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Thursday, April 10, 2014

Health Care Reform Articles - April 10, 2014


America’s healthcare prices are absurd. So, now what?

NYT’s Elisabeth Rosenthal “start[ed] a very loud conversation” she hopes will be “difficult politically to ignore.” How did she do it?
By Trudy Lieberman

It might be said that last year Americans finally began paying attention to the price of their healthcare. Maybe it was the focus on Obamacare, or the Great Cost Shift and the realization they now had to pay more of these out-of-the-ballpark prices themselves. But journalism deserves a lot of credit, too, for shattering that long-held, erroneous belief that whatever we pay is justified because we get high quality care in return. From work in legacy media—like Elisabeth Rosenthal’s ongoing New York Times series,“Paying Till It Hurts” and Steven Brill’s 2013 opus in Time—to social media like Reddit—from which a 20-year-old outraged Californian’s $55,000 bill for an appendectomy went viral late last year—journalism is helping the public realize the cost of care is simply too high.
I sat down with the Times’ Rosenthal, herself an emergency room doc, to talk about what journalists and the public can learn from her series, which began early last year and so far has included six major pieces and more than 10 follow-ups.
What inspired the series?
I was covering international environment and had just returned from the Arctic when editors asked if I wanted to cover the Affordable Care Act during the 2012 election. I didn’t want to do that and said so since I was pretty passionate about environmental issues and few others were covering them. But I said if you let me do a series on pricing and costs and why American medicine costs so much compared to the rest of the world, I’d drop everything to do it.
How does the public tend to look at medical costs?
People tend to look at the price tag for big ticket items such as the half million dollar cancer drug and express amazement; but then they just hope it won’t happen to them. I didn’t want to look at rare medical events but instead at encounters that everyone relates to. I wanted to get people energized to understand the costs and financial incentives. So I focused on ordinary procedures and conditions like colonoscopies, asthma, pregnancy, having a minor skin cancer removed, and getting stitches.
What was the main take-away you wanted for your readers?
I wanted them to understand the incentives that underlie the system and that inflate costs and force us to choose the most expensive way of doing things. I put a lot of thought into those market failures and how we got there. Someone once said we got the system those financial incentives were designed to create. My series started from there.


Forget ObamaCare

Vermont Wants to Bring Single Payer to America

by Sarah Kliff

April 9, 2014

Saskatchewan is a vast prairie province in the middle of Canada. It’s home to hockey great Gordie Howe and the world’s first curling museum. But Canadians know it for another reason: it’s the birthplace of the country’s single-payer health-care system.
In 1947, Saskatchewan began doing something very different from the rest of the country: it decided to pay the hospital bills for all residents. The system was popular and effective — and other provinces quickly took notice. Neighboring Alberta started a hospital insurance plan in 1950, and by 1961 all ten Canadian provinces provided hospital care. In 1966, Canada passed a national law that grew hospital insurance to a more comprehensive insurance plan like the one that exists today.
Saskatchewan showed that a single-payer health-care system can start small and scale big. And across the border, six decades later, Vermont wants to pull off something similar. The state is three years deep in the process of building a government-owned and -operated health insurance plan that, if it gets off the ground, will cover Vermont’s 620,000 residents — and maybe, eventually, all 300 million Americans.
"If Vermont gets single-payer health care right, which I believe we will, other states will follow," Vermont Gov. Peter Shumlin predicted in a recent interview. "If we screw it up, it will set back this effort for a long time. So I know we have a tremendous amount of responsibility, not only to Vermonters."
When Shumlin ran on a single-payer platform in 2010, it was unprecedented. No statewide candidate — not in Vermont, not anywhere — had campaigned on the issue, and with good political reason. Government-run health insurance is divisive. When the country began debating health reform in 2009, polls showed single-payer to be the least popular option.
Shumlin just barely sold Vermont voters on the plan (he beat his Republican opponent by less than one percentage point). Then, he got the Vermont legislature on board, too. On May 26, 2011, Shumlin signed Act 48, a law passed by the Vermont House and Senate that committed the state to building the country’s first single-payer system.
Now comes the big challenge: paying for it. Act 48 required Vermont to create a single-payer system by 2017. But the state hasn’t drafted a bill that spells out how to raise the approximately $2 billion a year Vermont needs to run the system. The state collects only $2.7 billion in tax revenue each year, so an additional $2 billion is a vexingly large sum to scrape together.
Shumlin knows what he’s up against. "I don’t underestimate the challenge," he said. "I know how hard this is, getting to the finish line. There are a thousand swords that could stab us in the heart. My question to the folks who wish for that to happen is, what’s your idea?"
Vermont’s case for single-payer health care can be summarized in one number: $82,975.

