Hey Patrick Murphy: At some point, you have to pick sides. (And right now you are on the wrong one.)

I like Patrick Murphy, Philly and Bucks County's young Congressman. He seems fairly responsive and upfront, he has a good personal story, he is likable, and many people think at some point, he will run for higher office. But he should be careful, because if the Congressman is ever going to be able to re-engage progressives on a level that he achieved in his 2006 election win, the time is coming for him to pick sides.

What I am I talking about? His membership in the so-called Blue Dog caucus.

The Blue Dogs are, in theory, simply supposed to be fiscally conservative Democrats. There is nothing inherently wrong with that. But the reality is much, much different. What they really do is frequently kill or water down good actual progressive legislation, usually with the needs of big business in mind. So, despite the fact of of our impending global catastrophe, they made the climate change bill a weak, almost do-nothing, embarrassment. But they did it with a smile, and by calling themselves moderate.

And now, they have their hands around the neck of health care reform, and are squeezing as tight as they can to make good bills into bad ones.

How?

As a first example, the House suggested that we pay for health care by taxing the wealthy. This would not only make the healthcare plan deficit neutral, it would make the plan actually produce a surplus. So, if you are primarily concerned about deficits, as the Blue Dogs supposedly are, you would like that, right?

But, what if you are really concerned with helping high income earners, or big business at the expense of others? Then no, you don't like that option. So instead, the Blue Dogs effectively proposed a middle class tax increase, and that the government should insure less lower income people. Again, effect on the deficit: the same. But to the Blue Dogs, helping less people, and taxing more from the middle class? A good day's work.

As a second example, the Blue Dogs have been trying to oppose a real public option for universal healthcare. As most people know, a real public option is crucially important to achieve real reform, and not to simply fatten the coffers of the insurance companies. It is also supported by a large majority of the country. But still, the Blue Dogs persist.

Oh, and on a completely unrelated note, there is this:

The Blue Dog's political action committee has collected $1.1 million in the first six months of the year -- more than any other political action committee, according to CQ. (Subscription required.) Nearly 54% came from the energy, financial services and health care industries, according to an analysis by the non-partisan Center for Public Integrity. That's up from 45% in 2004. The center's reporting appeared in Politico.

Right now, the biggest obstacle to universal healthcare for all Americans, paid for in a sane way, is not the GOP. It is the Blue Dogs. Which brings me back to Patrick Murphy...

Yes, on occasion, Rep. Murphy has said he disagrees with his own caucus, including on the public option. And he is doing some good stuff- like picking up the mantle on "Don't ask, don't tell." But at some point, the fact that he caucuses with- and therefore lends power to- a group that has stood against a real climate change bill, real mortgage reform, real financial oversight, and that is now slow walking health care to its doom, matters.

At some point, Patrick Murphy has to pick sides. He can have it both ways for only so long...

not so "fiscally conservative"

the blue turd line about their fiscal conservatism is nothing but dog crap.

their votes on war demonstrate this: there's no "pay-as-you-go" constrictions then. They have voted for every single off-budget supplemental that has passed their desks.

Or the bailout: no strings attached, no reporting requirements.

here's a piece at fdl about the blue dogs making sure taxpayers don't get a share of the profits from the banks we'resubsidizing: http://firedoglake.com/2009/02/02/fiscal-conservatism-blue-dog-style-muc...

fiscal conservatism, my butt.

and i for one will not be helping pat murphy ever again.

Nate Silver's take on Blue Dogs

Nate has a very interesting take on the whole situation, and I think it applies somewhat to Pat Murphy's district too. The bottom line is that of all the parts of the Dem agenda, the one that offers any hope of popularity in GOP-leaning districts of sitting Blue Dogs *is* health care reform.

Plus Nate reels off this funny line about the 2012 GOP: the Republican candidates in 2012 are Dopey, Sleazy and Romney

A Note to Blue Dog Democrats on Health Care and Pascal's Wager

http://www.fivethirtyeight.com/2009/07/dear-mr-blue-dog.html

Low sacrifice issues

I'll probably be flamed for saying this, but it always frustrates me when progressives go hard on social issues (that don't really cost any money) as a way to get a pass on the sacrifice issues: that is, the ones that involve money.

If you go loud and active on issues like Choice, Marriage Equality or Affirmative Action, that's all to the good. The trouble with those issues is that they are very deeply felt by certain segments of the population but they are not widely felt like an issue like taxes. Or the Right to Organize. Or Climate Change.

