration, the sources providing this information worked at the Department at the time of these incidents, have documents backing the claims and the information is available through the Open Records Act. In addition, the governor of the State of Georgia along with a state representative were approached during this time regarding these issues. No investigation was ever forthcoming and the governor refused to meet with these individuals to discuss these issues – by refusal, no follow-up contact from the governor's office was made after these individuals spoke by phone with the office of the governor's representative. Not even the Georgia Bureau of Investigation cared enough to give more than the "we might have to look into this" lip service.

Even though Georgia did not choose to expand its Medicaid program because of Obamacare, the fact remains that Georgia has been riddled with problems involving cronyism, mismanagement and outright fraud that affects health care outcomes. This leads to questioning the Medicaid programs in other states, regarding fraud, abuse and mismanagement, especially the states who expanded their Medicaid program because of Obamacare. Health care outcomes for those on Medicaid were worse than private insurance before Obamacare. Does anyone actually think expanding state Medicaid programs under Obamacare will improve outcomes and actually provide individuals with quality health care coverage and services?

Any government sanctioned health care through reimbursement for services or provision of services, as seen already in Medicaid, Medicare, the Veteran's Administration and the Indian Health Services, is terribly lacking, not from the quality of people providing service but from an administrative standpoint, and worse than private insurance companies. The federal government has no place in health care according to the Constitution, and the Tenth Amendment states that powers not delegated to the federal government are reserved to the respective states or the people. However, the states do not belong in the health care insurance industry either as it evolves into just another form of governmental bureaucratic waste system.

Is it any wonder that health care outcomes are marginal in a state run program such as Medicaid?

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