How does one doctor earn $21 million from Medicare?

Updated by  on April 9, 2014, 4:13 p.m. ET

One percent of doctors got more than 15 percent of Medicare payments

One percent of the 880,000 medical providers included in this study netted more than 15 percent of all Medicare payments in 2012, according to the New York Times' analysis of the data. That means fewer than 9,000 doctors managed to make more than $11 billion off Medicare.
That's an incredible concentration figure. The question is whether it represents great doctors meeting demand for their terrific work or providers who are bilking the system or overtreating their patients.
"Some of the scrutiny of the highest of the highest paid will focus on overuse," says Ethan Halm, a professor at the University of Texas Southwestern Medical Center, whose research focuses on health care quality. "If these small handful of eyeball surgeons are the highest paid, that could be a harbinger of overuse.
"But should we be surprised if the world's best pancreatic surgeon makes a lot per case, and does a lot of cases?"

What's new here: for the first time, we know what doctors actually spend their day doing.

By combing through the things that doctor asks Medicare to pay them for, you can see what your doctor is up to each day (yes, your doctor! The Wall Street Journal has a searchable database here).
"If I'm an internal medicine doctor, you might come to me for anything imaginable," says Bob Kocher, a former health care advisor to the White House. "Some poor psoriasis patient might come to me, and I've only seen seven people with psoriasis. Now, as a patient, you'll be able to use this data – or at least use tools built with this data – to know what does the doctor I'm about to visit actually do."

We have no idea why some doctors earn so much money


Seriously. No idea. This is the most important take away.

We do know huge variation in how much Medicare paid doctors in 2012. The highest-earning doctor was an ophthalmologist in West Palm Beach, Fla. who earned just shy of $21 million seeing 894 patients. The lowest-paid provider was an osteopath in Arizona who appears to have earned $2.29 (possibly a reconciliation payment to claims submitted last year).

Experts say we should be skeptical of the outliers, the people who say they're seeing way more patients than anyone else in their specialty. "If you're doing 100 times more of a procedure than any other doctor, that's a red flag," says Jennifer Schneider, who runs strategic analytics at transparency firm Castlight Health.
But for most other doctors, this data doesn't tell us whether high-earners are standouts in their profession – people who excel at complex surgeries, for example, – or if they're bilking the system.

Quebec election result raises hopes for a renewed focus on health care

BY AARON DERFEL, THE GAZETTE

MONTREAL — The election of a majority Liberal government in Quebec — headed by a brain surgeon with two cabinet hopefuls who also trained as doctors — raises hopes of a renewed focus on health care.

Philippe Couillard’s election as Quebec premier also coincides with the expiration of the 10-year federal Health Accord, which greatly benefited the province when Couillard served as health minister from 2003 to 2008.