Those are the issues that cost money and they are the issues that require the sort of reprioritizations that actually impact our resources (our money).

If a Progressive isn't with the people on Money, I'm not about to give them a pass by taking strong stances on social issues, because those issues don't hit everyone where they live (and by that I mean money).

If I haven't made it clear: it's about where we put the money.

---
This Too Will Pass, for the guts in your cerebrum.

What the Blue Dogs call "fiscally conservative"

is frequently just "I'm askeered of being painted a 'socialist' bogusly" and as Dan points out - often leads to policy stands directly counter to what you would think it would mean - concern about balancing the budget. "Fiscally conservative" should mean concerned about money being well spent, not "I support legislation so wishy-washy it doesn't accomplish anything". There are times when results matter and on health care - a strong public option funded by something that will be a realiable source of revenue matters.
-Sean
MrLuigi, my cat, actually only types half as badly as I do.

Why enough Blue Dogs will come around

President Obama, the Democratic party and thus the survival of the Blue Dogs, many of whom are in purple districts, depends on health care reform being enacted. And if it is enacted, the Blue Dogs districts will become blue.

Details are here: http://blog.stier.net/?p=374

That doesn't mean we can relax. Our goal is not just to enact legislation but to make it as good as possible. On some issues, such as creating an independent board to develop new payment and health care delivery practices that wil both save money and reduce costs, the Blue Dogs have some good ideas which should wind up in the final bill. They are not entirely wrong about rural disparities in Medicare payments and that can be fixed, too (although it will add to not reduce costs.)

But some Blue Dogs are just antsy about voting for any tax increase and want to reduce subsidies from 400% of FPL to 300% of FPL. That's the wrong direction and we've go to stop it.

So, I'm pretty sure we are going to win, but we need your help to make sure that we win as much as we want.

Rep. Patrick Murphy and Health Care

One more thing: I really wish Representative Murphy were not part of the Blue Dog caucus. Every additional member of that caucus strengthens the hands of a caucus leadership that on some issues is leading in the wrong direction.

But, unlike other PA Blue Dogs, Representative Murphy has been publicly breaking with the Blue Dogs on some issues and working within the caucus to make their position more palatable to progressives.

One more thing: I really

One more thing: I really wish Representative Murphy were not part of the Blue Dog caucus. Every additional member of that caucus strengthens the hands of a caucus leadership that on some issues is leading in the wrong direction.

On what issues would they be leading in the right direction?

Anyway, I hear you. Patrick Murphy is better than Mike Ross. But at this point, he is going to have to explain whether he agrees with them on the issue after issue where they have stood in the way of common sense legislation. And if he doesn't agree with them, then what the hell is he doing in the caucus empowering them?

Blue Dogs helpful on containing costs

As I pointed out above, the Blue Dog caucus has taken the same position as President Obama about creating an independent commission to suggest changes in Medicare (and, the publich health insurance plan) payment systems. The goal is to (1) from a payment system that reward Doctors and hospitals for doing s procedures--some of which may not be necessary--to rewarding them for keeping people health; (2)encourage more primary care and coordinated care.

The rought idea is to model the commission after the base closing commission: it would propose a series of changes which Congress can vote up or down as a whole.

The leaders of the committees that deal with health care are not crazy about giving up some authority to an independent commission. But such a commission would make is easier to make changes in health care payment and delivery systems that would improve quality and reduce costs. So I'm with Obama, and the Blue Dogs, on this.

Of course, some of the other things the Blue Dogs want for their own constituencies--such as increasing Medicare payments for rural areas--might increase costs. So they are in the paradoxical postion of supporting a general proposal that might make it harder for them to serve their special interests later. That might be hypocritical but it doesn't make the general idea--the independent commission--any less valid. Rather, it points to why we need it.

As far as the Commission

As far as the Commission specifically, the Progressive Caucus has already thrown up a lot of yellow flags about it. Because while sure, it could be a way to 'get the politics' out of Medicare governance, it could also be a way to cut at Medicare and the public option.

We are also concerned about the latest discussion regarding the Independent Medicare Advisory Commission (IMAC). We understand that no final decision has been made. However if discussions move forward to make IMAC a reality, we ask that you include us in discussion as we have concerns with the governance, oversight, and the impact it would have on seniors, people with disabilities , doctors, and hospitals. Furthermore, we are concerned that IMAC could weaken the public option and negate our responsibilities as Members of Congress.

http://cpc.grijalva.house.gov/index.cfm?ContentID=465&ParentID=0&Section...

