Real prison reform can’t happen without Medicaid expansion

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Tod Kelly

Tod is a writer from the Pacific Northwest. He is also serves as Executive Producer and host of both the 7 Deadly Sins Show at Portland's historic Mission Theatre and 7DS: Pants On Fire! at the White Eagle Hotel & Saloon. He is  a regular inactive for Marie Claire International and the Daily Beast, and is currently writing a book on the sudden rise of exorcisms in the United States. Follow him on Twitter.

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76 Responses

  1. Avatar Michael Cain
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    says:

    Assuming the ACA survives the current Supreme Court challenge (I placed my bet on Burt’s post, 6-3, tax credits for all stand), 2016 is the year that most states that haven’t already adopted Medicaid expansion do so. Hospitals in the typical state that hasn’t expanded are eating a charitable-care expense on the order of hundreds of millions of dollars because of other changes the ACA made in the flow of federal funding. So far, the hospital associations are just lobbying. In 2016, they’ll start actively campaigning against state legislators who refuse to support the expansion.Report

  2. Avatar Kolohe
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    says:

    I’m not against any of the this, but I’m skeptical that such treatment would help the *prevention* of crime, vice just lower the recidivism rate. (which is not nothing, and keeps prison populations down, but it isn’t the best case).

    Everything I understand about alcohol and drug (and every other kind of) addiction says that a person won’t seek treatment for their addiction until some sort of crisis makes the person ‘wake up’ to fact they have a problem. Often, that crisis is the interaction with the legal system. (see any famous person DUI arrest).

    I’m not sure how even with plentiful funding we’ll be able to get people the treatment they need, without them doing something first that the government will then react to. We’re certainly not going to preemptively send people to substance abuse programs, without a self-referral.

    We see the same issue for mental health of the stereotypical homeless person – even when they’re visible mentally ill to the casual lay observer, we don’t force them to get treatment unless or until they interact badly with a government official or just random other person.Report

    • Avatar Mad Rocket Scientist in reply to Kolohe
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      says:

      This seems like part of the fix. If there is the ability to pay for care (via MediCAID), and the number of providers magically increased, then we could do first offense intervention that was effective.

      Right now, in many cases, the first offense for drug or alcohol abuse is a misdemeanor, which means you pay a fine, spend a few days/weeks in jail, and go back on the street poorer, unemployed, and Jonesing harder than ever for a fix because now your life sucks even more. If there was the ability to pay for help, then the first offense could still be a misdemeanor, which could certainly serve as a wake up call, especially if the penalty included getting help instead of jail time.Report

      • Avatar Kolohe in reply to Mad Rocket Scientist
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        says:

        My impression, though, is that ‘substance abuse treatment’ in lieu of or on top of jail/probation (particularly the latter) is currently a fairly standard widespread practice. There may be (there probably is) an economic class correlation on who more frequently gets ordered treatment*, but it’s all part of the system as it stands today.

        *and, since often one has to pay for all or part of their treatment, another illustration of the type of thing shown by Ferguson and elsewhere where fees & fines start to snowball on those with limited economic means, making some jail time more likely in the long run. Or is this where Medicaid can intervene and break the cycle?Report

      • Avatar greginak in reply to Mad Rocket Scientist
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        says:

        Typically a substance abuse assessment and a handful of classes are given out to first offenders with things like DUI’s. Often people will have to do substance abuse treatment after getting out of jail if they do a few years. Treatment is often given as an option instead of jail.

        At least a few years ago, when i worked in SA trt, the research showed mandated treatment had similar efficacy to voluntarily entered treatment.

        Paying for treatment is usually the big hurdle. Sometimes CPS has money for treatment if a person is in that system. Other than that it is up to the luck of having insurance that pays or finding a program that has funding enough to treat people for free. Plenty of poor people end up going to jail instead of staying with their family and in the community because they can’t afford treatment. You want fewer poor people in jail then get them more treatment.Report

      • Avatar Mad Rocket Scientist in reply to Mad Rocket Scientist
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        says:

        @kolohe

        I think “help instead of jail” is standard in some states (but not everywhere) for the person who is busted while drunk or stoned & doing something silly but harmless (public intox, nuisance, etc.).

        The DUI does not lead to nearly enough “get help” orders, and a lot of times, by the time someone is busted in an altered state, they’ve also done something more than just annoy the public (usually property damage, breaking & entering, etc.). “Help not Jail” would have to be willing to not impose jail time for property damage & keep the violation as a misdemeanor (although restitution should still be on the table). Misdemeanors & arrests aren’t nice things to have on one’s record, but they are not as socially debilitating as felonies or having spent time in jail.Report

    • Avatar dragonfrog in reply to Kolohe
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      says:

      I’m not against any of the this, but I’m skeptical that such treatment would help the *prevention* of crime, vice just lower the recidivism rate.

