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Friday, February 5, 2010

What's on the Table for Health Care in Georgia?

Yesterday I had the opportunity to attend Legislative Day at the Capitol with other Georgia physicians representing the Patient-Centered Physicians Coalition of Georgia. As an advocate for the American College of Physicians (ACP) I acted as a lobbyist for key health legislation in our state.

Highlights are as follows:

1. The Governor has proposed a 1.98% cut to Medicaid within the 2011 budget.
2. The Governor has also proposed a 1.6 percent premium tax on hospitals as a source of revenue.
3. The House has proposed a $1.00 tax, or “user’s fee,” on tobacco products as a source of revenue (House Bill 39).
4. Comprehensive tort reform (Senate Bill 3) was passed in Georgia in 2005. This included caps on non-economic damages for medical malpractice cases. This is under Supreme Court appeal and is likely to be back on the table.
5. Prompt Pay (House Bill 321, House Bill 342 and Senate Bill 62) reform is proposed, requiring prompt pay (15 days) by third party payors who now often delay payment up to 90 days.

In the state of Georgia Medicaid reimburses about 48% of what private payors reimburse. A cut to Medicaid would mean a 16% cut to current provider reimbursement for Medicaid patients. Poor payment by Medicaid has led many practices to drop Medicaid, limiting access to health care for Medicaid patients. Patients who are unable to access physicians use the emergency room for care and have worse health outcomes, leading to increased expense. Inadequate reimbursement will lead medical practices with a high percentage of Medicaid to have inadequate revenue to meet operating expense.

However, the reality is that the Georgia state budget projections for 2011 and 2012 are daunting: . Global cuts—including education and teacher furloughs are occurring. I spoke with my district representative, Mary Oliver (D), who sees few choices given the current economic climate.

As a source of revenue, the Tobacco Tax is opposed by many congressional republicans, who are in general opposed to any additional taxes. They voice concern that it would primarily impact those of lower economic means. Those in favor, including The ACP, point out the 400 million in additional revenue it would generate for the state, and the positive impact it would have on public health, particularly youth smoking prevalence.

Georgia passed comprehensive tort reform in 2005 limiting non-economic damages to $350,000 in medical liability lawsuits. Medical groups point out that since this time malpractice insurance rates have stabilized and decreased. However this is currently under Supreme Court appeal. Just yesterday Illinois overturned tort reform legislation it passed in 2005. Opponents of tort reform, including representative Stacy Abrams (D) feel that tort reform is a “red herring,” not truly accountable for increased health cost within our system. Consumer advocate group Georgia Watch supports this view:
The Patient-Centered Physicians Coalition of Georgia supports protection of tort reform in our state.

Where do you stand on these issues?

With all of the focus on the national debate I urge readers to understand what’s on the agenda for health care in your state, contact your representative, and let your voice be heard.


  1. i am in favor of the proposed "user's fee" on tobacco products, also known as the tobacco tax.

    as an adolescent, i am a part of the demographic that this legislation would most directly and strongly affect: nascent smokers.

    while around 29% of the u.s population self-identifies as smokers, this is a condition, a label, a (death) sentence that usually begins early in a person's life. approximately 90% of smokers begin at or before age 18. research shows that majority of young people who are initiated as smokers and pick up the habit that quickly and surreptitiously transforms them into addicts are by-products of environmental conditioning: the people around them, including their parents, family and friends, are smokers, and being born into the tobacco culture leads to normalization, realization, and repetition of this legacy. once old enough (and often, even before reaching legal age), the aforementioned adolescents reach for a cigarette. their motivations for picking up smoking are varied but are mainly attributed to curiosity ("to see what all the fuss is about!") and/or status and socialization, an attempt to accessorize themselves with a sociocultural symbol of adulthood in their milieu. the only way to prevent the latter is to change the environment, by making cigarettes harder to access and less widely used and abused. (cont.)