Progressive Caucus Sure Doesn't Like The Commission

The Progressive Caucus sure doesn't like the commission. I don't blame them. I don't like it either.

The whole problem with health care, however, is almost all individual care services are highly popular in the sense of being widely in demand, but the total cost of all the services ia highly unpopular because of affordability problems.

This situation is somewhat analagous to military base closings, in which there was a general agreement that there were far too many military bases in the U.S., but each military base had its own passionate constituency. The base closing commission did shut down a good number of miltary bases, which had been located originally bar more for the political strategy of gaining votes in Congress than for purposes of military strategy.

So I can see the rationale for the commission, even as I sense that somewhere down the line it will be making cuts of services that are individually unpopular and that Congress by itself would not make. I would hope that the gains in affordability would improve health care more than the cuts in services would hurt health care.

Like the FCC? The base

Like the FCC? The base commission model might be a good one. But it also could be a way for insurance company lobbyists to make an end run around real reform.

Why the commission makes sense

We can't go back to the model of medicine in which every doctor decides what to do without anyone looking over his shoulder and insurance companies paying for it. That worked, at least for people with insurance, when doctors basically couldn't do all that much and health care was cheap.

And that is basically the model single payer supporterse like to point to, saying that eliminating paper work and administration will make it possible to insure everyone. That is just simply not true.

We can't provide health care for everyone over the long term unless we figure out ways to reduce costs. And we can't provide good care unless we set in place incentives and rules that encourage doctors to stay current with best practices including, of couse, preventive care, chronic disease management, coordination of care and the integration of medical care with diet and exercise. Those rules and incentive don't exist today.

The independent commission, together with the public plan and radically changing the business model of private insurance, is a mechanism to create those rules and incentives.

Ultimately Congress will have the authority to accept or reject recommendations of the commission. But having it in place will help secure the support of members of Congress whose backbone is not a strong as their voice.

For another post moving in the same direction see:
http://www.dailykos.com/storyonly/2009/7/24/757451/-The-Supreme-Court-of...

I agree we have to change

I agree we have to change incentives. But, I am not convinced that this will do it. Again, who appoints these people? How many of them are there? What are their qualifications? Will it control costs, if it is a five member panel, with the head lobbyist of Pharma, the head lobbyist of the Hospital Association, etc, serving on it? I am not saying that it is a terrible idea, but, I do think that it is a terrible idea to simply accept it without a clear understanding of its governance.

As you suggest, there are other ways of getting costs down, and changing incentives. And I think they would think carry less risk, such as getting away from fee for service medicine. Combining that with a public option would go a long way.

We need a mechanism to do all those things you want

One reason the public plan is so important is that it, together with Medicare, will be where we try out experiments with different deivery and payment models so that we figure out what works the best.

There are a lot of good ideas about what to do, some have worked at a small scale (eg at Geisinger and the Cleveland Clinic). But we dont' know what's best and will scales ups well and work nationwide.

Someone has to both push for change--encouraging experiments, evaluating them, making some small nationwide reforms--as we learn more sort of the way CMMS has authorized states to adopt various programs that expand care.

So the question, Dan, is who should do it?

Can we leave it up to Congress?

Should it be a single official appointed by the President?

Should it be a board appointed by the President with the advise and consent of Congress?

I'm not quite sure. But someone has to do it.

And I'm inclined to think:

1. Aside from major changes which should have Congressional approval, this is a task that should be carried outside of Congress.

2. A commission, including one that has representatives of major stake holders including consumers and labor, make more sense than an individual because a) these are complicated matters that require deliberation and multiple sources of information more than immediate decisions; b) we need to get buy in from those stake holders.

3. I trust Obama to appoint the right person or person and to ultimately push the commission in the right direction.

Re: this close

I don't think you need a commission to experiment. Again, I am not against the idea, in theory. But, I think the governance of it, the scope of it and how the members are appointed should be a big deal.

How well do the FCC and FEC function? What happens when Obama is no longer in office?

So who should make these decisions?

I'm curious what your suggestion is. And how the "what happens when Obama is no longer in office" applies to it.

At this point, we need to get the legislation passed with some mechanism for moving costs savings forward. And that requires some kind of agreement among the Ds about how we want to do this.