      Two points on that

      – Recidivism is crime – specifically, it’s crime committed by people who have been convicted once before. Preventing one category of crime, without somehow increasing instances of other types by a compensating amount, is crime prevention. (The argument “that’s not crime prevention, it only prevents recidivism” is as invalid as “that’s not crime prevention, it only prevents auto theft / gang recruitment / crime by minors / any other specific type of crime.”)

      – The crisis leading to seeking help may be related to law enforcement, but needn’t be. A health crisis, a breakup with a partner, a screaming match, having to couch surf because you couldn’t make rent…Report

      • Avatar Kolohe in reply to dragonfrog
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        says:

        There’s two different aims though. One is to have less people in prison. This may accomplish that. But the other is to get less people in The System – the larger network of prison, jail, probation, ex-offender lists, etc.

        Just having an arrest on your record (not even a conviction) has negative impact on any goal to reach and/or maintain most bourgeois lifestyles.Report

      • Avatar dragonfrog in reply to dragonfrog
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        says:

        I see what you mean there – having fewer crimes committed is one thing, having fewer people with any convictions at all is another. Programs focused on recidivisim / rehabilitating offenders will achieve the second goal only indirectly.

        Interesting about arrest vs conviction – at least where I am, at least legally (and that may be a big caveat right there), the only thing a potential employer is allowed to ask is whether you have any convictions for which a pardon has not been issued.Report

    • Avatar Mad Rocket Scientist in reply to Kolohe
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      says:

      Of course, it helps a lot if you’re not black.Report

      • Avatar Notme in reply to Mad Rocket Scientist
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        says:

        MRS

        Why are you only mentioning race? The article you linked to cites two other factors that are important, education and history.Report

      • Avatar Mad Rocket Scientist in reply to Mad Rocket Scientist
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        says:

        As well as financial resources. Three area that black communities tend to be ill-served with regard to.Report

      • Avatar Notme in reply to Mad Rocket Scientist
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        says:

        MRS

        Not all black communities have this problem though you imply it. There are some white communities that have the same problem. Why the obsessive focus on race?Report

      • Avatar Mad Rocket Scientist in reply to Mad Rocket Scientist
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        says:

        All true, but as the stats in the linked article show, a larger percentage of black communities find their men in prison. Since there are white communities with similar issues that don’t have such a severe chance of spending time in prison, one can conclude (as has been demonstrated by other studies) that the CJ system is biased against black defendants as compared to whites.

        Additionally, because we are a vindictive & distrustful bunch, we don’t just punish someone with prison time & then stop when they have served their time. We make sure that mistake follows them the rest of their damn lives & severely limits their opportunities to become productive citizens, so much so that the stories we hear of felons making it good are rare enough that they are feel good stories we hear on the news.

        So if a black person has an increased chance of going to prison, then they have a greatly reduced chance of participating in legal markets, which means they often have to use illegal markets to make ends meet, much less have any hope of getting ahead or stably supporting a family, which increases the chance of going back to prison. And the cycle continues.Report

  3. Avatar Jaybird
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    says:

    The other day, on NPR, they used the phrase “doctor shortage”. They were only talking about the VA so I’m sure that there’s no reason to think that it might actually hit the people who will qualify for Medicaid in the various states, but I thought it interesting that I’ve started hearing that phrase.Report

    • Avatar zic in reply to Jaybird
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      @jaybird I’ve been hearing it for a long time; it was one of the prime arguments against ACA in the first place — it would create doctor shortages.

      The flip side of that coin, however, is that people need care if they need care, no matter if they’re insured or not. Expanding insurance just means people can more easily pay for the care they need, the demand for doctors was there, the means to pay them was missing.

      So the phrase ‘doctor shortage,’ to me, suggests the rationing (via insurance/cost) that was already baked in to the health-care system pre-ACA.

      Now shortages willing to accept VA/medicaid rates is another matter altogether; but I submit similar shortages also apply to plumbers, auto mechanics, and lawyers.Report

      • Avatar Jaybird in reply to zic
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        says:

        Oh, I’ve heard it all the time in various economics blogs.

        I’ve also seen it waved away by the people who explained to me that I didn’t understand how much these people needed health care.

        I found it interesting to hear the phrase *ON NPR*.Report

      • Avatar Kolohe in reply to zic
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        says:

        Yeah, but let’s say I run a donut shop, and am falling behind baking them (because I didn’t get up early enough). If I then offer coupons to make the donuts even cheaper at the point of sale, won’t my line of customers get even longer? And create even more donut-deficient persons in my community?Report

      • Avatar Jaybird in reply to zic
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        says:

        Kolohe, people need to eat. They’ll die if they don’t. Children will die if they don’t get nutrition. Children.