Since the Harper government has already gone on record as stating it will not renew the accord, Couillard will likely play a leading role as the provinces press Ottawa for adequate funding on health, observers say. For Couillard, the stakes are high, since he campaigned on improving access to health care, with costly promises to hire 2,000 nurse practitioners and create 50 “super clinics” across Quebec, open 24/7.
“Quebec will join the voices of the other provinces, including Ontario, for a more collaborative approach to health-care reform,” said Michael McBane, coordinator for the Canadian Health Coalition in Ottawa.
“And I think Mr. Couillard has a good opportunity and a lot of credibility to be raising these issues for co-operation with Ottawa and the need for better planning.”
Antonia Maioni, a health-policy expert at McGill University, noted that former Quebec premier Jean Charest played a major role in the Council of the Federation, the group representing the territorial and provincial premiers, in negotiating the health accord. And it was Charest who recruited Couillard to the Quebec Liberal Party.
“We’ll see whether Couillard plays that role as well, as health is one of the top issues on the agenda of the Council of the Federation,” Maioni said.
“As far as bilateral relations are concerned, Quebec versus Ottawa, he may try and may get a hearing from Ottawa, because the Liberals are a federalist party, because Mr. Couillard is not seen to be someone on the left, but rather someone more to the centre-right.”
Indeed, Harper, who phoned Couillard to congratulate him on the Liberal rout of the Parti Québécois, had appointed him to the Security Intelligence Review Committee, the country’s spy watchdog, in 2010.
The 10-year health accord infused the provinces with $41 billion in extra transfers from Ottawa. The Conservative government has pledged to keep the health transfers rising by six per cent annually until 2017, after which any increases will be tied to the performance of the economy.

A ‘Code Death’ for Dying Patients

By JESSICA NUTIK ZITTER, M.D.
 

Sadly, but with conviction, I recently removed breathing tubes from three patients in intensive care.
As an I.C.U. doctor, I am trained to save lives. Yet the reality is that some of my patients are beyond saving. And while I can use the tricks of my trade to keep their bodies going, many will never return to a quality of life that they, or anyone else, would be willing to accept.
I was trained to use highly sophisticated tools to rescue those even beyond the brink of death. But I was never trained how to unhook these tools. I never learned how to help my patients die. I committed the protocols of lifesaving to memory and get recertified every two years to handle a Code Blue, which alerts us to the need for immediate resuscitation. Yet a Code Blue is rarely successful. Very few patients ever leave the hospital afterward. Those that do rarely wake up again.
It has become clear to me in my years on this job that we need a Code Death.


Health Goal Met, White House Reviews Missteps

By 
WASHINGTON — Days after hitting their target of signing up more than seven million people for health insurance, Denis R. McDonough, the White House chief of staff, and other top aides to President Obama gathered last week on the patio just outside Mr. McDonough’s West Wing office.
In an hourlong interview they requested, the officials said one of their biggest mistakes in the disastrous health care rollout last fall was worrying about the wrong thing. They said they focused too much on their ultimately unfounded fear that not enough insurance companies would participate in the health marketplaces and that premium prices would be too high. In turn, they said, they ignored what became the real problem, a website that was virtually inaccessible in its opening days.
“It wasn’t for lack of time; it was for lack of time on the right variables,” Mr. McDonough said.




Like all White House aides who have endured withering criticism and survived a political crisis, Mr. McDonough and the others sought to cast their actions in the best possible light. Not surprisingly, their conversation was filled with high praise for Mr. Obama and satisfaction that they had at last fixed the website and met their enrollment goals.
http://www.nytimes.com/2014/04/10/us/politics/health-goal-met-white-house-reviews-missteps.html?ref=health

Cost of drugs used by Medicare doctors can vary greatly by region, analysis finds


By ,  and , Published: April 9
An analysis of government data released Wednesday shows that the cost of drugs administered by doctors accounts for a growing piece of Medicare’s spending and varies widely from region to region in the United States, raising questions about whether some physicians may be misusing the pharmaceuticals.
Most of the 4,000 doctors who received at least $1 million from Medicare in 2012 billed mainly for giving patients injections, infusions and other drug treatments, those records show.