One of the arguments I have with single payer folks is that they act as if once we have single payer in place, then we've reached the promised land and we can move on to some other issue. That's crazy. Any reforms we make now that expand affordable coverage to everyone will be the beginning of ten years of debates and struggles over how to improve health care delivery and save money.

But if we blow the opportunity to expand affordable coverage to all now by trying to have all those debates and struggles next week or in the next two months, we will never get to the next stage.

That's what should be telling both Blue Dogs and Progressives. They need to take advantage of this unique moment, make a deal, and bet a good House bill into a conference committee.

And if we do that, then I'll worry a lot less about what happens when Obama leaves office because health care reform (and EFCA) is going to lead to a generation of Democratic control over national politics.

I am not saying I know what

I am not saying I know what the perfect solution is- although I think compensating providers for pools of people, rather than fee for service, and having a public option is a start. It works OK in other countries, right?

In any case, now you are talking about what needs to be done to make a deal, which is a different argument than where it started- that Blue Dogs should be applauded for leading us here. They are consistently wrong, and consistently on the side of big business over ordinary people. So, I am not really excited to jump into something so undefined, led by a group of people that I don't have any reason to trust.

We shoul take good ideas wherever they come from

I know its not the Philly way of doing things since for us, helping friends and harming enemies is the touchstone of politics.

(You would have thought that Socrates had demolished that idea in Book I of the Republic. Oh, well.)

Anyway, this idea came from Obama via Peter Orszag before it came from the Blue Dogs.

Did I say we shouldn't?

Did I say we shouldn't?

I thought so

led by a group of people that I don't have any reason to trust.

But maybe this is just a warning to look more closely when the other side proposes something.

On the whole, it often useful in politics to find good idea that come from the other side and embrace them. It makes it easier to find common ground on other issues.

And this commission--which really is a pretty minor change from the original bill which gave the HHS Secretary roughly the same powers and left it pretty unclear what kind of Congressional oversight would be involved--is a good ideas.

I am not against good ideas.

I am not against good ideas. Again, I am not convinced, until I see more details about how it would work, that this is particularly good.

Doing the right things...

I agree with Mark. On most of the issues that come before congress, Patrick Murphy does the right thing. I don't see any real reason to take issue with his choice to join the Blue Dog Caucus even though most of the Blue Dogs vote what I think is the wrong way Patrick rarely does.

There is value to having someone in that caucus with their heart in the right place. Probably more than they get from having one more member and being a member probably helps him in district.

My job is not to represent Washington to you, but to represent you to Washington.-Barack Obama
Philly for Obama

Sure there is value in that.

Sure there is value in that. There is also value in having those types of people in the Republican Party. If he switched parties, but still voted the same way, would you be cool with that?

An expert commission plays a role in the French system

I agree with Dan that the make up and governance of such a commission of health care experts is key to its working to actually maintain a system that puts the American people's interests ahead of the special interests of the health care industrial complex. Put an insurance lobbyist in control of it, and the whole thing likely blows up.

But there will be risk no matter who runs the show.

Once a public option is in place (that's the first BIG deal) I prefer the idea of a non-political expert commission (perhaps an ideal empowered MedPAC) that at least initally, in the broad daylight of media-covered public discourse (picture Obama-negotiated legislation passing House/Senate to empower it + a televised speech to explain it for the public and the history books) would be given ONE MISSION: make U.S. health care run as efficiently and as cheaply as possible, while providing good universal care.

I think making the commission's initial mission as public as possible and, at least in the early years, returning the public/media's attention to it regularly, is about as good as you can do, as far as trying to rig how things will go in the future. Future Congresses and presidents are going to have their hands on it, no matter what.

Beyond simply creating new efficiencies in delivery -- which should be a given -- the newly empowered commission could act directly to lower costs. Robert Reich, who blogs about health care almost as frequently as does Paul Krugman, has written about the importance of this aspect of whatever new health care system we create.

The newly-empowered commission could draw together the negotiating power of both the new public insurance entity and Medicare (perhaps even working together with some private insurers) and negotiate down the prices of pharmaceuticals, hospital stays, and other parts of health care, including doctor reimbursement.

From what I've read, that's kind of how things work in the French system, which I now come back to regularly as the best broad model for U.S. health care reform (I'm a great believer in avoiding investing in the development a new wheel; better to just steal good ideas). As many reports have suggested (see NPR, Dutton, and Business Week) the French share with Americans many similar attitudes about health care, especially regarding maintaining choice and avoiding rationing (personally, I'm avoiding a Peter Singer joke here). The World Health Organization calls the French system the best in the world, an opinion seconded by independent studies.

