Recently I saw a patient in my office for a workplace accident. I had seen him 3 weeks prior to that, and at that last visit I ordered an MRI scan.  The scan had to be pre-approved by insurance, but it was, and we scheduled the scan. On this most recent visit, I reviewed his chart, only to find that we had never received the MRI report. We contacted the facility that did the MRI and asked to have the report sent by fax, but by the time the exam was over there was still no report. I had to send the patient home with medication and a promise that we would call him when the MRI report came in and I had made a decision about what to do next.

An MRI costs about $1500. Now, I consider this price scandalous, considering that in most developed countries MRIs cost a fraction of that, but no matter. The main point is that a hospital charged an insurance company $1500 for a test and never bothered to send the results to the doctor who ordered it. For $1500 the test report should be printed in gold leaf and hand-delivered to my desk by a Persian eunich.

This kind of thing happens all the time. I doubt 50% of the tests I order with a dollar value above $500 appear on the patient's chart in 2 weeks. 

I don't have a degree in business, but I have worked long enough to see that every business has a Top Priority, something that they value more than anything else. Top Priority may be making good hamburgers, or picking up the garbage on time, or having every order fulfilled by close of business. In the case of medicine, Top Priority too often is getting paid. In this case, we had to make phone calls in advance to get this MRI pre-approved. No money, no test. The MRI center made certain the check was in the mail before the patient was in the machine, but as for delivering the report to the right person on time, well, they'll get to that later.

Lest anyone think I am scapegoating the MRI people entirely for this situation, I will say that I have been on the other end of it. I have provided services to a patient, expecting to be reimbursed, only to be later denied. It's not a good feeling, and it is the kind of thing you don't forget the next time you are in the same situation. No one likes being cheated.

So many medical organizations put "Pay Me First" at the top of their priority lists. The problem is that when you make something #1, it tends to take the shine off whatever is at #2. I see it often: Medical organizations that worry so much about getting paid  that quality of care starts to slip. It's not greed -- well, not greed entirely -- that drives this. Most medical practices consider themselves lucky if 70% of the services they bill for are eventually paid. When 30% of your bills go into the uncollectible file for one reason or another, you tend to focus on getting your money whenever you can.

That being said, I alight again on "there's no exuse." The object of medical treatment is good health, not getting paid, and it is distressing that many organizations in medicine don't see it that way. If there is any urgent reason for health reform in this country it is this: Everybody worries about money all the time, and it puts us all in bad humor, and bad habits, and bad medicine. 

Recently, WWL-TV, the CBS afffilate in New Orleans, ran a story about Carol Raines, a New Orleans resident who has been unable to obtain a surgery that would allow her to eat. According to the story, Ms. Raines and her husband were robbed at gunpoint in 1980. One of the robbers murdered her husband, and the other attempted to murder Raines with a gunshot to the jaw. She survived, but has suffered from medical problems ever since.

The man who shot her, Dwight Powell, is now in state prison. (His accomplice is still free, because Powell refused to give police his  name.)

Raines has, since the shooting, suffered from degenerative disease of the temporal mandibular joint, or TMJ, and over time the joint has deteriorated to the point where Raines can no longer open her mouth. Today she weighs 89 pounds and gets all her nourishment by drinking liquids through a straw. She needs joint replacements of both TMJs, but the artificial joints will cost $14,000, and her insurance will not pay for them.

The angle WWL chose for the story is that Powell, as an inmate of the prison system, would be eligible for the TMJ implants if he needed them, but Raines, the woman he tried to murder, cannot afford them. Although this angle adds to the sense of injustice of the story, I think WWL missed the more important point: Raines has health insurance. In fact, she has two plans, not one -- Medicare and United Healthcare -- and between the two neither will pick up the tab.

This is the real problem with health care in America. You may think you have health insurance, but you really only have the coverage your insurance company decides you can have. Few Americans, after all, really choose their health coverage. Most people take what their employers give them, or what Medicaid or Medicare offers. Very few people gets a choice -- in fact, the average auto insurance company allows buyers more coverage options than employers do. Carol Raines does not remember ever signing a document excluding TMJ replacements from coverage. But I promise you United and Medicare had no trouble finding the clause that allows them to do it.

The reason we don't have a decent health care system in this country is because about 70% of all Americans have either private insurance or Medicare, and sit fat and happy thinking they are covered. Certainly their insurance companies lead them to believe this is the case. The reality is that insurance serves most people well as long as the problems remain mundane, problems such as allergies, hypertension, or diabetes. When problems get complicated and expensive, the helping hands folks in the insurance business often do little more than help to hand their customers the bill.