        This is why it’s important to print more coupons.Report

      • Avatar zic in reply to zic
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        says:

        So your comment is more about your presumption of bias in NPR reporting? That’s sort of biting into the cookie that NPR’s this liberal mediatopia.

        Last I looked, NPR’s primary supporters where big biz, often big biz looking to soften it’s image.Report

      • Avatar Jaybird in reply to zic
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        says:

        It’s only about bias insofar as it’s about being surprised by something that opponents predicted.Report

      • Avatar zic in reply to zic
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        Opponents predicted shortages if ACA passed.

        Supporters (at least this one) understood that passage had nothing to do with the shortage, it only revealed it. It was already there; inability to pay for health care, in part, helped create it.Report

      • Avatar Jaybird in reply to zic
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        says:

        My argument would be that it’s not revealing it as much as widening it.

        Let’s continue running with Kolohe’s delightful example and point out that the problem with the donut shortage was not caused by the people who couldn’t afford donuts. To say that would be to beg the question. The people who can’t afford donuts *REPRESENT* the donut shortage.

        To address them, we don’t need even more donut coupons for the people who couldn’t afford them. Especially if there are different doorways into the donut shop and the people who go into the coupon doors find themselves in lines forever because of donut shortages while people who go to the register will find themselves getting donuts.

        The lack of the donuts are the problem. The lack of donut providers. The lack of fryers, of ingredients, of toppings.

        Not the lack of donut coupons to help the people who can’t afford donuts without a coupon.Report

      • Avatar Mad Rocket Scientist in reply to zic
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        says:

        Now shortages willing to accept VA/medicaid rates is another matter altogether; but I submit similar shortages also apply to plumbers, auto mechanics, and lawyers.

        Last time I checked, plumbers & lawyers who do work for the VA/MediCare/MediCAID don’t get paid a reduced rate the way doctors do.Report

      • Avatar j r in reply to zic
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        says:

        It was already there; inability to pay for health care, in part, helped create it.

        I am having a hard time understanding how this would work. People need health care treatment, but cannot afford it, so they go without. That means less health care spending and less money going to doctors, so doctors stop providing services. Is that the mechanism?

        I though the reason that we needed the ACA is to control rising health care spending. Can it be the case that health care spending is so much that it threatens a looming fiscal crisis, but so little that doctors stop bringing their services to the market?Report

      • Avatar zic in reply to zic
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        says:

        I though[t] the reason that we needed the ACA is to control rising health care spending.

        The ACA has always been that 1) a lot of people couldn’t afford health insurance, let alone care, 2) those people put off getting care until they’re in crisis, 3) they still can’t afford that care, leading to 4) the cost is redistributed to everyone else, driving their costs up.Report

      • Avatar j r in reply to zic
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        says:

        @zic

        I think that you are reasoning backwards. The implication to what you are saying is that the lack of preventative care is the primary driver of increasing health care costs and I am pretty sure that is not true. You can give all the primary care in the world, but people still get old. People still have accidents. Expensive new medical treatments still come to market.

        Health care costs grow because the total amount of healthcare provided is growing and there is not a suitable mechanism (either price sensitive consumers with the power to shop around or a single health care payer to enforce price controls). Our health care system has always been in this weird limbo between freely operating market and nationalized health care system. We have the worst of both worlds. And while the ACA certainly expands the number of people receiving health insurance, I’ve never quite understood what the cost control mechanism is supposed to be.Report

      • Avatar greginak in reply to zic
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        says:

        JR, some of the cost control mechanisms were doing a ton of research into what treatments work and how much they cost to have better educated consumers and docs. Seems like that should have been a win/win. It was gutted but if i mentioned who fought it, that would make me a partisan meanie pants i think.Report

      • Avatar Troublesome Frog in reply to zic
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        says:

        If I then offer coupons to make the donuts even cheaper at the point of sale, won’t my line of customers get even longer? And create even more donut-deficient persons in my community?

        I would think that the outcome of this experiment would depend almost 100% on the behavior of an opaque group of oligopolistic Donut Middle Men who keep all of the players at arm’s length and aren’t really accountable to either donut makers or donut eaters.Report

      • Avatar Kolohe in reply to zic
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        says:

        There are, of course, the best at exploiting the holes.Report

      • Avatar zic in reply to zic
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        says:

        @j-r

        First, eating donuts isn’t necessary to one’s ability to be productive. Good health, on the other had, is great at facilitating that.

        There are a lot of nuances here.

        First, ACA is not necessary to the policy of providing mental health or substance abuse health care, it’s just the policy that we’ve got. So as a start, this argument is rooted in the policies in place, not some utopian world that might be nice to discuss, but not, you know, going to change thing within the framework that exists on the ground. On the ground, right now, we see several million people who have health insurance that didn’t have health insurance, we see some major overhaul in quality and efficacy in how health care is delivered, we’re all having the same discussion instead of 50 different discussions (I maintain this is the #1 gain from ACA,) and to all appearances, the cost-curve has been bent downward, whatever that means.