An analysis of government data released Wednesday shows that the cost of drugs administered by doctors accounts for a growing piece of Medicare’s spending and varies widely from region to region in the United States, raising questions about whether some physicians may be misusing the pharmaceuticals.
Most of the 4,000 doctors who received at least $1 million from Medicare in 2012 billed mainly for giving patients injections, infusions and other drug treatments, those records show.
The data, an unprecedented trove of millions of billing records from Medicare — as well as interviews with doctors — highlight the role of pharmaceuticals in the nation’s staggering health-care costs.
Of $64 billion Medicare paid to doctors in 2012, $8.6 billion was used to cover drugs, an amount that has been rising for years.
Yet Medicare bureaucrats seeking to rein in drug costs have been stymied by rules that forbid the government to negotiate lower prices. In 2010, they even lost the ability to mandate, when two equivalent drugs are available, that physicians be paid only for the cheapest.
At the same time, pharmaceutical companies have offered physicians incentives, such as discounts, to use large volumes.
Now, with the data released by Medicare, the public has a clearer view of individual doctors’ drug practices.
Many of the physicians who have submitted multimillion-dollar bills to Medicare blame high drug prices and say the pharmaceutical industry is taking most of the money. Typically, Medicare reimburses a physician for the price of the drug plus 6 percent.

How a secretive panel uses data that distort doctors’ pay


By  and , Published: July 20, 2013 E-mail the writers
When Harinath Sheela was busiest at his gastroenterology clinic, it seemed he could bend the limits of time.
Twelve colonoscopies and four other procedures was a typical day for him, according to Florida records for 2012. If the American Medical Association’s assumptions about procedure times are correct, that much work would take about 26 hours. Sheela’s typical day was nine or 10.
“I have experience,” the Yale-trained, Orlando-based doctor said. “I’m not that slow; I’m not fast. I’m thorough.”
This seemingly miraculous proficiency, which yields good pay for doctors who perform colonoscopies, reveals one of the fundamental flaws in the pricing of U.S. health care, a Washington Post investigation has found.
Unknown to most, a single committee of the AMA, the chief lobbying group for physicians, meets confidentially every year to come up with values for most of the services a doctor performs.
Those values are required under federal law to be based on the time and intensity of the procedures. The values, in turn, determine what Medicare and most private insurers pay doctors.
But the AMA’s estimates of the time involved in many procedures are exaggerated, sometimes by as much as 100 percent, according to an analysis of doctors’ time, as well as interviews and reviews of medical journals.
If the time estimates are to be believed, some doctors would have to be averaging more than 24 hours a day to perform all of the procedures that they are reporting. This volume of work does not mean these doctors are doing anything wrong. They are just getting paid at the rates set by the government, under the guidance of the AMA.

Medicare paid 14 Maine doctors at least $1 million each in 2012

And payments statewide totaled $300 million that year, according to data made public for the first time – but much of it goes to costs, not profits.

By Eric Russell erussell@pressherald.com
Staff Writer
Fourteen Maine physicians received more than $1 million each in payments from Medicare in 2012, and 37 received more than $500,000.
In all, nearly 5,800 Maine doctors and other medical providers were paid a total of $300 million for services they provided to the state’s Medicare clients in 2012.
The numbers are in a data set released Wednesday by the federal Centers for Medicare and Medicaid Services that provides, for the first time, detailed information on how much money physicians receive in Medicare payments for services ranging from major surgeries to routine laboratory tests.
The data also gives the public a look into how Medicare, the federally funded health insurance program for senior citizens, operates and how much various services cost.
The American Medical Association tried for years to block the release of the information, citing privacy concerns. Last year, a federal judge ruled that it can and should be released.
The data includes information on more than 880,000 health care providers nationwide who collectively received $77 billion under Medicare’s fee-for-service program in 2012, the most recent year for which data is available.
The information offers a window into an industry that affects many, especially in a state like Maine, which has an older population and a high percentage of Medicare recipients. Twenty-one percent of Maine residents, 276,467 people, were Medicare recipients in 2012, according to the Kaiser Family Foundation, which tracks health statistics.
Maine’s top lobbyist for physicians cautioned against drawing conclusions without proper context, noting that the money reflects reimbursements, not profits.

