The Folly of Medicaid Expansion Studies and CMS Designs

Our top journals and researchers and health care leaders continue to ignore the major factor shaping differences in health care outcomes - differences between the populations studied. Studies that gain publication are supposed to explain away alternative hypotheses and the predominantly do not do that. In such a case, major limitations are to be included with the research. But we continue to fail to consider alternative hypotheses, and tolerate studies with few limitations, and often consider these studies to be important when they agree with what we assume or believe.

Look to the Source of Failure - Population Differences Are One Source, Health Policy Leaders are the Second Source of Chronic Failure By Health Care Design.

• CMS Micromanagement Type 1 Cost Cutting has failed to cut costs just as it fails to rein in the big health entities that are doing so well - and cause the need for cost cutting. Bigs get the win win win design. Too big to cut and policies that hurt their competition not big and big enough to shape their own favorable design. They also used their finances and association and lobbyists to prevent needed reforms that would favor basic health access and most Americans most behind.

• CMS Micromanagement Type 2 Quality Improvement is limited in more ways that can be discussed in a short period of time - while unfortunately lasting despite massive design failures for a long period of time. The massive failure costing billions known as CMMI reflects 40 years of failed assumptions. CMMI and most innovation needs to be terminated, not expanded or replicated or defended or doubled down.

State Outcomes Cannot Be Changed from Above and Far Away. Outcomes Improvements Require a Better Population for Better Health, Education, and Other Outcomes

• Failure to understand this results in failure to rein in costly, burdensome, meaningless micromanagement and Obsessive Measurement Disorder - killing our health care professionals.
• Medicaid expansion states have always had major differences before, during, and after expansion.
• If you fail to fix population differences and fail to stop policies that make the situations worse, you will not improve health care in the United States.

In General, the states that did not expand Medicaid

• Inherently have had the worst outcomes for decades - so stop paying attention to these ridiculous comparison studies with their bias and promotional material.
• Inherently have the worst social supports, worst drivers of outcomes, worst employers (even worse for 2621 counties behind), and lowest health care workforce levels because of concentrations of Medicare, Medicaid, and worst employers with their worst health plans

Employment Based Health Insurance Kills Health Care Where the Worst Employers Are Concentrated - Generally Acting Together with Worst Medicare and Medicaid

• This causes the financial declines that has terminated hundreds of small hospitals rural, urban, independent and specifically where health policy dictates closure. Finances are the key factor and finances are worst in expansion states, in counties most behind by CMS policies...
• Also terminated are thousands of practices with more thousands to come further impairing worst basic health access also by the hand of CMS design
• Also terminated are tens of thousands of local health care leaders where they were most needed. Local leadership has been excluded from the 2621 counties because of DRG and RBRVS and lower payments and worst quality health insurance and most abusive policies closing their hospitals and practices

Obamacare Was Born in Bad Assumption and Unfortunately the Political Climate Apparently Has Suspended Appropriate Critique. With more sanity our researchers could expose the many flaws - but they are not funded to do so and apparently are deceived by the assumptions of improvement from far away by outsiders that do not understand most Americans most behind or their remaining health care.

The shift of health insurance is quite dramatic. Quality health insurance follows the best public plans and the best populations and outcomes. As the population and plan quality shifts, the deficits closures compromises and access barriers worsen.

This has clearly suspended the necessary critique of all things ACA and many more over the past 40 years of abuses. Take your pick of Kip Sullivan's posts to see how CMS and policists avoid critical analysis.

Those in charge want to shape health care via their designs, when the fact of the matter is that outcomes transformations require transformations of the American people, not what remains of their health care.

• Expansion of the worst quality plans by ACA designers is a quantity focus when more problems due to health insurance plans are caused by the plan quality problem facing 62% of Americans and over 70% where health care is most behind. Good quality plans can support the uninsured and the necessary local workforce. Poor quality plans shape insufficient access and workforce and make the situations worse for those without plans or those with the worst plans. Veterans are concentrated in these counties because they originated there and because the must live in lower cost settings. Half of their care is local - and is insufficient because local care is lacking where concentrations of lower and middle income, elderly, poor, disabled, Veterans, dual eligible, high deductible, and worst employers are found.
• Micromanagement continues to runaway with our attention, with the health care literature, and with our health care dollars. Micromangement has not helped and hurts us in the worst possible ways.

Why would we want to make delivery team members personal and professional lives more difficult while not improving quality or improving health care costs? Does anyone read these articles to see what is happening. Does anyone care to help prevent more harm?