        But the discussion is about how ACA might help lower our prison rate, something I know is dear to both our hearts, and what role Medicaid might bear in achieving that. I know you’d prefer no ACA; but it’s still worth examining what benefits and other goals might be achieved because ACA is the policy.

        That said, we know that substance abuse and mental health care are sorely lacking for the people most in need of it; and inability to pay for it creates a barrier to accessing it. I’ll grant that this will mean increased costs; just as there are physician shortages, there are facility shortages for in-house treatment programs; there are probably shortages of mental health professionals, and a lot of those professionals (social workers, in particular) are overworked and underpaid. So I expect some of those costs to rise.

        But I also expect other costs to diminish. Like the extreme costs of keeping someone locked up in jail. And there’s the productivity of the people who would qualify for Medicaid but don’t take to their ability to be productive; we know convictions (jail time or no) create an economic drag. Then there are the fines, the loss of driving privileges (a problem in rural areas without public transportation,) and lawyers fees. These are all things that don’t bring the person with an addiction or a mental illness closer to better health or productivity, and add to the drag they create on the lives of people close to them — and that’s another economic cost that goes unmeasured.

        But I don’t want to bother with this long drawn out re-arguing ACA and I don’t want to waste my time on a policy that might be, unless it’s already starting from the reality we’ve got on the ground right now. I’d argue that for too long, our first line of dealing with people who have addiction or mental illness has been justice, and I’d like to see if health might be better; with more money spent on doctors and social workers and rehab programs and less on jails and courts and police and lawyers.Report

      • Avatar Chris in reply to zic
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        says:

        First, eating donuts isn’t necessary to one’s ability to be productive.

        Not gonna make cop jokes… not gonna make cop jokes.Report

      • Avatar zic in reply to zic
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        says:

        @chris a while back, a local radio station started calling donut shops, due to the cop joke. After a couple of weeks, without a single hit (there was never a cop at the donut shop,) the joke became the joke.

        Just sayin’Report

      • Avatar Chris in reply to zic
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        Here if you want to find a cop you just go to a 7-11. It’s not donuts, but free coffee that draws them in. Of course, our donut shops are spread pretty thin.Report

      • Avatar j r in reply to zic
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        says:

        @zic

        I think that you’re confusing me with @kolohe. I haven’t said word one about donuts in this thread.

        I said two things. I said that I don’t understand the economic mechanism by which an inability to pay on the part of the uninsured would lead to a shortage of doctors, as healthcare spending was increasing overall.

        And I said that I don’t understand the economic mechanism that by which a rapid increase in insurance coverage is supposed to bring down health care spending. It may make health care insurance more affordable to some people, but it does so by shifting the cost to others not by bringing down the total costs. If anything, more people receiving more health care goods and services is likely to increase spending.

        As for the role of increasing Medicare coverage in reducing incarceration rates, I’m open to the idea, but skeptical. Seems to me that the best way to reduce incarceration rates is to stop arresting and prosecuting people for victimless crimes and stop putting people back in jail for minor parole violations. Not sure that I am buying the connection, but like I said, I don’t have strong feelings either way at this point.Report

      • Avatar zic in reply to zic
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        @j-r I said that I don’t understand the economic mechanism by which an inability to pay on the part of the uninsured would lead to a shortage of doctors, as healthcare spending was increasing overall.

        The doctor shortage is primary care, before ACA passed, there was pent need for primary care doctors already; and a trend in the market creates to create specialists, and I’m sure in some specialty fields, there are shortages, too. There were millions of people who needed a primary care doctor, but didn’t have a primary care doctor.

        @will-truman bait here, a search engine to help you find areas that are ‘underserved.’ I ran Ohio and Primary care, and the list is very very long. The shortage we see now is, in part, the pent need from before.Report

      • Avatar zic in reply to zic
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        says:

        and @j-r I did confuse you and @kolohe I apologize to you both; really a problem of my not having good thread etiquette, and knowing when to respond in general and win specific. I need to put more effort into considering that before I post.Report

      • Avatar j r in reply to zic
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        From the little bit of self-educating that I’ve been able to do here and elsewhere on the primary care physician shortage, it appears that it is largely being driven by a move towards specialty-driven medicine. That raises two questions for me:

        1. Is that move a good thing? Would we be better served moving back towards a model where the primary care physician did more actual treatment and specialists were deployed less frequently?