LePage vetoes Maine Medicaid expansion bill

The bill received bipartisan support but not enough to override LePage, who says Maine cannot afford it and federal promises can't be trusted.

By Steve Mistlersmistler@pressherald.com
Staff Writer
AUGUSTA –– Gov. Paul LePage on Wednesday vetoed a bill that would have expanded MaineCare coverage to more than 60,000 low-income Mainers.
The measure also would have established a managed care system for all 320,000 beneficiaries, an effort to control costs in the $2.5 billion program, which is Maine’s version of the Medicaid health insurance program.
Under the Affordable Care Act, also known as Obamacare, the federal government offered to reimburse states for 100 percent of the cost of expansion for at least three years, then gradually reduce reimbursements rates to about 90 percent.
But in his veto message to the Legislature, LePage wrote that Maine could neither afford expansion nor trust the federal government to deliver on its promises.
“The expansion offered through Obamacare would have a disastrous impact on Maine’s budget, as well as those truly needy individuals, our disabled and elderly, who rely today on the scarce resources in our program,” LePage wrote. “Maine has been down this road before, and we must learn from previous experience.”
The Legislature will cast override votes on LePage’s veto, probably later this week, but the voting that sent the bill to LePage’s desk showed that expansion supporters – primarily Democrats – lack the two-thirds majority needed to prevail.
LePage’s veto was expected, as the Republican governor, has been a fierce and consistent opponent of Medicaid expansion, which is a key component of the Affordable Care Act. The federal law was designed to increase health care coverage by mandating that most Americans purchase health insurance.

LePage vetoes Medicaid expansion, calls the effort ‘ruinous’ for Maine’s future

By Mario Moretto, BDN Staff
Posted April 09, 2014, at 4:01 p.m.
AUGUSTA, Maine — As expected, Gov. Paul LePage on Wednesday vetoed a bill that would expand Medicaid coverage to roughly 70,000 low-income Mainers and dramatically overhaul the administration of the program by outsourcing it to managed care organizations.
The Legislature gave final enactment to the bill on March 28, starting a countdown for LePage to sign the bill, veto it or let it go into law without his signature. Wednesday was the deadline day. It was the third time LePage has vetoed Medicaid expansion in the 126th Legislature.
LD 1487 was presented by moderate Republican Sens. Roger Katz of Augusta and Tom Saviello of Wilton as a compromise effort to bring more of their party on board with expansion — the top priority for legislative Democrats.
In his veto letter to the Legislature, LePage referenced previous Medicaid expansions in Maine and said further growth in the publicly funded health insurance program would be “ruinous.”
“Maine has been down this road before, and we must learn from previous experience,” he wrote. “Medicaid spending grew by $1 billion in a decade, hospital bills were not being paid by the state, budgets were broken and thousands of elderly, and people with disabilities were forced to wait for critical services.
“For the sake of the truly needy and Maine taxpayers, we cannot go down this path again,” he said.
A provision of the federal Affordable Care Act, sometimes referred to as Obamacare, allows the states to expand Medicaid, known here as MaineCare, to every resident who makes less than 138 percent of the federal poverty level, or just under $16,000 per year for a childless, single adult. The federal government will pay the full cost of expansion through the end of 2016. After that, it’s share of the cost will drop, incrementally, to 90 percent.
Expansion was a linchpin in the federal health care overhaul, which envisioned state-funded health care for the poorest Americans and subsidized private health insurance plans, through new online exchanges, to anyone making between 138 percent and 400 percent of the federal poverty level.
But the U.S. Supreme Court in 2012 struck down the provision of the law requiring Medicaid expansion, leaving the decision up to each state.
The Democrat-controlled Legislature in Maine approved expansion twice last year, only to be thwarted by LePage’s veto. Overriding the governor would require two-thirds support in the Legislature — a threshold impossible to reach without Republican support. The overwhelming majority of GOP lawmakers, however, have stuck with the governor.
On Wednesday, Democrats called LePage’s veto “ideological” and urged Republican counterparts to join them in an override.
“We have a bipartisan plan for life-saving health care for tens of thousands of Mainers. It creates jobs, it saves lives, it saves money,” said House Speaker Mark Eves, D-North Berwick, who has championed the expansion effort for two years.
“Gov. LePage continues to stand in the way despite our good-faith effort to collaborate and address concerns raised by opponents [of expansion],” he said.
The Katz-Saviello plan attempted to win over Republicans by combining expansion with a plan to mandate big savings by outsourcing the publicly funded health insurance program to managed care organizations.
On paper, the bill addresses many of the concerns Republican opponents of expansion have raised for two years: The expansion lasts only as long as the federal government pays for nearly 100 percent of the cost, and it would require a vote of the Legislature to continue beyond that. It also includes an automatic opt-out if federal funding drops below promised levels. The Legislature’s nonpartisan budget analysts say the cost of the proposal is minimal.
It also uses built-in savings to clear out a waiting list of Medicaid recipients awaiting in-home and community services, which opponents have said needs to be addressed before the program is expanded to include all of Maine’s poorest residents.