A 2005 study by Harvard University showed that the average American who filed for bankruptcy that year had $12,000 in medical bills. Worse, 68% of these people had health insurance, and 50% of all filers cited health expenses as an important reason for their bankruptcy. The one thing insurance is supposed to do more than any other thing -- protect the client from the financial consequences of catastrophe -- is the one thing health insurance repeatedly fails to do.

 I have patients like Carol Raines, patients who have suffered severe financial setbacks from medical bills despite having all the coverage they could possibly get. You could be the next victim. It could be only a single blood test, or trip to the ER, or as in Raines's case, a terrible misfortune not of your own making, away.

That is the story the WWL news story missed. Until we, as a nation, realize that even those among us with "good" health insurance are terribly exposed, there will not be meaningful health care reform.

Yesterday I received a message at my office and was called to the bedside of health care reform. The patient's pupillary and gag reflexes were absent; there was no palpable pulse. Chest exam revealed no respiratory effort and absence of heart sounds. The patient was pronounced dead at the time of examination.

The cause of death? Reckless campaign promises, made by the two remaining Democratic candidates in the debate Wednesday night. This is how Walter Shapiro reported it in Salon:

Wednesday night's debate may have more lasting significance if either Obama or Clinton is elected president than it did in helping sort out the primary field. Pressed by [moderator George] Stephanopoulos to make a "read my lips" no-new-taxes-on-the-middle-class promise, both candidates took the bait. Clinton expressed this Republican-esque promise in unequivocal terms: "I am absolutely committed to not raising a single tax on middle-class Americans, people making less than $250,000 a year." Obama eagerly joined in this bidding war, saying, "I not only have pledged not to raise their taxes, I've been the first candidate in this race to specifically say I would cut their taxes."

Both of these candidates have been traveling coast to coast, promising sweeping health care reform. Now, I do not pretend to be a financial whiz, but I know enough about health care to say with confidence that it will be impossible to provide universal health care without raising taxes. Obama/Clinton may respond by saying that we will find the money to insure 47 million Americans by (1) ending the Iraq War, (2) making health care more efficient, and (3) allowing the Bush tax cuts on the rich to expire.

Hoooey. The Republicans have been foisting this something-for-nothing nonsense for decades now. It never works. Real, comprehensive health care reform will require tax increases on everyone. A mandate requiring every American to carry health insurance is, in itself, a tax. Clinton proposes mandates. Obama does not, but as soon as he looks at the budget numbers if he is elected president, he will change his mind. I don't think universal health coverage can be achieved without mandates, at a bare minimum.

At any rate, whichever health care reform is proposed, it is completely irresponsible for any candidate to promise that he or she can make it happen without broad-based tax increases. No other industrialized nation manages it without some kind of tax, be it direct (via income) or indirect (with mandates). It can't be done.

From my perpsectivie, health care reform is DOA on the Democratic side without taxation at least on the negotiating table. Let's assume Clinton is right and reform can be financed purely through savings from requiring everyone who can afford it to buy coverage. This is a big if. To put such reforms on the table without at least a backup plan for financing is ridiculous.

People who are serious about health care reform will admit it will be expensive and may require new taxes. People who won't are candy salesmen.

All this talk about who has the courage to answer the phone at 3 AM,and neither candidate has the guts to tell Americans universal health care is going to cost them money. Well, maybe we'll find someone serious about reform in 2012. 2008 is already history, as far as I am concerned.

Tax day seems like a perfect time to talk about another tax problem, one that threatens health care in the state of Mississippi. As America's poorest state, Mississippi enjoys the distinction of having a high percentage of citizens that qualify for Medicaid. Mississippi hospitals see a lot of Medicaid patients, with the largest burden falling on the state's 10 publicly-owned hospitals. At our local hospital, about 25% of hospital charges are billed to the Medicaid program.

And most of it is never paid. This is a serious problem.

Medicaid, as most readers know, is a federally funded program that provides health care for the poor. It is administered by the states, with federal matching funds. Each state gets matching funds based on its per-capta income, and the match ranges from 50% for relatively wealthy states like California and Connecticut to 80%, the highest in the nation, for Mississippi. What this means is that in Mississippi, for every dollar the state spends on Medicaid, the federal government gives 4.