They think it works better than even Canadian, British, and German systems, plus it has the advantage of fitting a lot of American attitudes regarding how health care should work.

We can also learn from French mistakes too. For example they've tried maintaining employer-paid insurance to a degree, but now are moving away from it.

Again, I agree that creating an empowered MedPAC, or whatever the commission would be, would be a hazardous endeavor, but I think it's preferable in the long run to make the management and maintenance of the public parts of health care less of an everyday political football.

Running with wrong pack

From my blog http://blog.stier.net, filling in some more detail about what's wrong with what the Blue Dogs are demanding.

Five members of Congress from Pennsylvania—Representatives Jason Altmire, Chris Carney, Kathy Dahlkemper, Tim Holden, and Patrick Murphy—are part of the Blue Dog Coalition, whose demands for changes in the Health Care reform bill before the House of Representatives has gained a great of attention in the last week or so.

While at least one of those demands might actually improve the bill, others are deadly to the health care reforms we so badly need around the country. Indeed those demands are so deadly for reforms that will very much benefit Pennsylvanians, that it’s time for us start asking our Pennsylvania Blue Dogs, why are you running with this wrong pack?

There are two aspects of the HR 3200, the House health care reform bill, that are especially important to Pennsylvanians.

The first is a public health insurance plan that competes with private insurers on a level playing field. This is critically important in Pennsylvania because, as HCAN PA documented in a recent report, there is very little competition in the health insurance market in our state. In three of four regions in the state—and in every Blue Dog District except part of Representative Holden’s—private insurers controlled by one company holds has about 70% of the market. That is a main reason that insurance rates are increasing over three times faster than wages in our state. (And, in the part of Representative Holden’s district where there is competition, insurance premiums are substantially lower than elsewhere in the state.

The Blue Dogs Coalition leadership wants to create a weak public option at best. And only one Pennsylvania Blue Dog, Patrick Murphy, has come out strongly for the public option.

We won’t have a good public plan if we don’t set the reimbursement rates for doctors and hospitals right.

HR 3200 calls for the public health insurance plan to initially begin with payments to physicians and hospitals at rates set 5% above Medicare reimbursement rates. After three years rates can be changed as necessary to ensure access, affordability and efficient delivery of care. Three major organizations of physicians, the AMA, the National Physician’s alliance and the American College of Physicians are satisfied enough with these rates that they have endorsed the legislation.

The Blue Dog leadership, however wants the public insurance plan to negotiate higher reimbursement rates. That will force premiums up for people who sign up with the public insurance plan. It will make it harder for the public insurance plan to compete with private insurance, thus raising all of our premiums. And it will raise costs for the federal government (and thus ultimately for us) by making higher subsidies for both public and private health insurance necessary.

Our Pennsylvania Blue Dogs say that they joined the coalition in order because it stands for fiscal responsibility. But what is fiscally responsible about this effort to increase our premiums and taxes and cripple the public health insurance plan?

So our Pennsylvania Blue Dogs need to choose: will they stand with the Blue Dog Coalition and protect insurance companies from competition? Or will they stand with their constituents and keep our insurance premiums, budget deficits and taxes from increasing?

The second critical issue for Pennsylvanians is the affordability of health insurance for the middle class. HR 3200 includes credits that will help people with income up to 400% of the FPL, the federal poverty level, which is $88,000 for a family of four, afford health insurance.

The Blue Dog coalition leaders want to reduce those credits to 300% of the FPL, or $55,000 for a family of four. The median income in the country for a family of four is $72,168. So the Blue Dog proposal will eliminate federal credits for middle income families making $55,000 to $88,000 a year, which is about 14% families in Pennsylvania. Removing these credits will increase monthly payments for middle income families by $200-300 a month. They will pay $1052 a month, which is three times what members of the $357 per month that members of Congress pay for health insurance.

Yes it is true that we will have to raise taxes to provide these subsidies. But the House plan will only raise taxes by more than a token amount on families making more than $1,000,000 a year. Ninety-nine percent of Pennsylvanians will see no tax increase at all.

Again, the Pennsylvania Blue Dogs need to choose: will they stand with the Blue Dog Coalition or will they stand with their constituents and protect Pennsylvania’s middle class?