Data trove shows US doctors reap millions from Medicare

By Sharon Begley and M.B. Pell, Reuters
Posted April 09, 2014, at 5:50 p.m.
NEW YORK — In 2012, an enterprising ophthalmologist in south Florida received $20.8 million in Medicare payments, the highest amount the government health plan for the elderly paid an individual provider that year, according to a preliminary analysis of federal data.
A family-practice doctor in Maryland may have received an average of more than $86,000 per patient that year, according to a Reuters review of the data. And a California laboratory apparently received $190 million, the most Medicare paid a single entity in 2012.
In Maine, clinical labs and ambulance services topped the list. Among physicians, rheumatologists and ophthalmologists, who largely treat older patients, rounded out the top 20 payments, along with cancer doctors.
After decades of litigation and over the strenuous objections of the American Medical Association, the leading U.S. doctors group, the federal Centers for Medicare and Medicaid Services on Wednesday made public for the first time how much Medicare pays individual doctors.
The massive data release, totaling nearly 10 million lines, also includes which medical services each of more than 880,000 physicians and other health care providers nationwide billed Medicare for in 2012.
“While the data are not perfect, this is a major milestone in health care transparency,” said cancer surgeon Dr. Marty Makary of Johns Hopkins School of Medicine, whose 2012 book, “Unaccountable,” argues for making public more information on doctors and hospitals.
Michael DeLorenzo, director of health analytics at the Maine Health Management Coalition, which publishes score cards on hospitals and doctors, applauded Medicare for releasing the data. But more analysis remains to understand how to use the information to improve the cost and quality of health care, he said.
“Just getting this data out there is just the beginning,” he said. “I think it needs a lot of work to put it in proper context.”
In addition to allowing patients to see which doctors perform a particular procedure most frequently — often a proxy for expertise in rare and difficult surgeries such as colon operations — the data are expected to offer a road map to where waste and fraud are most rampant not only in the Medicare program but throughout the American health care system.
“If you see that a doctor is doing a procedure hundreds or thousands of times that should be done only on a small number of patients, you wonder,” said Dr. John Santa, medical director of Consumer Reports. “Are they committing fraud by billing for something they’re not actually doing, doing unn

