Article by Allen Perkins

By Allen Perkins, M.D.

On Governor Bentley's desk for signature is Senate Bill 340. This bill will create Regional Care Organizations (RCOs) to facilitate care for Alabamians on Medicaid. After the Governor signs the bill, Mrs. M.'s story will be changed.

Mrs. M. is a 51-year-old widow with two teenagers who worked as a short order cook until she was 50. She knew diabetes was a possibility, partly because she was a little overweight but mostly because it runs in her family. She may have even been told she had it once or twice but she didn't go to the doctor regularly until after her husband died when she was 48 and she became eligible for Medicaid. While a lot of people can suffer from diabetes for years without having complications, Mrs. M. began suffering complications soon after her diagnosis. She developed neuropathy (numbness) of her hands so bad that she could no longer cook and became unemployed. Last year she developed chest pain that was due to blockages in her heart that were not operable. She also suffered greatly from heartburn but like many people couldn't tell the difference between these pains and her heart pains so each time would call for an ambulance. She made multiple trips to hospitals. For each of these episodes she would be treated either in the emergency room or be hospitalized and would have a heart catheterization. Her income was only $8000 last year so her family was eligible for Alabama Medicaid. Medicaid paid the hospitals $420,000 on her $2,000,000 bill this past year. Alabama's share of this was $140,000. She paid no taxes.

This is not a real patient story but is a compilation of several patients that I have seen. The common themes are inadequate preventive care; poorly coordinated sick care because of a fragmented, disorganized system; and ultimately very expensive care that is paid for by our taxes in one way or another.

On Governor Bentley's desk for signature is Senate Bill 340. This bill will create Regional Care Organizations (RCOs) to facilitate care for Alabamians on Medicaid. After the Governor signs the bill, Mrs. M.'s story will be changed.

Shortly after her husband died and the family became Medicaid eligible, Mrs. M. saw a doctor and had bloodwork done, which confirmed she had diabetes. She was enrolled in a diabetes care management program that existed as the result of collaboration between her doctor and others in the RCO. When Mrs. M. didn't show up for her appointment, a member of the team contacted Mrs. M. and talked to her. She found out that Mrs. M. couldn't afford a car and so could not get to regular appointments. The RCO made a note of this and arranged for Mrs. M. to get rides. She was put on medicine for cholesterol, blood pressure, and to keep her blood sugar down. Despite this the chest pains that started after her husband died (and that she did not tell the doctor about) became worse and she mentioned it to the team pharmacist in her diabetic group visit. Her doctor arranged to have a cardiology appointment and testing done, and fortunately the pain was not her heart. Today she continues to take her medication (plus an additional one to control her heartburn) and she continues to work on her weight. Her cost to Medicaid last year was $600 (4 office visits, 4 group diabetes visits, medication, transportation to her appointments, and her heartburn medicine) of which Alabama paid $200. She worries that when her children move out she will lose her Medicaid and not be able to afford other insurance. She has been told that in Alabama the new Insurance Exchanges don't provide help for people with incomes as low as hers and she will not be eligible for Medicaid.

Unfortunately, should Mrs M. lose her Medicaid and make under about $16,000, the Affordable Care Act will not help her. As a result of a U.S. Supreme Court decision, the Act does not mandate Medicaid expansion and states are only required to maintain current coverage. States must choose to expand to allow coverage for people with lower incomes (slightly above the Federal Poverty Guidelines). This was done because many, like Mrs. M., will have low paying jobs that do not provide health insurance. In Alabama we have not yet elected to expand Medicaid. No one knows what Mrs. M.'s story will be without expansion. This would be Mrs. M.'s story if Medicaid were expanded.

Mrs. M lost her husband and took a job as a short order cook. She had previously had health insurance but now, because she is not making above the federal poverty guidelines and works for a small company, is on Medicaid. She has been seeing a health professional regularly because of her family history of diabetes and can continue to see her even with the change in insurance. She is working hard and doesn't diet or exercise as she should. About a year ago she was told she has pre-diabetes. She was placed on a mild pill to control her cholesterol but more importantly was offered nutritional services and some support to help become more physically active. After losing 20 pounds, her blood sugar and cholesterol normalized and she has been off all medication for a year. The office calls to check in on her every month or so. For the past year her health care costs were $200 (2 office visits and a chronic care management fee paid to the doctor's office). The state of Alabama paid $20 towards this. Mrs. M. paid $900 in taxes to the state of Alabama.

Dr. Perkins is Professor and Chair of Family Medicine at the University of South Alabama College of Medicine in Mobile. The opinions he expresses are his own.

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