Why tolerate budget shifts causing fewer and lesser delivery team members as more has to be spent for digitalization, innovation, certification, regulation, micromanagement, consultants, and other non-delivery costs? https://www.dhirubhai.net/pulse/burnout-reductions-work-designs-shape-more-better-team-robert-bowman/

How can you have person centered or higher functioning primary care when designs shape half enough primary care for most Americans and even lower levels of delivery team members in these settings? https://www.dhirubhai.net/pulse/how-can-you-have-person-centered-primary-care-when-most-robert-bowman/

So if you praise ACA Obamacare and other CMS policies -

Please understand that you are protecting CMS from accountability for their contributions including destruction of economics, jobs, health care, local health leaders, and social determinants for half the population.

Why do we let CMS Behavioral Leaders print their plans in journals, when they and past CMS Behavioral Leaders caused the deficits of mental health in America?

Do you wonder why health care in American continues to get worse? Consider the policies across federal, state, local, and employer designs for the last 40 years across

• DRG to managed care to HITECH to ACA to MACRA/MIPS plus
• Readmissions, star ratings, ACO, Readmissions, and Medicare Advantage.

Please consider basic economics and consider the designs from the perspective of most Americans most behind. If leaders and designers only design for the top 30%, they cannot help but abuse the bottom 50% of Americans.

See the abuse of vulnerable populations, the lack of beneficent intent, the discrimination, and other ethical and moral violations of health care designers (the reasons we crafted protections from physicians and human subject researchers). Do NO Harm By Health Care Design

Ask yourself:

Why did the American Hospital Association tolerate DRG and the gross discrimination against hospitals all not the largest?

Why have there not been many more studies pointing out the patients killed or compromised because their DRG assumption was incorrect or they were dumped too soon or denied care or the nurse staff ratio was too low or nurses were pushed too hard?

Why do health care and physician and academic associations tolerate and support RBRVS other than they do best by such designs that favor those biggest and with the most lines of revenue and the highest payments in each line - which are worst for basic health access and for most Americans who live where there are few lines of revenue paid lowest?

Do you see how big health likes the current designs, profits most from them, adds lines of revenue to the design, takes advantage of programs designed for Americans behind, and fails most to address the needs of half of the nation most behind?

Medicare Expansion Studies have more flaws than can be counted

The states that did not expand Medicaid yend to be the same ones that opposed Medicaid at the start until compromise allowed to cut their costs. Note that these states in general

• Are weakest financially
• Are weakest in education, health literacy, taxation for schools and other taxation
• Have shaped most of the nation's 2621 counties lowest in health care workforce with half enough primary care mental health women's health and basic surgical workforce - you might want to understand that these counties are growing fastest as their remaining health care is designed away
• Have the worst employers and their worst private health insurance
• Have the worst quality Medicaid in terms of lower payments and worst abuses of patients and providers
• Have the worst quality Medicare plans paying the lowest and also most abusive
• Fail most for counties with concentrations of elderly, poor, disabled, and worst employers - because of federal, state, local, and employer designs.

Try to consider that our designs shape deficits and maintain them in ways that no training design can address

• More graduates cannot help as there are not the dollars to support them and the dollars already compromise care with fewer and lesser delivery team members
• New types of graduates such as nurse practitioners, physician associates, family physicians have contributed, but are still limited in areas such as primary care by the 250 billion stagnant spending a year with declines due to higher costs of delivery
• massive expansions are seen in NP PA DO and MD but can only increase workforce where RBRVS allows - procedural, technical, subspecialized, hospital, and therefore most concentrated and least distributed
• Special training is also a rearrangement of the deck chairs due to the financial design. Pipelines to primary care, rural, CHC, or underserved are incapable of addressing deficits and distract from true solutions.

The facts are quite clear. The financial design prevents any training intervention from working. Why should be trust health care leaders, academic designs since the 1980s, or claims that more training or more micromanagement can fix American health care? https://www.dhirubhai.net/pulse/why-most-americans-should-trust-health-care-leaders-robert-bowman/

Only in America does government tolerate so much abuse from health care and tolerate worsening over time as Americans age, get sicker, get poorer - and usually all three with health care design contributing.

Only in American does innovation, accountability focus, so-called quality improvement design, and cost cutting micromanagement select out the practices and populations and hospitals most behind - for the most abuse

Rural Hospitals - https://www.beckershospitalreview.com/finance/most-rural-hospital-closures-from-2010-to-2021-happened-in-states-that-didn-t-expand-medicaid.html

The Designers and their Assumptions and Abuses leave us few choices other than legal recourse on behalf of most Americans most Abused. https://www.dhirubhai.net/pulse/why-most-americans-must-organize-sue-cms-centers-medicare-bowman/