  2. a cigarette is more than just a symbol, though. it has been referred to as a nicotine "drug delivery device." nicotine is often a gateway drug, its high being as addictive as heroin and cocaine. in 1988, the u.s. surgeon general reported that the nicotine inhaled in a cigarette reaches the brain to produce its alluring effects twice as fast as intravenous heroin injections; nicotine takes just seven seconds to cross the blood-brain barrier and take hold of its users. having the properties of a stimulant and a relaxant, nicotine produces positive feelings in its users, ranging from calmness and relaxation to alertness and increased mental acuity. nicotine even triggers the release of beta-endorphin, a hormone known to inhibit pain. with such seemingly beneficial properties, nicotine quickly becomes a necessity rather than a novelty. over time, and not a long period of it, smokers become addicted to nicotine and its properties, such that cessation of cigarette use produces withdrawal. a syndrome that can last for weeks to months, withdrawal causes physical and mental symptoms such as increased appetite, weight gain, constipation, cough, sore throat, chest tightness, headaches, and tiredness as well as trouble concentrating, depression, anxiety, anger, frustration, impatience, irritability, restlessness, and even sleep disturbance.

    when nicotine is not enough, its users turn elsewhere for a high. in "a comprehensive national analysis between "gateway" drug use and other illicit drug use" a paper published out of the center on addiction and substance abuse based on a study performed at columbia university, it is noted that individuals who smoked cigarettes were 19 times more likely to use cocaine in one of its various forms. furthermore, the paper documents that approximately 90% of cocaine users were originally users of tobacco, marijuana, or alcohol. so, preventing and stopping nicotine use and abuse is about more than just kicking a habit. it is about preventing a lifetime and lifestyle of addiction, skirting a transition to abuse of other illicit and harmful substances, and thwarting the development of significant health consequences, ranging from cancers of the lungs, mouth, larynx, pharynx, esophagus, bladder, kidney, pancreas, cervix, stomach, and blood to lung, heart, vascular and ocular diseases. (cont.)

  3. the various consequences of nicotine use and abuse affect societies as a whole, not just individual users; this microscopic behavior has macroscopic effects. in the 1990s, it was estimated that the years of life lost to smoking-related deaths are 13.2 for men and 14.5 for women- and remember: this excludes the years of quality of life lost due to pre-tobacco-death related illnesses. imagine the effects this loss of life and productivity coupled with exorbitant medical costs to treat tobacco-induced illness in smokers has on the local, national, and global economies. it is astronomical. the center for disease control and prevention recently released data showing that healthcare related to smoking is costing americans approximately $96 billion per year. the loss of productivity in our national economy from chronic, diseased smokers amounts to an additional and whopping $97 billion annually. while it is an indirect cost, every american is paying the price for those who use and abuse tobacco products. this behavior is killing our country. smoking is taking the lives of our citizens, destroying our productivity, burdening our healthcare system and bankrupting the nation. it is time we take legislative action to prevent this epidemic from worsening, and what better place to start than at the beginning of the chain? it is high time to nip this problem in the bud.

    while the tobacco-use problem is complex, the solution seems fairly simple: we must stop ourselves from smoking. like all things, change starts at home, on the local and state levels. the georgia state legislature's proposed "user's fee" on tobacco products will undoubtedly affect behavioral change. it will hit longtime tobacco users and early, young smokers where it really hurts: in their wallets. the seemingly minor $1 tax on tobacco products delineated by house bill 39 will provide the state a significant source of much-needed additional revenue, a predicted $400 million annually. although those who voice opposition to the tax, claiming it would, as has described, "primarily impact those of lower economic means," that may be exactly the point. if tobacco users cough up the additional $1 tax per product, it would help the state fund healthcare-related costs of smoking as well as make up for the loss of productivity due to smoking-related illnesses. if tobacco users are unable to afford the tax, they will be unable to purchase- and use- tobacco products. i see the tax, and its effect on those of lower economic means to be a good thing rather than a drawback, as adolescents and young adults make up a sizable percentage of the unemployed and underemplyoed. in this nation, the youth have been hit the hardest by high unemployment rates in the job market due to our current economic climate. the georgia department of labor cites current unemployment at 10.3%, the highest it's been on record. in the breakdown, those 16-25 have the highest inter-population unemployment rates. as recently as 2008, there was a full percentage difference in unemployment between those 16 and older (5.4%) and those 25 and older (4.4%), the younger population at a disadvantage. in this economic climate, the majority of adolescents and young adults cannot afford to smoke- literally. (cont.)