        2. If the specialty-driven model is here to stay, would we be better served in letting the primary care physician go the way of the dodo and get most of our primary care from physician’s assistant’s and nurse practitioners? Is the AMA the only thing keeping us from going that way?Report

      • Avatar zic in reply to zic
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        @j-r those are excellent questions. Part of what I like about ACA is that it specifies that we probe them in various ways.

        would we be better served in letting the primary care physician go the way of the dodo and get most of our primary care from physician’s assistant’s and nurse practitioners? Is the AMA the only thing keeping us from going that way? Reading the American Association of Physical Assistants webpage, I’d say ACA trends toward more PA-directed primary care, funneling patients to specialist and screening for those who do need a doctor’s time, but not necessarily a specialist’s time.Report

    • Avatar Saul Degraw in reply to Jaybird
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      As I understand it, the doctor shortage is a combination of various factors. Will Truman and Russel Saunders probably knows much more but as I understand the factors, they are:

      1. Primary Care/General Practice doesn’t pay much and hasn’t paid much for years. Doctors are moving more and more into specialization which pays bundles.

      2. It is getting harder and harder for doctors to have their own practices and many are joining systems like Kaiser or One Medical where they are salaried employees instead of people with their own practices.

      3. Doctors don’t want to move to rural places anymore for a variety of economic and cultural reasons.Report

      • Avatar Kolohe in reply to Saul Degraw
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        VA facilities are never (2) and rarely (3) (that was the unstated premise in the Guam VA problems in the John Oliver bit on US possessions and territories)Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
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        4) The number of medical schools is limited, and the AMA is reluctant to extend it’s blessing to new schools, or to immigrants with medical training absent extensive retraining.Report

      • Avatar Will Truman in reply to Saul Degraw
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        The latter part of 4 is true to an extent, but the first part is (or has become) more complicated. Medical schools and residencies are hard and expensive.Report

      • Avatar LeeEsq in reply to Saul Degraw
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        Contrasting the behavior of the AMA and the various bar associations is revealing. The AMA does all it can to limit the number of people who can practice medicine in the United States. It refuses to accredidate new medical schools and makes importing immigrant doctors difficult. Bar associations don’t make it easy to become a lawyer but they freely accredidate new law schools and only makes immigrant lawyers take the bar and moral character examinations. It does not make them go to law school again.Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
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        @will-truman

        So, I am told, is law school. Didn’t seem to stop that explosion.Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
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        My understanding is that admission to medical schools are extremely competitive and difficult, and that medical schools rarely have a hard time finding a supply of qualified candidate students, which tells me that there is a large supply of people willing to try learning how to be a doctor, but a very limited supply of training slots available.

        Opening more slots tomorrow would give us more doctors in ten years. How many doctors and of what practice might be a good question, but there would be more.Report

      • Avatar Dand in reply to Saul Degraw
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        @leeesq

        My understanding is that it isn’t the AMA but another organization.

        @will-truman

        Where is the bottleneck if not medical schools?Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
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        @will-truman

        Toward the cost of opening a school, I say hogwash. Schools have been pissing money away on amenities that have little to do with their core mission, and on boosting administrative salaries to corporate CEO levels. They have the money, they just don’t really want to spend it there, which makes me wonder why* (since I doubt decent Med Schools lose money)?

        That (residencies) I get, except I have to wonder if that isn’t just a bit of defeatism. Perhaps there is another way to complete the training besides a residency. Or, if we know that in 10 years, there is going to be something of a glut in people seeking residences, we could, you know, plan for that and have slots ready for them when they graduate. Or we could do more to help immigrants get their medical license (accelerated programs to cover gaps in training & experience, etc.).

        *The ACA may not be able to tell a university whether or not they can open a med school, but they can make a very expansive & potentially wasteful list of accreditation requirements such that smaller schools can’t hope to meet those demands. For example, ABET has a comprehensive list of requirements for engineering programs, but a university does not have to have a working fission reactor or fusion bottle before they can get ABET accreditation.Report

      • Avatar Jaybird in reply to Saul Degraw
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        It’s very difficult to make a doctor.

        You can take anybody off the street and turn them into any number of professions (if you can use a full keyboard, you too can be a sys admin!) but you can’t just make a doctor.

        Now… it’s somewhat easier to make a laser-focused specialist. The person whose job it is to find a vein and take blood (or give you a bag of fluids)? That’s a lot easier to make than a doctor. An x-ray tech? Easier to make than a doctor.

        Luckily, most people don’t *NEED* a doctor. They merely are, to use an example close to home, experiencing flu-like symptoms. A nurse practitioner who is just going to check for kidney stones, make sure that there isn’t an intestinal blockage, and check the blood sample for an unearthly level of white blood cells is good enough in 99.9% of cases.

        The doctor shortage can be mitigated for the most part by these people who do a good job for 99.9% of cases… but it’s like a handgun. You don’t need one until you need one very, very badly.Report

      • Avatar Will Truman in reply to Saul Degraw
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        The AMA doesn’t accredit law schools. The LCME and AOA do. The AMA is a co-sponsor the LCME, along with the American Association of Medical Colleges, and right now both organizations actively recognize the need for more medical schools, but they can’t build them. And even if they wanted to, they couldn’t block them because if a potential school got sufficiently frustrated they could go the AOA route (the AOA would love more DO schools). Like I said, I’ve watched debates on this go on for years.