This Generation of Med Students Wants a Truly Just Healthcare System for All

By James Besante    
Common Dreams, April 9, 2014
While much has been made of the 7.1 million people who bought new private health insurance policies under the Affordable Care Act, and the additional millions who newly signed up for Medicaid, two big questions hover over these figures.
Even if they’re insured, will people be able to get the care they need? And what about the 31 million people who the government says will remain completely uninsured?
Medical students are acutely aware of the continuing barriers to health care that our patients face, and I can tell you – based on firsthand experience – that my fellow students are not about to give up the quest for truly universal, comprehensive care that’s readily accessible to everyone.
Their convictions owe a great deal to the late Chicago Cardinal Joseph Bernardin, who fought tirelessly on behalf of the powerless and downtrodden.
In 1995, one year before his death from pancreatic cancer, Cardinal Bernardin said, “Health care is an essential safeguard of human life and dignity, and there is an obligation for society to ensure that every person be able to realize this right.”
But nearly two decades later, the realization of the “right to health care” remains elusive, despite the passage of the ACA.
As a medical student, every day I work with patients who have delayed getting medically necessary care because they were worried about the costs of treatment. In many cases their condition has worsened as a result.
They may have been uninsured. Or they may have had a health insurance policy, but their plan’s high copays and deductibles kept them away.
Such worries are understandable. Studies show the leading cause of bankruptcy in America is medically incurred debt. Impressively, 78 percent of those individuals and families so bankrupted had health insurance when they first got sick.
The ACA doesn’t change this picture as much as some might think. People who signed up for private coverage in the exchanges are finding they have substantial cost-sharing, i.e. high deductibles and copayments, proven barriers to seeking care.
Patients are also finding themselves squeezed into “narrow networks,” which significantly limit their choice of doctors and hospitals. Accidentally step out-of-network, and your costs soar.
The sad truth is that for many health insurance is an umbrella that melts in the rain—when you need it most, it isn’t there.
One thing that's clear: the business of corporate medicine is doing very well under the ACA. Health insurer profits, stock value, and CEO salaries are all up. In fact, the entire law was written around preserving the gluttonous bottom lines in American health care. The ACA handed private insurers $500 billion in taxpayer subsidies to continue profiteering off illness in our country.
Health insurers profit by avoiding the sick, collecting premiums, denying claims, and shifting g more and more costs onto the patient.
http://www.pnhp.org/print/news/2014/april/this-generation-of-med-students-wants-a-truly-just-healthcare-system-for-all

Inmates getting coverage under ObamaCare, as states shift cost to feds


FoxNews.com
WASHINGTON –  The Obama administration often touts that people with pre-existing conditions and countless others can now get covered under ObamaCare. But there's another group that's starting to benefit from the law -- prison inmates. 
Cash-strapped state and local prisons increasingly are using the Affordable Care Act to pay for their inmates' medical costs, taking advantage of a little-known provision that lets them shift some of those expenses to the federal government.
Ohio, Illinois and Iowa are among the states trying to offload the rising costs of health care – which include mental health programs – by enrolling inmates into a new expanded Medicaid program when they get sick. 
But it doesn't stop there. The states also are working to enroll them even before they're released from prison, so they have coverage when they get out.
Currently, 26 states and the District of Columbia are proceeding with a Medicaid expansion which allows them to extend medical coverage to single and childless adults. Jail operators in at least a half-dozen of those states are then, using that criteria, extending coverage to inmates. The shift means the federal government would pay some emergency costs that used to be entirely covered by the states and counties -- plus, inmates are starting to get coverage for when they leave. 
Proponents of shifting prisoners into the expanded Medicaid -- in turn giving them access to health care, including mental health and rehab services, when they are released -- say this reduces recidivism. Others, though, argue that federal taxpayer dollars shouldn’t be used to foot the multibillion dollar bill.
“The political element of ObamaCare is that we were helping what we called the deserving poor or what we used to call the deserving poor,” Manhattan Institute fellow Avik Roy told Fox News. “A group of people who are just down on their luck … bring them the opportunities they need to get ahead and get back on their feet. And sometimes that’s true of people who served time in prison, and sometimes it’s not.”

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