In the past, states, being states (that is, always looking for a free ride on the federal government's credit card), employed a clever workaround for the matching dollar issue. Instead of raising taxes for Medicaid dollars, the states paid nothing and simply instructed hospitals to put up the money themselves. The accounting worked this way: A hospital seeking Medicaid money would put up its own money, and the feds would match it. In Mississippi, that meant if a hospital had $2 million in Medicaid charges, it would put up 20% of that, and the federal government would then pay the rest.

That changed in the late 1990s when Washington decided this dodge was not the intent of the law. Congress then passed regulations to gradually close this loophole, requiring states to actually raise revenues to pay their percentage of Medicaid. Which is where the trouble began.

Most states have scrounged around and come up with revenue plans to pay their percentages out of pocket. Some states have adopted hospital bed taxes, in which hospitals pay a percent of revenue earned by each hospital bed. Others have raised excise taxes, including cigarette or alcohol taxes. Arkansas levied a one cent tax on soft drinks.

Mississippi, as a very conservative and tax-adverse state, has so far done nothing, instead allowing hospitals that care for Medicaid populations to fall into insolvency largely over unpaid Medicaid charges. The state government is considering action, with all the urgency of a bunch of frat boys moving to complain that the kitchen sink is running hot and cold Budweiser.

Our dear Governor, Haley Barbour, favors the bed tax. Key members of the state legislature favor cigarette or alcohol taxes. Unfortunately, there is a standoff because neither side will support the other's proposal. Private hospitals are lobbying legislators against the bed tax, because they only see a small number of Medicaid patients (less than 5%) and would rather do without the Medicaid than pay a new tax. The governor is against the cigarette tax, probably for two reasons: (1) He made a fortune as a Washington lobbyist before becoming governor and doesn't want to burn old bridges by offending the tobacco industry; and (2) he is angling for a cabinet-level appointment should John McCain win the presidency in the fall and doesn't want a tax hike on his record. (For the record, the cigarette tax in Mississippi is 18 cents a pack.)

So while these two groups selfishly duke it out over Medicaid funding, hospitals that provide care to the poor suffer with unpaid Medicare bills. A few weeks ago, the public hospital in Natchez declared bankruptcy. Another hospital in the Mississippi Delta is considering defaulting on its bonds. A third, in Hattiesburg, declared a $32 million loss last year and instituted wage cuts and layoffs. That Hattiesburg hospital may also be looking at bankruptcy.

This is the human suffering political stubborness has wrought. The standoff between the Governor and the Legislature is like two groups of sailors on a sinking ship arguing whether they should use plastic or metal buckets to bail the water. They posture while several of the state's most important hospitals go down to the bottom.

The worst part is that, with the 80% match, a dollar raised for Medicaid results in a $4 bonanza for the state. If I could find an investment that yielded a 4 to 1 return, I would be hocking the hubcaps on my car for investment money. It is irresponsible that our representatives in Jackson would jeopardize one of the largest industries in the state for their own political gain.

And by the way, the standoff also hurts patients, and their access to quality medical care. But I forget myself. This is Mississippi. We don't give a damn about the poor.

As a Katrina-displaced New Orleans physician now practicing in Mississippi, I have yet to acquire a taste for our Mississippi governor, Haley Barbour. Maybe it is his political origins, first as a successful Washington lobbyist and later as chair of the Republican National Committee. Or his history of fundraising for the 2000 Bush campaign and consistent opposition to campaign finance reform. Since I arrived in Mississippi, I have watched as he hastily rewrote gambling regulations in 2005 so casinos on the Katrina-devastated Gulf Coast could relocate from gambling boats onto dry land. It always bothered me that one of Barbour's first post-Katina policy acts was to re-establish gambling, even as thousands remained homeless.

It also bothers me that, as Barbour brags about his effectiveness in bringing the Mississippi Coast back from Katrina, he continues to ignore the needs of the poor. As the casino income on the coast soared to a record $1 billion in 2007, Barbour dragged his feet in providing housing to hurricane victims. By November 2007, a full two years after Katrina, Barbour had spent a paltry $167 million of a $1.7 billion emergency federal housing block grant on storm victims living in poverty.

Yes, that's million, with an m. And this is in Mississippi, where, I can assure you, it is not hard to find poor people.