        The cost issues are immense. You don’t just need a lecture hall and a some professors to teach. You need facilities, a qualifying hospital willing to host you, and you need faculty that derive from a well that’s already running low on supply.

        It is not inconceivable that residency requirements could be modified to allow for something else in lieu of residency, but that hasn’t happened despite the choice being in the hands not of the AMA (or LCME or AAMC or the ACGME which handles residencies) but the state boards of the states facing the shortages. I’m not convinced that there isn’t another way – in fact, I actively support some sort of bypass, a sort of apprenticeship – but that states that are crying for physicians haven’t gone this route tells me that they don’t see another way that they are satisfied with. And every physician I have ever talked to about it, including those like my wife who are desperate for the physician shortage to be alleviated, agrees.

        I wish it were as simple as the AMA. First, because I don’t like the organization (they primarily represent the interests of specialists, and not primary medicine). Second, because then it would be a much more easily solvable issue. Instead, it’s a boatload of moving parts.

        I would, as mentioned above, support a bypass of some sort. I’d also like to see the residency map updated and expanded (congress stopped funding residencies in the late 90’s, freezing a generous supply of them in the east and a dire shortage in the west). Absent that, I’d like to see more states try to bite the bullet and start up their own residencies, as Montana recently did, or find ways to expand existing ones (which is a part of Clancy’s current job, though it’s nowhere near being off the ground yet – and not because of unnecessary ACGME/AMA/AAMC roadblocks).

        I mean, there are some unnecessary roadblocks. To use Clancy as an example, she has delivered over 1000 babies and performed over 300 c-sections, which is significantly more than the average freshly-minted OB residency graduate, and she wouldn’t be able to get privileges to deliver babies at over 75% of hospitals out there. But that’s not the AMA, or national or statewide government or guild policy, for the most part. It’s just a part of a machine with all sorts of moving parts, and a culture, which makes it a hell of a tough nut to crack even when everybody recognizes the problem.Report

      • Avatar Dand in reply to Saul Degraw
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        @will-truman

        Have you written a post on this in the past that you have a link to? If not I think it would be a good subject for a future post since your comments are very informative.

        If residency slots are the issue then all raising the number of Med schools would do is create a crisis similar to the law school crisis.

        Do you think making immigration easier for doctors would do any good?Report

      • Avatar Will Truman in reply to Saul Degraw
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        says:

        Dand, thanks! One of my first posts on Not a Potted Plant touched on this, though I can’t find it and from what I remember it was a bit oversimplified anyway.

        In the drafts I have a collection of about ten links for a post I’ve been meaning to write for quite some time here. I keep finding new things for it, which keeps making it a bigger project, which keeps pushing back when I write it. At some point, I may just post the links in a “make of this what you will” fashion

        Ironically, one of the reasons I haven’t been able to get around to it is that I will need some spousal support (looking after the little one) and spouse has been supremely busy lately… due in large part to the physician shortage at her job (with the residency).Report

      • Avatar Will Truman in reply to Saul Degraw
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        says:

        Oh, and to answer your question, immigrants run into the same problem that medical school graduates would. In fact, there’s a relationship. As medical schools have been graduating more students, they’ve been edging out immigrants for the existing residency slots. When there was a greater shortage of medical school slots, residencies would often reach internationally. As the disparity between residency slots and medical school graduates has closed, though, it’s getting harder for foreign students to get slots. This affects not just foreign nationals, but also Americans who study abroad. My understanding is that they’re all having a harder time getting even run-of-the-mill family practice residency slots.Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
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        says:

        @will-truman

        I agree with the gallery above, you should do that post!Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
        Ignored
        says:

        a qualifying hospital willing to host you This I could see as a major impediment to a new med school. The facilities cost issue is not (for the reasons I stated before).

        The residencies issue seems to be unexpectedly much more political than I would have guessed, which scares me more than a little. Did the ACA process even try to address this?Report

      • Avatar Jaybird in reply to Saul Degraw
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        says:

        I keep hearing stories about residency that involve, for example, shifts that last one jillion hours.

        This strikes me as an opportunity to have two residents each working 1/2 jillion hours. Or three working 1/3rd of one jillion hours.Report

      • Avatar Burt Likko in reply to Saul Degraw
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        says:

        If only we had an Actual Doctor who sometimes hung around these parts to address questions like that…

        Actually, I can recall discussing this exact issue (ridiculously, cruelly, and dangerously long hours for residency shifts) with him and being pleased to learn that there is a trend away from this sort of thing. “Trend” and “actually happening on a widespread basis” are different things, I realize, but “trend” is better than “hopes and wishful thinking.”Report

      • Avatar Mad Rocket Scientist in reply to Saul Degraw
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        says:

        @jaybird

        This is one thing I’ve heard a lot regarding the residency system, that reforming it is difficult because the doctors we have are of the opinion that they had to trudge through a brutal residency, so should the new crop of kids.