A vote is coming. And we are about to find out whether five Pennsylvania members of Congress will keep running with the Blue Dogs or will run with the people who put them into office.

fiscal responsibility my eye

as i've said countless times, the blue dogs' fetish for "fiscal responsibility" is inconsistent and highly situational. it's a myth that needs to be destroyed.

when it comes to iraq and bailing out banks, there is no sense of fiscal responsibility from the blue dogs. medical expenses are one of the leading causing of bankruptcy: but in 2005, the blue dogs voted for a bankruptcy bill that offers NO protections to people on the hook for medical expenses. where's the fiscal responsibility there?

how many supplemental war funding bills (ie, war spending that's not offset by cuts, and which are passed down to our kids, grandkids, and great-grandkids) have the blue dogs voted for? ALL of them. Where's the fiscal responsibility?

so basically, it boils down to this: when it comes to killing people or doing big business' bidding, there is no limit to Blue Dog spending.

When it comes to social programs and services that keep people alive, all of a sudden we have to make sure we watch our wallets.

so yeah, I'm glad Pat Murphy is vocal about the public option. But let's not kid ourselves that these people are "fiscal conservatives". they are, to quote Paul Krugman this AM, "corporate tools"

funny story about dahlkemper's office

when i pointed out that the war in iraq cost 3 times the estimated cost of health care reform (at least) and that it had not only made us no safer, but that the blue dogs like kathy kept throwing money at it with reckless abandon, with no pay-as-you-go restrictions, the person on the phone told me "i am an american soldier, that war IS making you safer, and don't you EVER call back here again."

so i called back, complained, and the chief of staff called me back to apologize on the guy's behalf.

The rural health care issue and PA

Also from my blog, on the rural health care issue.

The Blue Dog leader on Health Care is Congressman Mike Ross of Arkansas. He has been arguing that we need to increase Medicare reimbursement rates in rural areas because they are lower in those areas and have to be raised in order to attract good doctors and to keep hospitals open.

We at Health Care For America Now share those concern. But like the Blue Dog idea of negotiating reimbursement rates in the public health insurance plan instead of setting them at Medicare rates plus 5%, Rep. Ross’s solution will raise premiums in the public health insurance plan, not just in rural areas but across the country. It will also cripple the public plan and reduce competition for private insurance, which will also raise premiums. And, because higher subsidies will be required for these higher premiums, the cost to the Federal government and, ultimately, taxpayers will be greater.

And, at any, rate it’s not totally clear that Medicare reimbursement rates create access problems in rural areas. Costs for many things, after all, are lower in rural areas than urban areas, so it makes sense that reimbursement rates will be lower. Other problems, particularly higher rates of un-insurance, a problem that is exacerbated if premiums in the public are too, lead to hospitals closing in rural communities.

Moreover, reimbursement rates are not the problem in Pennsylvania. While much of Pennsylvania is rural, we have been and can continue to deal with rural health care access without crippling the public health insurance plan.
There is some variation in Medicare reimbursement rates between urban and rural areas in Pennsylvania—as costs vary as well. But our state average reimbursement $6860 is higher than the national average of $6,611.

The average reimbursement rates in the districts of Representative Altmire and Murphy, $7152 and $8344 respectively, are far above the national average. Rates vary in different parts of the other districts because costs vary as well. But the average rates in the districts of Representatives Carney ($6350) Dahlkemper ($6262), and Holden ($6042) and not very far below the national average.

In addition, 13 rural hospitals in Pennsylvania, including one in Representative Dahlkemper’s district and four in Representative Carney’s district, have qualified under Critical Access Hospitals program of the federal government. They are thus already reimbursed on a “cost-plus” basis by Medicare, which is above usual reimbursement rates.

Moreover, the most important thing we can do in Pennsylvania to insure that rural hospitals stay open is provide insurance to the people most likely to use them. We know that when hospitals close or move it is almost always those hospitals located in lower income areas. And the hospital managers always say they can’t survive because of an “unfavorable patient mix” that is too many patients without health insurance. Hospitals in Pennsylvania had a respectable total margin of 4.7% in 2008. However, if 90% of uncompensated care had been covered by health insurance, that total margin would be a stellar 7.04%, enough to keep rural hospitals in business and bring down health care costs.

I don’t know whether things are different in Arkansas. But in Pennsylvania, the best way to guarantee health care access in our rural areas is to make sure that everyone who lives in those areas has quality, affordable health insurance.

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