So, it should not have been surprising to hear Barbour utter these words in his State of the State speech on January 21, 2008, which ironically enough was Martin Luther King day:
 

In this past four years, we’ve made significant progress in saving Medicaid for the nearly 600,000 Mississippians who rely on it. We have enacted reforms because we know it is wrong for a family to work hard at two or three jobs, to raise their kids and pay for their healthcare, and then have to turn around and pay extra taxes so others who are able to work and take care of themselves choose not to but instead get free healthcare at taxpayers’ expense. That’s not right.

Under this Administration, the Division of Medicaid checks people’s eligibility face-to-face, and the Medicaid rolls have decreased to fewer than 600,000. This drop is what you should expect when the number of people employed has increased by more than 50,000.

On Martin Luther King Day, of all days, Barbour stoops to blaming the fiscal problems of the state on people "who are able to work and take care of themselves [but] choose not to."  The mythical welfare queen rises from the grave. To be fair, Barbour goes on to enumerate the fiscal challenges that Mississippi faces with Medicaid funding. There are many. But it is irresponsible to crow over how many people Mississippi has kicked off Medicaid, blaming the ejected for being lazy and gaming the system for free health care.

 
Barbour is right about one thing: He has very efficiently denied Mississippians healthcare. He has trimmed statewide Medicaid enrollment from 785,000 in 2004, to 540,000 by 2006. That loss of 245,000 enrollees far exceeds the modest 50,000 job increase Barbour boasts, which incidentally occurred over the much longer period of 2003-2007. By his own numbers, Barbour is publicly admitting he has stripped 195,000 citizens of health insurance, even given his assumption that every single job added to the state economy carries full health care benefits.

His myth of the Medicaid Queen is not even close to being true. In my medical career I have treated thousands of Medicaid patients, and I have yet to meet one who chose to sit at home to collect those fabulous Medicaid benefits. Not that Medicaid is all that great an insurance anyway, but it, like almost every insurance, makes all its payments directly to doctors and hospitals. Not a dime of Medicaid money is ever paid directly to a patient.

Medicaid money goes into my pocket, my nurse's pocket, my office manager's pocket. It pays the salaries of the cooks and maintenance people at the hospital where I work. In fact, I can't think of a federal program where the money  goes to harder working and more honest, caring people than it does with Medicaid. Here in McComb, MS, we have a six story hospital that employs at least 1,000 people. That hospital, one of the largest employers in Pike county, might not exist without Medicaid.

And for Mississippi, Medicaid is a real bargain. State funding is backed by federal matching dollars, and Mississippi, as America's poorest state, qualifies for the highest matching fund percentage in the nation, 76.29%. For every dollar Mississippi spends on Medicaid, the feds kick in three.

In Governor Barbour's mind, cutting thousands of qualified poor people from the Medicaid rolls and thus foregoing hundreds of millions in matching dollars is good for the state. This is the same governor who in 2007 happily engineered a $296 million tax incentive package to lure a Toyota plant to Tupelo. That plant will eventually employ 2000 people, a considerable number, but nonetheless small compared to the many thousands working in the medical field in the city of Jackson alone. Our own county hospital creates half as many jobs, and cost far less tax money to build.

It takes a special gall to seize the occasion of Martin Luther King Day to accuse the poor of dragging Mississippi down. Barbour, of course, would deny that race has anything to do with his statement, but, to put things kindly, Mississippi doesn't have a civil rights history that easily excuses that interpretation. That he said this on Martin Luther King Day, a day when most politicians walk on racial eggshells, suggests extraordinary insensitivity to the needs of his own constituency.

The Medicaid line item is a huge part of most state budgets, and this is especially true for a poor, medically under-served state like Mississippi. It is true that even with a 3-to-1 match Mississippi is having trouble meeting the needs of its citizens. Barbour owes it to the voters to admit money is tight. But blaming the tight budget on poor people, when Barbour has pursued a policy to maintain the nation's highest grocery tax and among the lowest corporate and cigarette tax rates, is, to borrow Barbour's own words, "not right."

Yet this is the Republican way. Barbour is no different from his Republican brethren, who think 100% of Americans would have health insurance if poor people would only behave responsibly. He would have us believe it is acceptable to give away $296 million to one of the world's richest corporations for 2000 jobs with health insurance, but unseemly to fund health insurance directly.

It is time that conservatives be called on their heath care lie. They have no intention of promising health care for everyone. Their game is Barbour's game -- force people off government assistance, and pretend they are better off for the loss. As long as they are allowed to persist in this fiction, they will succeed in their goal of depriving millions of poor Americans of the one thing everyone deserves -- good health.