  4. i see the tobacco tax in house bill 39 as the first meaningful piece of legislation since the law enacted on april 1st, 1998, which prohibits the sale of all tobacco products to individuals under the age of 18 in each of the fifty unites states. it's time we take a second legislative step.


  5. Morgan Amanda,
    Thank you for your very well-researched response. The American College of Physicians, and 70% in Georgia agree with this "user's fee" for tobacco as a good thing, both in terms of the public health implication, and in terms of revenue generated. I guess the other main argument against this sort of tax would be from the individual liberties standpoint. Where do we draw the line? Consider a recently imposed transfat restriction enacted in California.
    What's next ? Perhaps a soft drink or french fries user's fee. I'm in favor, but it's worth considering.

  6. I agree with you: taxation can go too far, to the point that it infringes on our civil liberties. It is a fair point to make that smoking is a choice, as nicotine is not yet an illegal substance, but unlike soft drinks, cheese fries, or quarter-pounders, nicotine products, namely cigarettes, come with (multiple) government issued and enforced disclaimer(s)- the Surgeon General's Warnings. These read as follows:

    SURGEON GENERAL'S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

    SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health.

    SURGEON GENERAL'S WARNING: Smoking By Pregnant Women May Result in Fetal Injury, Premature Birth, And Low Birth Weight.

    SURGEON GENERAL'S WARNING: Cigarette Smoke Contains Carbon Monoxide.

    In addition to mandating the inclusion of the warning labels, which were formerly very small- a la 'fine print'-, the federal government now dictates their increased visibility. The Family Smoking Prevention and Tobacco Control Act of 2009 stipulates that said labels must cover 50 percent of both sides of each individual pack; it also specifies that this label be printed in all capital letters. While research shows that the carbonation in soft drinks can contribute to osteopenia, the calories in cheese fries to obesity, and the cholesterol in a quarter-pounder to atherosclerosis, none of these items come with government-issued warnings, nor are they regulated by the FDA in the same manner the tobacco industry is. Until the Surgeon General issues a similar warning on transfats, I do not support their restriction by the State of California. Perhaps that is a place to draw the line.

  7. When comparing a sin tax on smoking to, say, trans-fatty foods, I'd draw the line where an individual's action can directly hurt others.

    In court, this standard is already applied to matters of free speech.

    I support the indoor smoking bans imposed by my state (Massachusetts). We need to make it more difficult and inconvenient for people to access tobacco due to its _public_ health risk. I don't see a fundamental violation of civil liberties here mainly because the tobacco is still available for those who want it. But people who choose to create a health hazard to others ought to pay a penalty in the form of a tax.

    California's ban on trans-fat does feel like a case of the government overstepping its bounds. My choice to ingest hydrogenated oils doesn't affect others directly. One could argue that the health problems and medical costs stemming from the consumption of trans-fat places a burden on society, but the problem with that argument is that trans-fats aren't the singular cause of diet-related health issues. Like the source article stated, someone who orders french fries probably isn't concerned with eating healthy. In the end, it won't matter if those fries were trans-fat-free. That consumer will likely be obese and have the same risk of heart disease, diabetes, etc. What will the government ban next? High-fructose corn syrup? Carbs?

    Hurt the public? Regulate. Hurt yourself? Your choice.