        I remember being in basic training, and even out in fleet, and listening to salty dogs carrying on about how tough basic was back in their day, and how they used to get cussed at, insulted, and beaten, and how kids these days are somehow inferior because they weren’t cruelly abused in basic. Strangely, none of them could articulate how such abuse made them better professional sailors, other than some noises about “toughened us up”.Report

      • Avatar Will Truman in reply to Saul Degraw
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        says:

        @mad-rocket-scientist

        PPACA did multiple things to try to address the issue. While it didn’t create spots, it turns residency spots into use-them-or-lose-them for programs, and if they are lost the funding gets redistributed elsewhere. Going forward, residency slots of hospitals that close or close their programs will also be redistributed instead of eliminated. Lastly, it provides more flexibility for residency programs to use more than one hospital (this may have helped Montana launch its residency, for example, allowing them greater ability to use hospitals from across the state). It wasn’t as much as I was hoping for, but it’s not nothing.

        @jaybird , residency hours have been tightened considerably. It’s been bumpy, but at Clancy’s residency it did result in finding the money for one more residency slot. There’s only so much that this can be cut, though, without needing to add years to the residency (which would reduce the number of graduates).Report

      • Avatar Will Truman in reply to Saul Degraw
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        says:

        @burt-likko It’s more than just a trend. in 2003, they passed some rules and regs. Clancy started the first year after they were implemented. Interestingly, the first year the director said that he had never seen residents so exhausted as he had the first year after they took effect. In order to keep everybody under 80 hours every week, they basically made sure that everybody worked 80 hours every week, so Clancy would be doing a pediatric rotation, and instead of getting to rest when she got home, she had to scramble over and handle obstetrics call or inpatient. So there were no “down” rotations, unless you were doing something across the state.

        The second year, though, as mentioned they added a new slot for “Night float” which reduced the overall workload and made things more manageable. I think there were quite a few kinks to work out.

        @mad-rocket-scientist is right about the “hazing” aspect of it. There was a ton of resistance in what came across in very much this manner, which was just maddening to me because physicians are way out in front when it comes to preventing other professions from working too much (truckers, specifically) and warning of all of the dangers of overworking. They’ve since done something else to the residency hours, lowering them further. I can’t find any reference to it, but Clancy has mentioned that the residents today are far more protected than they were back in her day.

        Interestingly, the reason that they cut down on the hours was patient safety and the threat of drowsy doctors to patients… and I linkied a link a little while back that said it actually didn’t affect patient outcomes at all.Report

    • Avatar Chris in reply to Jaybird
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      says:

      The VA has had doctor shortages for some time, because the VA has been generally underfunded for some time. NPR has probably used the phrase “doctor shortages” in the neighborhood of the acronym “VA” for a while now; certainly since investigations into issues with the VA began in earnest a couple years ago.Report

  4. Avatar Saul Degraw
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    says:

    I largely agree with this post but I am much more skeptical than Michael Cain about the prospects of the 22 hold outs going for medicaid expansion.

    The GOP has not let off on the rhetoric that Obamacare is bad bad bad. I don’t think they are necessarily rational actors like so many in the pundit and wonk-sphere like to suggest but highly ideological ones whose theories and belief turn them against everything that has the vaguest whiff of the welfare state even if it does in a largely market-friendly way like the ACA.

    The GOP seems to have been taken over by the hardcore partisans who have viewed any Democratic elected government or politician as being somehow illegitimate.Report

    • Avatar Michael Cain in reply to Saul Degraw
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      says:

      According to the Kaiser Family Foundation (map, with a link to a table showing more details), 6 of the 22 are “considering” expansion to one degree or another. Of the remaining 16, the governors in Alaska and Wyoming now favor expansion. Gov. Brownback, in Kansas, said last week that he would sign an expansion bill if it were revenue-neutral. A governor-appointed panel in Idaho has recommended expansion because it’s cheaper for the state than the costs of current state and county indigent-care programs. Nebraska’s expansion bill died despite a 27-21 majority (cloture required a two-thirds supermajority). All of those states are a handful of rural hospital closings, with the state hospital association trumpeting “Hundreds of millions of dollars of charity care!” away from approving expansion.

      I could see maybe 10 holdouts by the end of the 2016 legislative season, all but one or two of them in the Deep South.Report

  5. Avatar Damon
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    says:

    How about this? Let’s end the drug war and pardon everyone who’s in jail for non violent drug related crimes.

    Shove the users in treatment plans. Then we can talk about the balance of the prison pop.Report

  6. Avatar aaron david
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    says:

    “One basic challenge with drug and alcohol treatment is that these services are in a separate system that people don’t want to use, and don’t use. With the Medicaid expansion, you can go to a neighborhood clinic and they can help you get Methadone or Suboxone. They can also get you the psychiatric care you need within the same umbrella of your regular care. So it is much more likely that people will use it.”

    Why wouldn’t they use the one system, but will use the Medicaid system? From what you posted, that alone is way, way to much wishful thinking.Report

    • Avatar greginak in reply to aaron david
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      says:

      There isn’t one system because over the years the funding streams for the different kind of services developed separately. The medical system will treat medical stuff but not substance abuse and wouldn’t provide many kinds of mental health services. Starting in the 90’s Dem’s pushed for an end to insurers paying less, or not at all, for mental health services. This has improved the access to people for mental health care. Substance abuse is also in an odd place since what insurers will pay is often nothing or limited. Since the AA model was prominent for some many years insurers didn’t get in the business of paying for in or out patient treatment. That has started to change but requires having good insurance. My experience is if people want substance abuse treatment or MH care they don’t’ care which bucket the money comes from, they just want to get the care they need. If Medicaid paid they would use that if they could.Report

      • Avatar aaron david in reply to greginak
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        says:

        Again:
        ““One basic challenge with drug and alcohol treatment is that these services are in a separate system that people don’t want to use, and don’t use.”

        How would this change? If it is there, and people don’t like using it, how would bringing in a new system fix that.Report

      • Avatar greginak in reply to greginak
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        says:

        I think they are saying for for simply substance abuse trt it is easier to go to your regular docs office where you can also get psych meds if you need them along with your general medical care. They are referring the use of some drugs like suboxone to treat substance abuse which you can get from a doc but not generally at substance abuse treatment centers. If you can go to your regular doc’s office to get psych meds and some SA trt that makes it easier for someone to get care in a place they are known and likely feel more comfortable then a new provider. Getting into the substance abuse trt system requires a new provider , going to a different place and learning a new system. That may be necessary for some people, but for some people it just places another hurdle that get all services through you GP’s office and medicaid removes.

        Lots of people want to get into substance abuse treatment but lack the money or good insurance to pay for it. Those people often have a short window when they are willing to try treatment while they are struggling to stay sober and before falling back to their drugs. Removing extra steps is always a good thing for people who are struggling.Report

      • Avatar zic in reply to greginak
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        says:

        @aaron-david it’s a bureaucratic nightmare; each program is run by a different agency, based upon the funding streams. This will also vary by state dramatically, as programs here are generally administered by the state. Applying for assistance has been made as humiliating as possible, too. Moochers, you know.Report

      • Avatar aaron david in reply to greginak
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        says:

        @greginak
        That maybe true, but if that is what they are arguing, they need to be much clearer. And they need to show how this proposed system will make up for that.

        @zic
        So, how is this going to reduce the bureaucracy? Again, if that is what the article Tod is quoting is arguing, they need to both say that and show how. And while I am well clear on how humiliating it has been made, that is a reflection of how the population at large thinks about this. In any case, the authors didn’t seem to mention how this would change the public perception of “moochers.”Report

      • Avatar greginak in reply to greginak
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        says:

        @aaron-david I’d actually say the best point is that many people in prison have mental health and substance abuse problems. If we want to get them out and keep them out then those issues need to be addressed. Unless millions of jobs for ex cons open up that also have really good insurance some sort of Gov insurance is the only way their needs are going to be met. Treating their needs is good for them and good for everybody else since it reduces recidivism. And also the simpler that can be done, the better.Report

      • Avatar aaron david in reply to greginak
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        says:

        @greginak
        “I’d actually say the best point is that many people in prison have mental health and substance abuse problems.”
        Yep

        “If we want to get them out and keep them out then those issues need to be addressed.”
        Absolutely

        “Unless millions of jobs for ex cons open up that also have really good insurance some sort of Gov insurance is the only way their needs are going to be met.”
        This sounds, to me, like a parole issue. In other words, we already have a system in place that the people the article is using for its base have to interact with. If these actions are what we are doing to help ensure a low recidivism rate, and help non violent offenders get out early, well we should use that. I know that you work with the system in AK, and obviously have greater knowledge of its ups and downs than I do, but it seems that adding extra bureaucracy to the mix wont help.
        “Treating their needs is good for them and good for everybody else since it reduces recidivism. And also the simpler that can be done, the better.”
        Exactly. One of the sticking points for me is the authors, and by extension Tod, are doing a lot of hand waving in regards to dealing with increased gov’t action. As I pointed out, if people aren’t going to one set of treatment options because ” people don’t want to use, and don’t use” them, just creating more wont help. Work with what we have, or use actual reasoning in the argument for greater gov’t expansion.Report

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